Describe Clinical Assessment: Clinical Care Pocket

INSTRACTIONS:
This is what happened in my clinical day. I was assign a patient, she is 79 years old female Caucasian and she was admitted to hospital with Acute Kidney Injury and lung cancer stage 4. Patient medical history: lobectomy for lung cancer with chemotherapy, cardiac surgery, both knee replacement, and gallblader removal. When I did my assessment to the patient, I found wheezing in the right upper lobe and she has edema plus 2 in her lower extremities. Her vital signs BP 159/79; pulse rate 109. ECG result she has an Arterial fibrillation. I think question 1 I need to be TRENDED are pulse rate 109 (tachycardia); BUN from 83 for admitted value to 64 current value; the creatinine is elevated also. RBC, Hemoglobin, and Hematocrit also elevated. Question 2, yes, my first nursing priority was Acute Kidney Injury then, I will have modified to Lung cancer stage 4 and state the reason, I think because the patient is experiencing tachycardia, it might cause cardiac arrest if it is untreated. Question 3, doctors prescribe new order of Cardizem medication is a calcium channel blocker. It works by relaxing the muscles of your heart and blood vessels. Cardizem is used to treat hypertension (high blood pressure). Question 4, My discharge teaching is if you have sudden chest pain or trouble breathing call 911; eat food low in sodium (salt), potassium, phosphorus and protein; drink certain amount of liquids as the provider recommend. Question 5, to Question 10 you know what to do, just answer the essay question and strictly follow the rubric every question. This is 10 paragraphs overall; each question is one paragraph. Put number each paragraph and don't copy the question each paragraph to answer the question. Put more words for those higher points.
RUBRIC Points Possible Points Achieved
PATIENT PREPARATION
1. Trending of relevant clinical assessment data 8
2. Modification of plan of care 4
3. Physician Orders 3
EDUCATION
4. Educational/discharge priorities 7
CARING/PSYCHOSOCIAL
5. Engagement 2
6. Cultural/Spiritual 2
7. Developmental level 2
8. Safety 3
9. ANA evaluation 2
LABS
10. Analysis of labs 5
QUESTIONS:
1. What clinical assessment data did you just collect that is RELEVANT today that needs to be TRENDED because it is clinically significant to detect a change in status? (state specific VS, lab values, and assessment data you collected and WHY relevant/ important)
2. Does your nursing priority or plan of care need to be modified in any way after assessing your patient?
3. After reviewing the primary physician's note for today, what is the RATIONALE for any new orders or changes made today? If there are no new orders, what physician orders might you anticipate for the day?
Education:
4. What educational and discharge priorities have you identified and how will you address them this shift? Explain what teaching you provided and evaluate your patient's understanding of the teaching you provided.
5. What can you do to engage yourself with this patient's experience, and show that they matter to you as a person?
6. Examine and discuss cultural/spiritual preferences and considerations for you patient.
7. Determine your patient's developmental level and is this appropriate for this stage of life? What considerations must you take in order to properly provide care and education to a patient at this developmental level?
8. Describe safety issues you identified when caring for your patient. How did you provide a safe environment for your patient?
9. Evaluate how you incorporated your ANA standard into your patient care.
10. Analyze abnormal and pertinent lab values and relate to your patient's condition/illness.
LAB TEST NORMAL TANGE ADMIT VALUES CURRENT VALUES
RBC 4.7-6.1 3.79 3.49
Hgb Female 12-16 % 11.5 10.7
Hct Female 36-48 % 34.9 33.1
K 3.5-5.2 5.8 5.9
BUN 7-18 83 64
Cr 0.6-1.3 3.5 2.4