PRACTICE CLINICAL WORKSHEET ~1~
The University of the West Indies
The UWI School of Nursing, Mona
PRACTICE CLINICAL WORKSHEET
STUDENTS’ NAMES: Sobremessanna Smith, Dinelle Watson, Shanneika Smith DUE DATE: October 31,
2019__________________________
STUDENTS’ IDS: 620079558, 620096175, 620102708
Client Initials: T.D.W. Age: 47 years old Sex: M Weight: 170 lb Height: 6”/182.8 cm
Marital status: Married Occupation: Accountant Social History:
Accountant. Employed fulltime. Lives in
house with water closet toilet, electricity
and garbage disposal by truck. Is married
and has a seven-year-old son.
Medical History: Hypertension-Diagnosed 1 year ago Surgical history: None
Current Medication: Nifedipine 10 mg PO BD
Panadiene 500 mg PO BD
Family History: Mother – Hypertension
Father-Diabetes
Allergies: Penicillin
Chief Complaint: Abdominal pain and constipation since 2/7 ago. Vomiting since 1/7 ago.
Vital Signs: Pulse: 103 bpm Current medical diagnosis: Appendicitis, Day 1 Post Appendectomy
Respiration: 26 bpm
Temperature: 100-degree Fahrenheit
Blood Pressure: 140/92 mmHg
Adopted with permission from Excelsior Community College School of Nursing, 2008, 2014
PRACTICE CLINICAL WORKSHEET ~2~
Review of Systems: Skin, Hair and Nails: Complain of dark rash on upper back since 3/52 ago; HEENT: No complaints, wears
glasses, last eye exam 2 years ago; Neck: No complaints; Respiratory: SOB since pain started; Cardiovascular (CVS): No complaints;
GI: “I eat like an ox” but “very slim since youth”, Abdominal pain since 2/7 worsened today -8/10, constipated since 2/7, vomiting
since 1/7 ago; Genitals: no history of STI’s, no complaints; Urinary: no pain or burning when urinating, urinates approx.. 3 times
daily; Musculoskeletal: complains of pain in right ankle since 5/7 after twisting same; Neurological: No complaints
Adopted with permission from Excelsior Community College School of Nursing, 2008, 2014
PRACTICE CLINICAL WORKSHEET ~3~
The University of the West Indies
The UWI School of Nursing, Mona
PRACTICE CLINICAL WORKSHEET
STUDENTS’ NAMES Sobremessanna Smith, Dinelle Watson, Shanneika Smith DUE DATE ___October 31,
2019_______________________
STUDENTS’ IDS 620079558, 620096175, 620102708
MEDICATION DOSAGE/ ACTION/ ROUTE CLASSIFICATION NURSING
NAME FREQUENCY RATIONALE FOR CONSIDERATIONS
(TRADE/GENERIC) ORDERED ADMINISTERING
Pethidine 75mg Q6 hrs Rationale: The IM injection Opioid agonist Assess cognitive,
(Meperidine) 3/7 days patient is receiving analgesic. behavioral, functional
this medication for deficits of pt.
the relief of pain.
Monitor cognitive,
Action: Binds to behavioral, functional
opioid receptors status of pt.
within CNS
(Saunders, 2016, p. Monitor urine pH
764). (alterations of urine pH
toward the alkaline
condition may lead to
accumulation of the
drug with possible
increase in side effects)
(Saunders, 2016,
p.764).
Adopted with permission from Excelsior Community College School of Nursing, 2008, 2014
PRACTICE CLINICAL WORKSHEET ~4~
The University of the West Indies
The UWI School of Nursing, Mona
PRACTICE CLINICAL WORKSHEET
STUDENTS’ NAMES Sobremessanna Smith, Dinelle Watson,Shanneika Smith DUE DATE October 31,
2019_______________________
STUDENTS’ IDS 620079558, 620096175, 620102708
MEDICATION DOSAGE/ ACTION/ ROUTE CLASSIFICATION NURSING
NAME FREQUENCY RATIONALE FOR CONSIDERATIONS
(TRADE/GENERIC) ORDERED ADMINISTERING
Gravol 50 ml Q6 hrs Rationale: The IM injection Anticholinergic Obtain baseline B/P,
(Dimenhydrinate) 3/7 days patient is receiving Antihistamine pulse rate.
this medication to
prevent and treat Assess for dehydration
vomiting. if excessive vomiting
has occurred (poor skin
Action: Competes turgor, dry mucous
with histamine for membranes,
receptor sites on longitudinal furrows in
effector cells of GI tongue)
tract, blood
vessels, and Assess hydration status
respiratory tract. (Saunders, 2016, p.
Depressant action 373).
on labyrinthine
function.
Diminishes
vestibular
stimulation
Adopted with permission from Excelsior Community College School of Nursing, 2008, 2014
PRACTICE CLINICAL WORKSHEET ~5~
(Saunders, 2016,
p.372).
The University of the West Indies
The UWI School of Nursing, Mona
PRACTICE CLINICAL WORKSHEET
STUDENTS’ NAMES Sobremessanna Smith, Dinelle Watson, Shanneika Smith DUE DATE October 31, 2019
STUDENTS’ IDS 620079558, 620096175, 620102708
NURSES PROGRESS NOTES
S
Patient complained of pain in the abdomen rated 7/10 on a pain scale and verbalized that he did not know how to care for his
wound on discharge.
Middle aged male awake, alert and oriented to person, place and time.
