Hondros College Level 2 Clinical Tool

Clinical Worksheet

Student Name: Monica Treta Date: July 26, 2010

Demographic Data

Client Initials: B.D.

Age: 61

Sex: Female

Admitting Medical/Psychological Diagnosis: Cerebral Vascular Disease

Patient’s Chief Compliant (What brought them to the hospital): CVA with hemiparesis (right side)

Past Medical/Psychological History: History of seizures, diabetes mellitus, hypernatremia, stage 4 pressure ulcer on
coccyx, bipolar disorder, GERD, PVD, Anemia

Past Surgical History: Craniotomy, PEG tube (removed), right great toe amputation
Hondros College Level 2 Clinical Tool

Pathophysiology of Chief Disease State

(Choose the chief disease state or condition, (eg. HTN, DM, CAD, COPD, pneumonia, pregnancy, pre-term labor, birth,
schizophrenia, bipolar…etc.) and explain the disease and how it affects the body holistically. Think of how the disease may
affect the heart, eyes, skin….etc.). Put reference in APA style at the end of explanation.

Cerebral vascular disease

Hondros College Level 2 Clinical Tool

Vital Information

Height: 5’ 5”

Weight: 79.5 kg

Allergies: NKA

Time 0730

TPR 76, 12

BP 124/76

SPO2

Laboratory Data
Client Value Normal Value Why was the lab ordered?

White Blood Cell 7.7 µl 4.5-10 µl To determine the presence of an infection

Red Blood Cell 4.43 µl 4.0-5.0 µl To monitor for hemorrhage

Hemoglobin 12.5 g/dl 12-15 g/dl To determine the presence of anemia

Hematocrit 38.30% 36-46% To monitor the volume of RBCʼs

Platelets 227 µl 150-400 µl To detect thrombocytopenia

BUN 19 mg/dl 5-25 mg/dl To detect renal dysfunction or dehydration

Creatinine 0.8 µmol/l 45-132.5 µmol/l To detect renal dysfunction. An increased

level may indicate congestive heart failure.

Sodium 137 mEq/l 135-145 mEq/l To detect sodium imbalance

Hondros College Level 2 Clinical Tool

Client Value Normal Value Why was the lab ordered?

Potassium 5.2 mEq/l 3.5-5.5 mEq/l To detect potassium imbalance. Decreased

levels can cause heart dysrhythmias.

Chloride 106 mEq/l 95-105 mEq/l To check level in relation to potassium and
sodium and acid/base balance.

Carbon Dioxide 23 mEq/l 22-30 mEq/l To detect metabolic acidosis or alkalosis

Glucose 217 mg/dL <110 mg/dL Screen for metabolism of sugar.

HGBA1C 8.7 mmol/L 5.5-9.3 mmol/L To detect a history of uncontrolled diabetes

Hondros College Level 2 Clinical Tool

Medications

Client-specific Major SE Client/Family

Name Dose Action
purpose Labs to monitor Teaching
acetaminophen 650mg q6h nonopioid analgesic, pain hepatotoxicity, renal Do not exceed
antipyretic failure, leukopenia, recommended dosage,
neutropenia, hemolytic toxicity may occur when
anemia, cyanosis, used with other combination
anemia, jaundice. products. Do not use with
Monitor liver and renal alcohol or herbs. Recognize
function. signs of overdose.
amlodipine/Norvasc 10 mg daily dihydropyridine calcium Anti-hypertensive, anti- Headache, fatigue, Take the drug even if
channel blocker - anti- anginal edema, dizziness, feeling better. May take
anginal, flushing, palpitations. Nitroglycerin as well. Seek
antihypertensive No labs to monitor. medical treatment if chest
pain persists or if dizziness,
palpitations, chest pain, jaw
pain or fainting occur.
cilostazol/Pletal 100mg 2x daily platelet aggregation prevent blood clots due dizziness, headache, Report any unusual
inhibitor to immobility palpitations, bleeding, report side effects
tachycardia, nausea, like diarrhea, shin rashes,
vaginal hemorrhage, and subcutaneous bleeding.
bleeding, rash, back Discontinue tobacco use.
pain, cough. Monitor
CBC, HCT, HGB, PT.
citalopram/Celexa 40mg po daily SSRI/antidepressant depression fever, tremor, Monitor for decreased blood
somnolence, insomnia, pressure and tachycardia.
anxiety, suicide Continue therapy as
attempt, dry mouth, prescribed, do not stop
urti, cough, rash. taking suddenly. use
Monitor liver function. caution when operating
hazardous machinery.
Consult prescriber before
taking other medications,
OTC medicines, or herbal
remedies. Do not consume
alcohol during treatment.
Use birth control during
therapy.
Hondros College Level 2 Clinical Tool

