family nursing

CLINICAL WORKSHEET

This activity creates an opportunity for you to prepare for a virtual clinical experience. This activity provides you with the opportunity to manage patient care, prioritize interventions, and identify aspects of care that could be delegated.

Table of Contents

STUDENT LEARNING OUTCOMES

At the end of this activity, student will be able to:

1. Describe pathological events associated with the patient’s disease process or condition.

2. Create a plan of care that is prioritized and is based on the patient’s care needs.

3. Identifies path to healing or health and path to death or injury.

4. Describes aspects of care that can be delegated and appropriate personnel to complete delegated tasks.

ASSIGNMENT

1. Log into thePoint and launch the assigned vSim, following all instructions posted on your learning management system (LMS).

2. Review the information contained in the patient information.

3. Review the smart sense links associated with the Nursing Care, Diagnostics, and Pharmacology, found in the suggested reading area.

4. Complete all areas of the attached clinical worksheet.

5. Submit the completed worksheet.

Date: 11/3/2020 Student Name: Assigned vSim: Jackson Weber

Initials: Jackson Weber

Age: 5 M/F: Male

Code Status: Full

Diagnosis: Clonic-Tonic

Length of Stay: TBD

Allergies: NKA

HCP: YES

Consults: Neurologist

Isolation: NO

Fall Risk: Yes

Transfer: No

IV Type: Peripheral

Location: L. AC

Fluid/Rate: D5 NS+20 mEq KCI/L at 56 ml/hr

Critical Labs: N/A

Other Services: Social Worker

Consults Needed:

-Social Worker

-Neurologist

Describe your patient’s reason for admission: Jackson Weber is a 5-year-old Caucasian male. The patient was diagnosed with clonic-Tonic seizures 2 years ago. Upon his diagnosis, Jackson’s neurologist started him on oral phenobarbital. Patient has not been following up with appointment or seen a neurologist in the past 15 months due to his mom’s schedule, and she is a single parent. He has been doing well until last night when he was brought in due to an active seizure.

Health History/Co-morbidities: Jackson has not seen his neurologist for the past 15 months due to his mother’s work schedule.

What are your desirable outcomes?

1. Patient will modify environment as indicated to enhance safety.

2. Patient will maintain treatment regimen to control seizure activity.

3. Patient will recognize the need for assistance to prevent accidents or injuries.

What needs to happen for this patient to safely Discharge (health wise and educational):

4. To monitor for recurrent seizures and seizure activity

5. Monitor oxygen saturations

6. Education to parent

7. Administering ordered medications

Clinical Worksheet

Concerns-What are your priority concerns for this patient for ? (Signs & Symptoms) (What information is relevant/irrelevant) List your most immediate concern first.

What Assessments did you focus on for this patient? What findings (Cues) did you assess that support your concerns? Is there anything else that you would need to assess that would support your above concerns?

(How will I identify the above signs & symptoms? They need to be related to the above concerns.)

Management of Care: What are your top 3 nursing cares/interventions that need to be done for this Patient Today?

1. All toys and other hazards should be moved out of the way to keep Jackson safe – rolling Jackson to his side will help him breathe better and keep him from Choking – someone shouldStay with Jackson until he fully wakes up after the seizure