Professional Documents
Culture Documents
Date:
Allergies: NKA
Code Status: FULL
Yes ( ) No ( )
Restraints: Yes ( ) No ( )
Pain management:
History of present illness: Loss of protein in Urine, generalized edema, Anasarca, Worsening SoB, patient feeling tired, and
gaining weight rapidly
Medical diagnosis (es): Nephrotic Symdrome
Past Medical/Surgical History: hypothyroidism, proteinuria, hypertension, obstructive sleep apnea, anasarca
within range for his condition. However, he did vomit twice (once at 6:00am and again at 11:00am) today unexpectedly.
Continue to monitor I&O, vitals, and teach patient about diet.
DVT PREVENTION: (YES)
(NO)
(NO)
TEXTBOOK PICTURE
Diagnosis/es definition and pathophysiology:
Nephrotic Syndrome
Generalized edema
Vomiting
Protein urea
Shortness of breath
Disease etiology/cause:
Genetic disorders
Immune disorders
Dehydration
History of cancer
Kidney Biopsy
On following pages
On following pages
Suggested treatments:
Laxis
Low sodium diet
Bed Rest to help form blood clot from kidney biopsy
Suggested nutrition:
MEDICATION LIST
Trade name
Generic
name
Dose
ordered
Route
ordered
Time of
administration
Drug action/indications
Levothyroxi
ne
Synthroid
0.1mg =
1Tab
PO
AC+Brea
kfast
Indications: Thyroid
replacement supplement
Action: Stimulates
metabolism of all body tissues
by acceleration rate of cellular
oxidation
Heparin
heparin
5,000units
= 0.5mL
SubQ
Injectio
n
Q12H
Furosemide
Lasix
80mg =
8mL
IV
Push
BID
Henle
Metoprolol
Metoprol
ol
Tartrate
25mg = 1
Tab
PO
Q12H
Indications: hypertension,
early intervention in acute MI
Action: unknown; a selective
beta blocker that selectively
blocks beta receptors
AmLODIPin
e
Norvasc
5mg =
1Tab
PO
Daily
Trade name
Generic
name
Dose
order
ed
Route
ordere
d
Time
of
admini
stration
Drug action/indications
MethylPREDNISolo
ne
SoluM
EDROL
1Gm
=
8mL
IVPB
Daily
Indications: severe
inflammation or
immunosupression
Action: decreases inflammation
Tylenol
650m
g=
2Tab
s
PO
Q4H
Ondansetron
Zofran
4mg
=
2mL
IV
Push
Q6H
PRN +
Nause
a and
Vomiti
ng
senna
senoko
t
1Tab
PO
BID
0.5mL
IM
Injecti
on
Prior
to
disch
arge
- hypoglycemia, leukopenia
- many OTC and prescription products
contains acetaminophen; beware of this when
calculating total daily dose
- tell parents to consult prescriber before
giving drug to children younger than age 2
- advise parents that drug is only for short
term use
-fatigue, headaches, arrhythmias
-monitor liver function test results. Dont
exceed 8 mg in patients with hepatic
impairment
-instruct patient to immediately report
difficultly breathing after drug administration
-tell patient to report of discomfort around IV
insertion site
-heart palpitations, dizziness, fainting
-avoid long-term use of this medication
-may lead to electrolyte imbalance
-inform patient to store in a cool place
problems,
Action: vaccine against
Streptococcus pneumoniae.
DIAGNOSTIC TESTS
Include all normal and abnormal values that may be significant for the patient. Include Laboratory test, CT scan, MRI,
endoscopies, XRs, intervention radiology procedures, or any other significant test for the patient
Name of the test and date
Chemistry
Potassium
Sodium
Chloride
Calcium
Patient result
Normal value
5.4mEq/L
136mEq/L
105mEq/L
7.5mg/dL
3.6-5.2 mEq/L
134-145mEq/L
96-108mEq/L
8.2-10.4mg/dL
Phosphorus
Cholesterol
Triglycerides
Hematology
WBC count
RBC count
Albumin
Protein
Eosinophil Absolute
5.4mg/dL
592mg/dL
1208mg/dL
2.6-4.5mg/dL
120-199mg/dL
0-150mg/dL
6.96thou/mcL
4.58mill/mcL
0.6gm/dL
4.3gm/dL
0.71 thou/mcL
4-11thou/mcL
3.9-5.9mill/mcL
3.5-5.2gm/dL
6.2-8.1gm/dL
0.110.5thou/mcL
Normal
Normal
Low: parasitic infection, thyroid disfunction, protein urea
Low: glomerulonephritis, nephtotic synrome
High: allergy, drug reaction, parasitic infection
Urinalysis
WBC Urine
RBC Urine
AST
ALT
Sedimentation Rate
Creatinine
BUN
Fine Granula Cast
Hyaline Casts
17/hpf
0-5/hpf
High: infection, tubulointerstitial nephritis
6/hpf
0-4/hpf
High: focal glomerulonephritis, infection,
24IU/L
0-40IU/L
Normal
33IU/L
30-65IU/L
Normal
80mm/hr
0-20mm/hr
High: inflammation
1.52mg/dL
0.7-1.5mg/dL
High: glomerulonephritis, pyelonephritis
47mg/dL
8-23mg/dL
High: impaired kidney function,
2/ipf
?
