unit v chapter questions
March 7, 2023
midterm report card 2
March 7, 2023
0

clinical package

  • Mobility or Safety
  • Elimination
  • Oxygenation: Gas Exchange
  • Thermoregulation or fluid and electrolytes
  • Inflammation/infection
  • Tissue Integrity
  • Pain

Date:

7/19/2019

Student name:

Clinical Site/Unit:

TCU

Clinical Site Instructor:

Clinical Site Mentor:

George

Overweight/underweight:

Allergies:

No known

Marital Status:

divorce

Religion:

lutheran

Cultural Background:

white

Primary Language:

English

Code status:

1

Diet/Nutrition:

Activity:

Treatments:

IV/Tubes/Ostomies:

Interdisciplinary Cares (OT/PT/RT):

Dressings/Wounds:

(type & location)

Oxygen:

(delivery method & amount)

Dialysis:


Admitting Medical Diagnosis(s):

Multiple sclerosis

Primary (if different than Admitting)

Secondary

(Do not include History Of):

Localize edema

Medication Data Sheet

Scheduled Medications that your patient is currently taking.

Drug Name and Classification

Expected action & indication for use

Side Effects/ Adverse Reactions

Medication/Food Interactions

Nursing Administration Special Instructions & Assessments

Client Education & Evaluation of Medication Effectiveness e.g. Pain Scale

Metoprolol 25mg

MiraLAX

Multi vitamins

Omega 3 fatty acid 1000mg

Aquaphor ointment

Vitamin d 500mg

.

Magnesium 400mg

Bisacodyl suppository 10mg

Camphor menthol lotion

Acetaminophen 650mg

Daily “Brains”, to be completed during clinical day.Begin your day with a plan and change/make notes as needed.You may print and use this template or create your own.

Room #:18

Diet:

Ambulation: wheel chair

IV fluids:

Allergies:

Medications

Treatments

Nursing care/interventions

Vital Signs

0700

Remove hand splint

Check vital signs

Check for constipation

138/70

0800

Calcium

Metoprolol

Multivitamins

Mega 3

Apply oitment

0900

1000

Ensure

1100

1200

Tizzadine 4mg

1300

ASSESSMENT SUMMARY: Complete in narrative form based on the form filled out during clinical day.

Body System

Vital Signs and Pain Level:

138/70 pain level is zero

Sensory:
 
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