NURS 313R – Summer 2024

Highlighted indicates important data to collect during your 1-hour prep time. If time remains, start to fill in the extras starting
with additional scheduled medications and course of present hospitalization.

University of Nevada Las Vegas

School of Nursing
NURS 313R - L
Nursing Care of Acutely Ill Populations

CLINICAL WORKSHEET

CLIENT INFORMATION

Client’s Age: 24 Sex: M

Admission date: Admitting doctor: Dr Math Allergies: NDKA

Ht: 5’11 Wt: 73.5 kg Culture/Religion: Catholic Marital Status: Single

Family support: yes or no ETOH use: yes or no Tobacco: yes or no

Other disciplines/consults caring for client (e.g. Physical Therapy, OT, dietitian, Cardiology, etc): Trauma team, surgeon, PT, and wound
team

Vital Signs: T 37.2 HR 91 R 20 BP 140/84 O2 Sat 96% RA Monitors: N/A Code Status: Cat 1

Reason for hospitalization: Leg laceration

Summarize hospital course/events from admission to present:

The patient was admitted to the hospital after calling 911 and being picked up by the EMS and brought to Hospital. The patient had a
recent surgery to repair his tibia after a fall and has been trying to recover since. It was established that the patient contracted sepsis and
has been receiving treatment for the diagnosis. In addition to that, the wound care nurses have been in his room to put on wound vac on his
wound. The patient has expressed how he wants to return home, but there are certain laboratory results that that doctor is waiting on before
the patient is discharged.

Summarize client’s past medical history:

Past Medical History: DM2

History of Present Illness: The patient’s leg gradually became red, swollen, and warm to the touch.

Therapeutic orders for day of care: Non weight bearing L leg; IS 10x while awake; activity as tolerated

Diet: Regular Activity: As tolerated; non weight bearing L leg

IV Type & Site: LFA IV gauge 22 fluids: Saline locked Rate: N/A

Reason for IV: Surgery; medication administration

Other (dressings, etc.) L ankle is wrapped in gauze; Wound vac negative pressure on L ankle; laceration on L hip open to air

Education needs/discharge planning; Include client and family:

The patient and the family need education regarding pain control. The patient states his father would not allow him to take opiates for pain
control as they lead to addiction. However, the patient then complains of severe pain and is anxious that the pain is indicative of possible
leg amputation. Education is needed to reassure the patient that pain is a normal response to the severe injury he had and that there are
ways to wean off of the opiates to prevent dependence. Patient needs to educated wound vac care prior to discharge. Education s/sx of
infection. Patient and family needs education on NON weight bearing status. Patient and family instructions on wound care process.
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LABS AND DIAGNOSTIC TESTS:

Cite references used for labs and tests
LABS (Prep-look for abnormals, note basic chemistry and CBC)
Date: 7/30 Date: 7/31
Normal Rationale for changes in labs and 2 signs and
Lab result: Lab result:
Values symptoms of all abnormal
Baseline Day of care
Na 136~145 139 141
mEq/L
K 3.5~5.1 4.0 3.8
mEq/L
Mg 1.6-2.6 1.96 1.94
mg/dL
Ca 8.4-10.2 9.3 9.4
mg/dL
70-110 117 H 96 The patient was experiencing slightly elevated blood glucose
mg/dL levels due to the stress from the injury. The body is responding to
Glucose the increase in stress from trauma. Some signs and symptoms of
hyperglycemia include dry mucous membranes and increased
thirst (Vallerand & Sanoski, 2023).
BUN 9-26 mg/dL 7 8

Creatinine 0.6-1.5 0.82 0.77

mg/dL
Albumin 3.5-5 G/dL

Protein 6.4-8.3 G/dL

ALP 40-150 U/L

ALT, 0-55 U/L

SGPT
AST, 5-34 U/L
SGOT
WBC 3.4-10.3 12.49 H 8.77 The patient was experiencing slightly elevated WBC count due to
K/mm3 possible infection from exposed tissue. The patient then received
a one-time dose of antibiotics that reduced number of WBC
present in the blood. Signs and symptoms of elevated WBC
include inflammation and fever (Vallerand & Sanoski, 2023).
RBC 3.57-4.97 4.71 4.25
M/mm3
Platelets 130-351 228 225
K/mm3
Hgb 11-14.9 G/dL 13.7 12.3

Hct 32.6-43.4 % 40.0 36.0

PT 9.3~12.4 sec

INR 0.1~1.2

PTT 22~33 sec

CPK 22~198 U/L

CK MB 3~5% or 5-25
IU/L
Troponin 0.03~0.29
ng/ml
Total <200 mg/dL
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cholesterol
Trig <150 mg/dL

HDL >60 mg/dL

LDL <100 mg/dL

Other Significant Labs:

DIAGNOSTIC TESTS & RESULTS:

