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Vsim of nursing Clinical Worksheet mary richards
Clinical Worksheet
Mary Richards
Jasgou1752
1. Date: 3/09/2021
2. Initial: MA
3. Age: 82
4. Gender/Race: African American, female
5. Code status: full code
6. DX: congestive heart failure
7. Length of stay: 1 day- admitted 03/09/2021
8. Allergies: No Known
9. HCP: Dr. Idontknow
10. Consults: home health nurse should be contacted or case worker
11. Isolation: none
12. Fall Risk: yes
13. Transfer:
14. IV type: Lactated ringers IV @ 100 mL/hr through a 20-gauge IV catheter.
Site assessment WNL
15. IV location: right arm
16. Fluid/rate: LR infusing @ 100 mL/hr
17. Critical labs: HCT and Potassium, Digoxin lvls
18. Other services: N/A
19. Consults needed: N/A
20. Why is you pt. in the hospital: pt. Was bought today emergency Department when
her son found her confused and complaining of Trouble with her vision
21. Health Hx/Comorbidities: Patient Diagnose with heart failure 30 years ago In
hypertension 40 years ago
22. Shift Goals/ Pt. educational needs:
• Patient will demonstrate adequate cardiac output AEB VS all within normal limits
. Absent of dysrhythmias and no symptoms of failure
• Patient will participate in activities that reduce workload
• Patient will report decrease episodes of dyspnea and angina
• Patient will no longer have symptoms of nausea or vomiting episodes . Patient will
have no complaints of trouble with her vision