?: (No normal range found)
renal disease, viral infections
25/ipf
0-4/ipf
High: renal disease, viral infections
ANTICIPATED DISCHARGE PLAN (CHECK APPROPRIATE DESCRIPTIONS)
Destination:
Care level:
______ Home
______ Self
______ Assisted
______ Rehabilitation
______ Family
Needs:
_____ Equipment
_____ teaching
_____ Relocation
How was the concept of restoration to the Image Of God portrayed in the clinical settings? Describe the situation,
9
Discuss the cultural assessment of this patient. Did the patient have special cultural needs? Were there interventions
needed related to these needs?
Patient is a 51-year-old Caucasian male. He is married and lives with his wife. Has two kids, speaks English, and has never
drank or smoked. He is cabinetmaker and enjoys hunting deer and golfing. He is also a Christian and reads his Bible
weekly.
As evidenced by [defined characteristics]: Verbalizing confusion, questioning members of health care team, and expressing anxiety
Relevant data
10
Verbalizing
confusion,
questioning
members of
health care team,
and expressing
anxiety
11
1. Poor-fitting socks,
long robes, or long
pants legs can limit a
persons ambulation
and increase fall risk
2. Patients who are not
familiar with the
placements of furniture
and equipment in their
room are more likely to
experience a fall
3. Older adults with
reduced visual capacity
will benefit from
adequate lighting.
4. Evidence suggests
that people who engage
in regular exercise and
activity will strengthen
muscles, improve
balance, and increase
bone density
12
Relevant data
13
Relevant data
Expressions
of concern
about current
health
condition
1. Provides
baseline for
planning care
and accessing
appropriate
resources.
2. Promotes
awareness and
identification of
feelings so they
can be dealt with.
3. Enhances
commitment to
goal, optimizing
outcomes and
promoting sense
of hope.
4. Specific
assistance to
resolve life
stressors such
as relationship
problems,
substance abuse,
or suicidal
ideation are
important to
advance recovery
process.
ASSESSMENT
0=
Rarel
y
1=
Sometimes
2=
Most of
the time
3=
Consistentl
y
Total
points
0=
Rarel
y
1=
Sometimes
2=
Most of
the time
3=
Consistentl
y
Total
points
NURSING DIAGNOSIS
15
PLANNING
0=
Rarel
y
1=
Sometimes
2=
Most of
the time
3=
Consistentl
y
Total
points
0=
Rarel
y
1=
Sometimes
2=
Most of
the time
3=
Consistentl
y
Total
points
IMPLEMENTATION
16
EVALUATION
0=
Rarel
y
1=
Sometimes
2=
Most of
the time
3=
Consistentl
y
Total
points
COMMENTS:
_________________________________________________________________________________________________________
_
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________
17
Date: _________________________
ANDREWS UNIVERSITY
NURSING STUDENT EVALUATION FOR ROTATION CLINICAL EXPERIENCE
Semester of Experience: _____________________ Date: ____________________________________
Hospital: _______________________ ________ __ Unit: ____________________________________
Student name: -_______________________________________________________________________
Instructions: Please indicate your response by writing YES or NO according to student accomplishment
Christian Services
YES
(1
point)
NO
(0
points)
Not
Total
applicabl points
e
Professional Behavior
1.Arrives on time, appropriately prepared and present throughout clinical
2. Conducts self in confident, dependable, professional manner
3. Follows established standards of care (policies, procedures)
4. Recognizes and responds to ethical issues appropriately
5. Demonstrates personal initiative
6. Attends and contributes positively in clinical experience and conference/s
7. Maintains client confidentiality
8. Maintains personal appearance according to the policies of the School of Nursing and
affiliated agencies
18
RN Signature: _______________________________
Date: __________
19