Patient/Client Data – Clinical Decision-Making Worksheet
Student Name: Week: 4 Dates of Care:
Patient Initials Sex
M Age
77 Room
716 Admitting Date Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Shortness of breath, fever, and chills
Attending physician/Treatment team: Consults:
Present Diagnosis: (Why patient is currently in the hospital) ER Management: (if applicable)
Allergies:
No Known Allergies Code Status:
DNR Isolation: (type and reason)
Admission Height: Admission Weight: Arm Band Location (colors & reasons)
Left
Communication needs: (verbal, nonverbal, barriers, languages)
Verbal, Spanish speaking, needs an interpreter.
Past Medical History: (pertinent & how managed)
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)
Tests/Treatments/Interventions impacting clinical day’s care (include current orders)
Assessments and interventions: (Include all pertinent data)
Vital signs: (2 sets per day)
Time
T
P
R
B/P
Time
T
P
R
B/P GI:
Diet:
Swallow precautions:
Tube feedings:
NG / G tube:
Blood Glucose: (time & date)
Last bowel movement: (time & date)
Pertinent Labs/Test:
Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)
Respiratory:
02 modalities:
02 Saturation: 98%
Suction: N/A
Resp Rx’s: N/A
Trach: N/A
Chest Tubes: N/A
Pertinent Labs/Test: Chest X-ray noted worsening hazy density in the left midlung may reflect edema, atelectasis, or nonspecific pneumonitis.
Assessments/Interventions: (Lung sounds, cough, sputum, SOB)
Lung sound was clear, no cough, no sputum, no SOB. Neurosensory:
Neuro checks: No
Alert & Orientated: x4
Follows commands: yes
Speech Comprehensible: yes
Pertinent Labs/Test: No pertinent labs/test
Assessments/Interventions:
(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)
Followed Cardinal Field of Gaze. No tremors, tingling, numbness, paralysis, headaches, dizziness.
Glasgow coma scale: 15, no head trauma.
Cardiovascular:
Telemetry: Yes
Pacemaker/IAD: No
DVT Prevention: N/A
Daily Weights: N/A
Pertinent Labs/Test: No pertinent labs/test
Assessments/Interventions:
(Peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)
Pulse is regular in S1/S2, rate 78, no abnormal sounds heard, pacemaker no telemetry. No edema, chest pain, discomfort, palpitations. Musculoskeletal:
Activity: As tolerated
Traction: N/A
Casts/Slings: N/A
Pertinent Labs/Test: No pertinent labs/test
Assessments/Interventions:
(Strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps
Followed ROM. No pain, fractures, amputation. Gait is steady. Slight weakness, age related.
Renal:
Catheter (indwelling/external):
CBI:
Dialysis:
A/V access:
Pertinent Labs/Test:
Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)
Patient has a urinal and a commode by his bedside. Urine is yellow in color. No burning with urination, no hematuria, no incontinence, no monitoring of I & O.
Patient drinks adequate amount of water. Skin:
Braden Score: 13
Pertinent Labs/Test: No pertinent labs/test
Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toenails, wounds, drains, bed type)
Has slight bruising on left arm, red no blanching. Skin turgor 3 secs. No surgical incisions. No edema. No wounds, no drains. General medicine bed.
Pain:
Pain score: 0
Assessments/Interventions: N/A
(scale used, location, duration, intensity, character, exacerbation, relief, interventions)
Numerical pain scale, Patient was not in any pain. Vascular Access: (IV site)
Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)
Peripheral, left antecubital, 22 gauge, inserted
Pt was on an antibiotic Arythromycin in NaCl 0.9% IVPB. Site appeared: no redness or bruising.
Gyn:
Gravida/Para:
LMP:
Last Pap:
Breast exam:
Pertinent Labs/Test
Assessment/Interventions: (bleeding, discharge)
N/A
Male Patient Post-operative /procedural:
Assessments/Interventions:
(immediate post procedure care)
N/A
No Post op
Safety:
Call light: Yes
Bed Rails: Yes
Bed alarms: No
Fall risk: No
Assistive Devices: No
Sitter use: No
Restraints (type, duration & reason):
Assessment/Interventions (modifications to room, environment, Patient)
N/A
No modifications were made to the patient’s room.