XR Tibia Fibula L 2VW No acute fractures
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CLINICAL WORKSHEET
CLIENT MEDICATIONS (Prep-record scheduled meds and what you will administer for the shift)

Dose, Reason this Classification/ Side

Medication Nursing Responsibilities/
Route, client is taking Action Effects/Contraindica
Brand/Generic Teaching
Freq. this medication tions
Acetaminophen 650mg For mild pain C: antipyretics and SE: renal failure NR: Assess type of pain,
(Tylenol) PO and fever nonopioid analgesics (high doses), rash location, and intensity prior
Q6H PRN and 30-60 mins after
A: inhibits synthesis C: Hepatic/renal administration
of prostaglandins that disease,
serve as pain and malnutrition T: Inform patients with
fever mediators in the diabetes it may alter blood
CNS glucose monitoring results
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ASSESSMENT DATA
Subjective: Comments/Responses:
HEENT Patient denies experiencing any headaches or having any history of head injuries.

PULMONARY Patient denies experiencing any shortness of breath. The patient denies coughing
and or having any history of pulmonary diseases
CARDIOVASCULAR Patient denies having any chest pain and or swelling. Patient denies having any
history of heart problems.
GI Patient denies having any diet changes. Patient denies experiencing any recent
changes in appetite and or any stomach aches.
GU Patient denies having any trouble using the urinal near his bed. Patient denies
experiencing any pain during urination.
NEURO Patient states that he has neuropathy in both of his lower extremities and that he is
unable to feel sensations.
MUSCULOSKELETAL Patient denies experiencing any weakness in his upper extremities, though he does
have weakness in his left leg.
INTEGUMENT Patient has a wound on his left leg due to surgery of a broken bone as well as
infection.
PAIN (use symptom Patient denies experiencing any pain.
analysis: PQRST)

PHYSICAL EXAMINATION
Objective:
GENERAL SURVEY: 24-year-old male laying down on his phone, appears well-nourished, clean and stated age. He is anxious and
cooperative with clear speech. Vital signs are T 37.2 HR 91 R 18 BP 140/84 O2 Sat 96% RA

HEENT: Eyes are clear, moist and free of discharge. Crude hearing and vision intact. Missing R ear. Teeth are intact and appropriate
for age. Oral mucosa is moist, pink and intact. Ability to swallow intact. Absent hoarseness. Normocephalic. No bleeding, pain,
deformity, redness, swelling, drainage or foreign body present.

PULMONARY: Breath sounds are clear and equal in all lung fields. Respirations are spontaneous, unlabored and chest excursion is
symmetrical. Anatomic airway present. No cough or pain with inspiration. No retractions, nasal flaring, subcutaneous emphysema,
stridor or wheezes. Patient does not complain of shortness of breath or difficulty breathing. Absent artificial airway.

CARDIOVASCULAR: S1 S2 noted x5 precordial sites with regular rhythm and HR 91 bpm. No murmur or rub. Chest pain noted. No
presence of pacemaker, internal defibrillator or telemetry box. Cap refill within 2 seconds in upper and lower extremities bilat. Radial
+2 bilat and pedal pulse 2+ bilat. No edema noted in upper or lower extremities noted.

GI: Abdomen was round and soft, no distention noted. Abdomen is symmetrical and umbilicus is midline. No tenderness upon
palpation. Bowel sounds are normoactive x4. Color is consistent with ethnic background. No palpable masses noted. No rectal
bleeding noted. No presence of nausea, vomiting, or diarrhea. Last BM was 3 days ago upon admittance.

GU: Patient is continent, uses urinal with minimal assist. Urine output 1000mL with yellow color urine. No odor or sediment noted.
Genitalia intact without discharge. No bladder distention. No hemo or peritoneal dialysis.

NEURO: A&O x4. PERRLA 3mm conjunctivae clear, sclera white. Speech is appropriate for situation. General movements are
coordinated bilat. Light sensations are present in upper and lower extremities. No mental status changes noted. No presence of facial
droop, slurred speech, unilateral weakness or numbness noted.

MUSCULOSKELETAL: Gait is unsteady. Requires minimal assistance getting up from bed. No weakness, deformities or lesions in
upper and lower extremities noted. Swelling noted in L leg, non-pitting. Limited movement in L leg. Some resistance against gravity
for L ankle. 5/5 full AROM in cervical spine, shoulder, arms, wrists, R leg, and R ankle.
SKIN/MUCOUS MEMBRANES: Skin laceration on L ankle with exposed tendons, flexors and tissue. Wrapped in gauze with
existing, clean, dry and intact dressing. Abrasion on L hip open to air. Color consistent with ethnic background. Mucous membranes
are moist and without drainage. Peripheral IV LFA 18G with clean, dry and intact dressing. IVs are saline locked. Wound vac
drainage 100mL
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PSYCHO-SOCIAL: Insured under NV Medicaid. States he smokes vape and smokes marijuana occasionally. States he drinks alcohol
occasionally. States he has a long term girlfriend for 3 years.
EDUCATION: What did you teach this client & family and how did they respond?
The patient was very anxious about sudden onset of dizziness after we gave him IV pain medication. He said he got scared because he
got dizzy and asked if it was normal. I told him that getting up fast from a lying position can cause dizziness and that he was possibly
due to the medication. I asked him if he still felt dizzy and he said no. I told him that it’s okay to be scared being in a hospital and that
he can ask us anytime he feels anxious. He responded with “thank you for everything.”

