Name
Date: 20/7 Student Name: Lee Arthur Clinical Site Instructor: S. Owen
Previous Shift Report: Pt is alert and oriented but still confused
Client age: 86 Gender: F Height: 5’2” Weight: 111lbs BMI: 20.49
Baseline vitals: BP 132/76 Pulse 98 Resp. 18 Temp.98.1 F Pain Score 4/10 Transfer Status: Assist of 1
Allergies: Sulfamethoxazole, Advil, Aspirin, Latex Code Status: DNR/DNI Occupation: Homemaker
Religion: Lutheran Pastoral Care: N/A
Marital Status: Married Cultural Background: U.S Primary Language: English
Diet/Nutrition: No MSG Activity: Not specified Fall Risk: Yes
Use of (type/amount/frequency): Alcohol: None Tobacco (pack years): past use over 50 years ago 1 pack/yr
Treatments: Creams (lotions), INR IV/Tubes/Ostomies: N/A
Interdisciplinary Cares (OT/PT/RT): PT/OT post op
Dressings/Wounds: (type & location) : N/A
Oxygen: (delivery method & amount) nasal cannula 1 L/min Dialysis: N/A
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. Make sure these are on your Systems
Disorder Remediation Template. (Should be in the appropriate location)
Date Test Normal Value Client Value Significance
4/1 INR 0.9-1.1 2.34 High # indicates thinning of blood which takes longer to
clot and pt is at risk for bleeding.
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. Make sure these are on your Systems Disorder
Remediation Template. (Should be in the appropriate location)
Xray of chest 4/7/16 new central congestion and small left effusion with left lower lobe consolidation related to poss. Pneumonia
Xray of the left hip 43/16 internal fixation left femoral neck fracture with bolt and short intramedullary rod. Main fracture
components are in anatomic alignment.
1
, Name
Date: 20/7 Client Initials: ES Student Name: Lee Arthur
Clinical Site/Unit: TCU
ASSESSMENT SUMMARY: To be completed during the clinical day.
Date: 4/11/16 Client Initials: ES Student Name: Lee Arthur Clinical
Site/Unit: TCU
ASSESSMENT SUMMARY: To be completed during the clinical day. NEW ASSESSMENT
Body System Subjective data-Health History Objective data- (head to toe) Assessment findings
2
Date: 20/7 Student Name: Lee Arthur Clinical Site Instructor: S. Owen
Previous Shift Report: Pt is alert and oriented but still confused
Client age: 86 Gender: F Height: 5’2” Weight: 111lbs BMI: 20.49
Baseline vitals: BP 132/76 Pulse 98 Resp. 18 Temp.98.1 F Pain Score 4/10 Transfer Status: Assist of 1
Allergies: Sulfamethoxazole, Advil, Aspirin, Latex Code Status: DNR/DNI Occupation: Homemaker
Religion: Lutheran Pastoral Care: N/A
Marital Status: Married Cultural Background: U.S Primary Language: English
Diet/Nutrition: No MSG Activity: Not specified Fall Risk: Yes
Use of (type/amount/frequency): Alcohol: None Tobacco (pack years): past use over 50 years ago 1 pack/yr
Treatments: Creams (lotions), INR IV/Tubes/Ostomies: N/A
Interdisciplinary Cares (OT/PT/RT): PT/OT post op
Dressings/Wounds: (type & location) : N/A
Oxygen: (delivery method & amount) nasal cannula 1 L/min Dialysis: N/A
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. Make sure these are on your Systems
Disorder Remediation Template. (Should be in the appropriate location)
Date Test Normal Value Client Value Significance
4/1 INR 0.9-1.1 2.34 High # indicates thinning of blood which takes longer to
clot and pt is at risk for bleeding.
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. Make sure these are on your Systems Disorder
Remediation Template. (Should be in the appropriate location)
Xray of chest 4/7/16 new central congestion and small left effusion with left lower lobe consolidation related to poss. Pneumonia
Xray of the left hip 43/16 internal fixation left femoral neck fracture with bolt and short intramedullary rod. Main fracture
components are in anatomic alignment.
1
, Name
Date: 20/7 Client Initials: ES Student Name: Lee Arthur
Clinical Site/Unit: TCU
ASSESSMENT SUMMARY: To be completed during the clinical day.
Date: 4/11/16 Client Initials: ES Student Name: Lee Arthur Clinical
Site/Unit: TCU
ASSESSMENT SUMMARY: To be completed during the clinical day. NEW ASSESSMENT
Body System Subjective data-Health History Objective data- (head to toe) Assessment findings
2