Facial grimacing noted. Mucous membranes pale and moist. Lying in semi-Fowler’s position. NGT in left nostril on free drainage
draining 50 ml of bile stained fluid. NPO status being maintained. IV line in dorsum of right hand with 500ml D5W in progress
at drip rate of 14 drops/min. CVS: no heaves seen. S1 and S2 sounds heard. No abnormal heart sounds heard. RESPIRATORY:
Chest expansion equal bilaterally. Rhythm regular. No adventitious sounds on auscultation. ABDOMEN: slightly distended.
Dressing to midline incision soiled same marked, dated and timed in Recovery Room. No further oozing observed. Hypoactive
bowel sounds heard in upper quadrants and left lower quadrant. Skin around dressing cool to touch. Urinary catheter insitu
with 300 ml of amber coloured urine in urine collection bag. No edema seen in lower extremities. V/S T 97.50 F, P 105 bpm, R
24 bpm, BP 140/90mmHg, Hemoglobin 7 mg/dL
Adopted with permission from Excelsior Community College School of Nursing, 2008, 2014
PRACTICE CLINICAL WORKSHEET ~6~
Acute pain related to surgical incision evidence by grimacing, P 105 bpm, R 24 bpm, patient verbalizing feeling pain on a scale of
7/10
Deficient knowledge related to limited information on wound care evidence by patient verbalizing not knowing how to care for
his wound on discharge.
Risk for infection evidence by IV line in dorsum of right hand, urinary catheter insitu, surgical wound
Diagnosis Interventions
Acute Pain Administer 75 mg of pethidine by IM every 6 hours
for
3 days
Administer patient’s vital signs (pulse rate,
respiratory
rate, blood pressure) before meal each day.
Deficient Knowledge Teach patient once per day how to perform proper
wound care until date of discharge
Educate the patient’s family on how to attend to the
wound on date of discharge
Risk for infection Perform and teach asepsis for dressing changes,
wound care, peripheral IV and catheter care while
administering patient’s bath
Teach the patient after toileting and before eating a
meal how to wash hands properly
Diagnosis Guideline Recommendations
Acute Pain Assessment and Management of pain Collaborate with the person to identify their goals
for pain management and suitable strategies to
ensure a comprehensive approach to the plan
of care (Recommendation 2.1)
Teach the person, their family and caregivers about
Adopted with permission from Excelsior Community College School of Nursing, 2008, 2014
PRACTICE CLINICAL WORKSHEET ~7~
the pain management strategies in their plan of
care
and address known concerns and misbeliefs
(Recommendation 3.3)
Deficient knowledge Facilitating Client Centered Learning Assess the learning needs of the client.
(Recommmendation Ia)
Use plain language, pictures and illustrations
to promote health literacy.
(Recommmendation Ia)
Risk for infection Care and Maintenance to Reduce Vascular Nurses will consider the following factors
when
Access Complications performing catheter site care IV using aseptic
technique: Catheter material (composition);
Antiseptic solution; and Client’s tolerance
(skin integrity, allergies, pain, sensitivity
and skin reaction) (Recommendation 3.0)
Nurses will prevent the spread of infection by
. following routine practices and using
additional
Precautions. (Recommendation 2.0)
Adopted with permission from Excelsior Community College School of Nursing, 2008, 2014
PRACTICE CLINICAL WORKSHEET ~8~
The University of the West Indies
The UWI School of Nursing, Mona
PRACTICE CLINICAL WORKSHEET
STUDENT’S NAME Shanneika Smith DUE DATE October 31,2019
STUDENT’S ID 620102708
Diagnosis #3 Need Identification: Safety and Security NANDA Domain: 11 Class 1
Assessment Data Nursing Diagnosis Definition, Justification Patient’s Possible diagnosis
Subjective/Objective characteristics Outcome
Subjective Risk for infection Risk Infection is the Tommy Doe Wright Achieve timely Possible disturb
N/A evidenced by Susceptible to is at risk for wound healing body image
invasive procedures invasion and infection because he free of signs of
Objective secondary to multiplication of underwent an infection /
Urinary catheter, Urinary catheter, pathogenic intrusive procedure. inflammation
nasogastric tube, IV nasogastric tube, organisms, which According to purulent drainage ,
lines may compromise ”NANDA ”, 2018- erythema and
IV lines
health.(“ NANDA”, 2022 skin integrity fever.
2018-2020) is a risk factor for
Characteristics the risk of infection. Attain normal
Alteration in Urinary Catheter range vital signs
peristalsis care if not done Blood Pressure
correctly, increase 120/80 mmhg,
Adopted with permission from Excelsior Community College School of Nursing, 2008, 2014
PRACTICE CLINICAL WORKSHEET ~9~
Alteration in skin the transfer of pulse rate 60-100
integrity microorganisms. beats per minute,
Inadequate The nasogastric tube Respiratory rate
vaccination may be misplaced in 12-20 breaths per
Insufficient the windpipe and minute and
knowledge to avoid caused substances to Temperature 36.1-
exposure to pass through. 37.2 degree Celsius
pathogens
Malnutrition
Obesity
Smoking
Stasis of body fluid
What data would be required to make the possible diagnosis an actual diagnosis?
Adopted with permission from Excelsior Community College School of Nursing, 2008, 2014
PRACTICE CLINICAL WORKSHEET ~ 10
~
The University of the West Indies
The UWI School of Nursing, Mona
PRACTICE CLINICAL WORKSHEET
STUDENT’S NAME ___________________________________________________________ DUE DATE __________________________
STUDENT’S ID
Diagnosis #2 Need Identification: NANDA Domain:
Assessment Data Nursing Diagnosis Definition, Justification Patient’s Outcome Possible diagnosis
Subjective/Objective characteristics
What data would be required to make the possible diagnosis an actual diagnosis?
Adopted with permission from Excelsior Community College School of Nursing, 2008, 2014