Choose a priority nursing diagnosis based on chart review during the prep day and generate a Nursing Care Plan for this nursing diagnosis.
(Please cite source for nursing interventions)

Nursing Care Plan

Clinical Week: 11 Date: 7/31/24
Q
Interventions S
Assessment Nursing Goal E
N
Evaluation
(Focused) Diagnosis Outcome Date/ Time
Monitoring
 Requires Initial Ng Dx: Initial Goal Monitor vital signs such as HR, BP, RR for signs of an P The patient met
assistance Anxiety R/T anxiety attack. goal as his anxiety
standing unfamiliar By end of decreased as
Independent Actions
 Concerne situation AEB shift the indicated by the
Provide emotional support by encouraging them to
d and uncontrolled patient’s express their feelings and concerns.
S patient after anti-
anxious of pain and anxiety level anxiety medication
wound expressed will decrease was administered
healing distress and to a 4/10 as Dependent Actions and a discussion of
 Pain 9/10 nervousness evidence by Administer pain medication as prescribed. P his fears and
 Swelling patient self- concerns.
L leg reporting. Health Teachings
 Skin Teach the patient of breathing exercises to
laceration encourage anxiety management.
on L ankle E
with Discharge Planning
exposed Discuss options of counseling psychological support
tendons, after discharge. S
flexors
and tissue
 Urine
output Revised Ng Revised Goal Monitoring
1000mL Dx: P
Independent Actions

Dependent Actions
P
Health Teachings
.
P
Discharge Planning

S
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QSEN Competencies (Pre-Licensure KSA) *Match the appropriate QSEN competency to each of your
interventions above. You may find more than one applies. It is not necessary to use each competency.

* P = Patient Centered Care * E = Evidence –based Practice (EBP)

* S = Safety * I = Informatics
* T = Team Work and Collaboration * Q = Quality Improvement

Why is this a priority nursing diagnosis for this patient?

The patient’s laceration is a very big, important factor in terms of nursing care. It is susceptible to infection and
causing a lot of pain. However, after meeting the patient, it is clear that he is exhibiting issues coping with the pain
and the possibility of amputation. The patient kept asking if what he was feeling was okay and “normal.” He
expressed that he did not want to take opiates for pain control but he was in a lot of pain and decided to manage it
with the medications after all. It took a long conversation of his expression of concerns to finally reassure him of
his situation. I changed the priority nursing diagnosis to Anxiety because his concerns were becoming a hindrance
in his healing process.

SBAR SHIFT →SHIFT REPORT

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This form is to assist in performing complete, precise patient hand off from shift to shift.
Situation

S Room: 403-1 Age: 24 Sex: M

Level of Care: Physiological needs
Physician: Ricalde
Admitted from: HOME (home, nursing home, assisted living, etc.)
Background
Admission Diagnosis: Ankle laceration
B Date of Surgery (if applicable): 7/30
Pertinent past medical history: DM2
(hypertension, CHF, etc.)
Assessment
Code Status: Cat 1 (advance directives, DNR, POA for health care)
Abnormal V.S. BP 140/84
IV site – lock/fluids/site/drips/when to change IV site: LFA 18G saline locked

A Procedures done in the last 24 hours (include any known results): debridement surgery
Abnormal Assessments: Requires assistance standing; Concerned and anxious of wound healing; Pain
9/10; Swelling L leg; Skin laceration on L ankle with exposed tendons, flexors and tissue; Urine output
1000mL
Current pain score: 7/10 What has been done to manage this plan:
IV Dilaudid Q3H last dose took at 10:20, PO Oxycodone Q4H last dose took at 9:30
Safety needs/fall risk /skin risk, etc.: Safety needs, skin risk, fall risk
Recommendation
Needed changes in the plan of care? (diet, activity, medication, consult):

R
Non weight bearing on left leg
What are you concerned about? His anxiety levels
Discharge Planning: Wound vac care and home nurse
Pending labs/x-rays, etc: N/A
Call out to Dr. Ricalde about anti-anxiety medication to ease his concerns
What the next shift needs to be aware of: He wasn’t taking his pain medication because
of his dad; I expressed to him that his dad does not need to know what he is taking and it is
confidential. He has expressed anxiety and concerns about his healing.
1/2009 sg #NUR182 *Document any change in condition and physician notification on patient MR

References
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APA format