Professional Documents
Culture Documents
BRING TO CLINICAL,
Student Name: Brian Sandman Clinical Date: 2/28/17
Citation:
Johns Hopkins Arthritis Center. (n.d.). Retrieved February 22, 2017, from
https://www.hopkinsarthritis.org/
Hinkle, J. L., Brunner, L. S., Cheever, K. H., & Suddarth, D. S. (2014). Brunner & Suddarth's textbook of
medical-surgical nursing. Philadelphia: Lippincott Williams & Wilkins.
Glucose 70-110 2/20/17 163 Uncontrolled type 2 Can cause high urinary output.
diabetes Protein in the urine.
Body begins to metabolize itself if
Glucose cannot enter the cells for
food
Hemoglobin A1C N/A Oddly no A1C was done in the past
Year and a half in EPIC
Cholesterol N/A
Pre-albumin N/a
ABG: N/a
pH
CO2
HCO3
Other important labs Blood 2/27/17 + Strep infection Can lower immune response
significant for this patient: culture strepto At risk for nosocomial infection
cocci
Allergies:
Allergies: Aspirin Type of Reaction: Rash
Medications:
Medication Dose/Route/ Why this Major Side Nursing
generic and Frequency patient is Effects Implications &
trade names **Pediatric receiving this Special
calculations medication Precautions
Safe?
Tylenol 650 mg P.O. Fever reducer Liver toxicity Do not exceed 4
acetaminophen g a day
Ordered Treatment(s):
Dressing changes (wounds) YES NO NA
yes
Ice X
Foley X
NG x
Ted hose x
SCDs X
Intake/Output X
O2 therapy NC 3L
Diet/Fluids:
Diet Order: Diabetic Restrictions: N/A Precautions: N/A Gag Reflex Intact: yes
Dentures YES NO
Nausea YES NO
Vomiting YES NO
Intravenous Therapy:
IV Fluid Type: 5% dextrose
IV rate: 144 ml/hr
Constipation YES NO
Diarrhea YES NO
Flatus YES NO
Incontinence-bowel YES NO
Burning YES NO
Incontinence-urinary YES NO
Activity:
Type of activity ordered: Ability to walk (gait): PT came Morse Falls scale score:
2x today to walk with her down 50
What kind of bath will you the hall
plan to do: CNA did a bed
Oral care, how often: Bed bath
bath
via CNA
Nausea YES NO
Vomiting YES NO Description:
NG tube YES NO Describe drainage:
Religious preference:
N/A
Occupation: Retired
Pain
Pain Score ____6_________ out of 10 (10 being severe pain, 1 minimal pain)
Characteristics Dull ache
Onset Post Surgery
Location R hip
Relief Rest
Associated
symptoms n/a
*****Complete this table for pediatric patients only
**Developmental Milestones