divalproex/Depakote 500mg po 2x daily anticonvulsant/vascular Mania sedation, drowsiness, Swallow tablets whole, do
headache suppressant dizziness, nausea, not crush. Give with food
vomiting, constipation, or milk to decrease GI
diarrhea, dyspepsia, upset, do not discontinue
hepatic failure, abruptly, dependency may
pancreatitis, rash. result. Use contraception
Monitor liver function, while taking this drug.
CBC, PT, platelets,
vitamin D.
folic acid 1mg po daily folic acid replacement anemia bronchospasm, Take exactly as prescribed.
flushing. Monitor CBC. Alter diet to include high
folic acid content. Urine
may turn bright yellow.
Notify prescriber of allergic
reaction. Avoid
breastfeeding.

furosemide 40mg po daily Loop diuretic Hypertension Fever, vertigo, Advise patient to stand
transient deafness, slowly, to avoid alcohol and
abdominal discomfort to minimize strenuous
and pain, hepatic exercise in hot weather.
dysfunction, nocturia. Report ringing in ears,
Monitor kidney severe abdominal pain, sore
function, glucose, throat or fever.
cholesterol, uric acid
and electrolytes.
potassium chloride/ 20 meq 1 tab po daily Potassium supplement Patient on Lasix Arrhythmias, heart Make sure powders are
Klor-Con block, possible cardiac completely dissolved, give
arrest, GI hemorrhage, with or after meals with a
obstruction or full glass of water or juice.
preforation, respiratory Always verify preparation
paralysis. Monitor before administration.
potassium levels and
renal function.
Hondros College Level 2 Clinical Tool

lisinopril/Zestril 10 mg daily Angiotensin Converting Anti-hypertensive Hyperkalemia, Report signs of

Enzyme Inhibitor - dizziness, headache, angioedema, breathing
lowers blood pressure fatigue, angioedema, difficulty or swelling of the
anaphylaxis. Monitor face. Lightheadedness may
white blood count occur, call MD if syncope
every 2 weeks for the occurs. Do not stop drug
first 3 months. suddenly, report signs of
infection.
metoprolol/Lopressor 50mg 2x daily Beta-adrenergic Hypertension Fatigue, dizziness, Take at the same time
blocker depression, shortness everyday, do not stop
of breath, bradycardia, suddenly. Take with food,
diarrhea. Monitor do not crush. Report any
CBC, liver and renal sudden weight gain.
functions. Continue diet and exercise
program.
omeprazole/Prilosec 20mg po daily Proton Pump Inhibitor Gastroesophageal reflux Headache, abdominal Take capsule at least 1 hour
disease pain, diarrhea, nausea before eating. Report any
and vomiting, URTI, changes in urinary
dizziness, rash. elimination. Avoid alcohol.
Monitor CBC and liver
function.
oxybutynin/Ditropan 5mg 2x daily anticholinergic neurogenic bladder anxiety, restlessness, Avoid hazardous activities,
dizziness, seizures, avoid alcohol, wear
palpitations, blurred sunglasses to prevent
vision, dry eyes, photophobia, avoid hot
nausea, vomiting. weather, strenuous exercise.
Monitor urinary status.
simvastatin/Zocor 40mg po hs HMG-CoA reductase Control hyperlipidemia Headache, abdominal Take drug with evening
inhibitor, antilipemic pain. meal to enhance
Monitor LDL total effectiveness. Should be
cholesterol, liver combined with a low fat
function, CK level diet.
novolin 50 units 2x daily antidiabetic/pancreatic control blood sugar/ blurred vision, dry Teach signs of hypo/hyper
hormone diabetes mouth, hypoglycemia, glycemia, recognize
flushing, rash, ketoacidosis symptoms,
urticaria, teach client how to obtain
lipodystrophy. Monitor glucose level. Avoid OTC
blood sugar and products unless directed by
keytones. prescriber.
Hondros College Level 2 Clinical Tool

A general assessment will be done in each area. Generally an interview is collected first then the physical examination is
completed. Star(*) the area of prime importance for a focused assessment r/t client health problems, medical diagnosis or
collaborative problems, nursing needs such as actual nursing diagnoses, risk diagnosis, health promotion or education needs,
and technical skill related needs.

