Patient history: The patient has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity / hemiplegia of left side of the body . A

Patient history: The patient has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity / hemiplegia of left side of the body .

Admission diagnosis: altered mental status.

Discharge diagnosis summary: AMS / possible acute toxic encephalopathy, and SIRs.

Ola was 40yrs he presented to the hospital with Altered mental status, he was lethargic and not following commands in hospital. She was admitted for AMS (altered mental status) .he was Keppra loaded as she appeared post-ictal . placed on seizure precaution with neuro checks overnight in the ICU and he improved and was transferred to floor. His mentation continued clear. Blood cultured drawn 12-22 returned positive for staph epidermidis times 2 -> most likely contaminant. He did meet SIRS( Systemic Inflammatory Response Syndrome) criteria with CBC < 4 and heart rate > 90, although upon review of his medical record his leukocytosis is chronic. he was given dose of vancomycin and BCx redrawn with NGTD -> ID evaluated patient and antibiotic were deescalated . TSH elevated normal T4.

Date: ________ Student Name: ____________________________ Clinical Site/Unit: ___________________________

Clinical Site Instructor:__ ____________________________Previous Shift Report: ____________________________

Client Initials: _______ Client age: _______ Gender: _____________ Height: __________ Weight: ______________

Allergies: ______vicodin __________________________ Code Status: _________________ Transfer Status: ______________

Marital Status: _____________ Religion: _________________ Occupation: ___________________________________

Cultural Background: ____________________________ Primary Language: _______________________________

Diet/Nutrition: ____________________________ Activity: _______________________________ Fall Risk: Yes / No

Use of (type/amount/frequency): Alcohol: _____________ Tobacco (pack years): ______________________________

Medical Diagnosis(s):

Admitting Diagnoses to Acute Care Facility

1._____altered mental status _______________________________ 2.______________________________________

Primary Diagnoses for Admission to TCU/LTC

1._____acute toxin encephalopathy ________________________________ 2.____ Systemic Inflammatory Response Syndrome_________________________________

3._____sepsis ______________________________4.______stap.epidermis _______________________________

Secondary Diagnoses

1.____chronic pain __________________________________ 2._______ _____________________________

3.________traumatic brain injury _______________________________ 4._confusion__________________________________

Surgical History 1.______________________________________ 2.___________________________________

3._______________________________________ 4.___________________________________

Treatments: _______________________________ IV/Tubes/Ostomies: ______________________________________

Dressings/Wounds: (type & location) ___________________________________________________________________

Oxygen: (delivery method & amount) _______________________________ Dialysis: ___________________________

Recent LAB Results:

Why is this lab significant for this client’s condition? If the lab result was abnormal, include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column.

Date Test Normal Value Client Value Significance

Wbc 4-10 4.1 ________________________________________________________________________________________________________________________________RBC 3.80 -5.40 4.95 ____________________________________________________________hematocrict 35.0- 47.0 37.5

Mcv 80-100 76

______________________________________________________

MCH 2 7-34 - 22

___________________________________________________________________________________________________

PLT

___________________________________________238________________________________________________________

Recent Diagnostic tests: (list X-rays, CT scans, MRIs, ECGs, Ultrasounds, Cardiac Catheterizations, etc.)

List the test, the test result, and include an explanation of the significance of the results in relation to the medical treatment, other diagnostics, and nursing considerations/interventions for your client. ____________________________________________________________________________________________________________________

PATHOPHYSIOLOGY:

For the primary admitting diagnosis to the acute care facility and primary diagnosis for the TCU/LTC, provide a 3-5 sentence explanation of the pathophysiology of the problem. Then complete an ATI template for the above four diagnoses (4 total). Use the “Active Learning Template: Systems Disorder” template from ATI Active Learning templates. Complete, print, and attached to paperwork

PATHOPHYSIOLOGY CONTINUED:

For the top two secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization.

If your client is post-surgical, what problems or complications could possibly occur? What nursing assessments would you need to include in your post-operative or post-procedure monitoring

PATHOPHYSIOLOGY CONTINUED:

4 secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization.

Medication Data Sheet

List all scheduled medications for your shift

NURSING PROCESS

Write 2 complete Nursing Diagnoses based on your client problems you noted on your assessment for this day.

Nursing Diagnosis #1:

___________________________________________________________________________________________________

Client Goal: ________________________________________________________________________________________

List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.

1. _______________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

2: _________________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

Nursing Diagnosis #2:

__________________________________________________________________________________________________

Client Goal: ________________________________________________________________________________________

List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.

1. ______________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

2. ________________________________________________________________________________________________

Rationale: ________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

Post-Clinical Education:

Provide the group with education on a topic you learned about preparing for your client/clinical packet. For example a medical diagnosis, intervention, medication, lab value, treatment method, etc. Use this space to write your speaking notes and reference(s).

Ola was 40yrs he presented to the hospital with Altered mental status , he was lethargic and not following commands in hospital. She was admitted for AMS ( altered mental status) .he was Keppra loaded as she appeared post-ictal . placed on seizure precaution with neuro checks overnight in the icu and he improved and was transferred to floor. His mentation continued clear. Blood cultured drawn 12-22 returned positive for staph epidermidis times 2 -> most likely contaminant. He did meet SIRS criteria with CBC < 4 and heart rate > 90 , although upon review of his medical record his leukocytosis is chronic . he was given dose of vancomycin and BCx redrawn with NGTD -> ID evaluated patient and antibiotic were deescalated . TSH elevated normal T4.

The pt has history of traumatic brain injury secondary to motor vechicle accident and with cognitive and physical deficits spasticity / hemiplegia of left side of the body