ASSESSMENT DIAGNOSIS AND PLANNING IMPLEMENTATION EVALUATION

Data Interventions Outcome criteria met, not met,
Subjective & Objective findings Nursing Diagnoses (PES) and Teaching & Discharge
Planning need to be reevaluated at the end
Outcomes
of clinical

Client suffered a cerebral vascular Noncompliance related to
accident and as a result has
hemiparesis of her right side. The manifested by speech deficit.
CVA also caused her to have
seizures, altered mood/behavior,
bipolar, dementia, speech
impairments and other
neurologically related deficits. She
is alert and oriented, but when
asked what day it is, she states
“here we go again” and doesn’t
answer the question. Her speech
can be unclear, but she is mostly
understood and able to
communicate her needs. She is
often noncompliant with her diet,
ADL’s and medications. She
expresses herself repetitively and is
anxious at times. She has a stage 4
pressure ulcer near her coccyx and
is not allowed to be in her
wheelchair for more than 2 hours
per day. She often resists going
back to her bed when the 2 hours
are up.
healthcare management as
Client will communicate an
understanding of disease and
treatment every day before
commensing daily activities.
Nurse will : Outcome criteria not met.
Make the client an active partner in
healthcare management. Recognize
that the client has absolute control
over whether he or she follows the
healthcare regimen. Always treat
the client with respect and develop
mutual outcomes for treatment.
Instruct the client about the
purpose, action, side effects, and
administration of medications.
Assess the likelihood of medication-
related problems and non-
compliance with medication
regimen. Provide structured
education tailored to the individual.
Monitor the client’s ability to follow
directions, solve problems and read.
Avoid using threats, pressure and
inappropriate fear arousal to
increase compliance.
Hondros College Level 2 Clinical Tool

ASSESSMENT DIAGNOSIS AND PLANNING IMPLEMENTATION EVALUATION

Data Interventions Outcome criteria met, not met,
Subjective & Objective findings Nursing Diagnoses (PES) and Teaching & Discharge
Planning need to be reevaluated at the end
Outcomes
of clinical

Client seems to enjoy being social Chronic confusion related to Nurse will : Outcome criteria has not been met.
and recognizes other employees of cerebral vascular attack as Gather information about the
the facility. She expresses affection manifested by anxious and client’s pre-dementia cognitive
and emotion. Her family visits repetitive behavior. functioning. Asses the client for
often. It has been noted that she signs of depression. Determine the
doesn’t like the staff to take care of Client will have minimal episodes of client’s normal routines and attempt
her and would prefer to do as much agitation on a daily basis. to maintain them. Begin each
for herself as possible. She is interaction with the client by
unable to walk and has poor muscle identifying yourself and calling the
control on the non-paralyzed side of client by name. Provide scheduled
her body. She is incontinent of activities that are matched to the
bowel and often refuses to be client’s abilities and personality.
changed in the bed, she prefers to Provide periods of rest along with
stand up in the bathroom with the periods of activity. Give one simple
assistance of the bar. She is able to instruction at a time and repeat if
maneuver her body with the necessary. Break down self-care
paralysis by supporting herself on tasks into simple steps. Engage the
one side while standing, and client in communication by
moving her affected arm and leg individualizing the nurse’s
with her mobile arm and leg. She interactions to maximize client
supports her right leg with her left interaction and response. Avoid
leg while in a wheelchair, and she using restraints if possible. If client
covers her right arm with a towel becomes increasingly agitated,
while out with other patients. She assess for pain.
enjoys playing bingo, however is
unable to read the letters and
numbers, when pointed out to her
she quickly forgets which “space” to
mark and needs a reminder.

Implementation: What could be delegated as a RN?