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COMMUNITY COLLEGE OF RHODE ISLAND

NURSING PROGRAM
PRELIMINARY DATA SHEET FOR CLINICAL ASSIGNMENTS
Student: ______Mary Prefontaine___________________________Date: ______________October 20, 2012_________
Room # _-___ Patient (initials) ____-___Age _88____ Marital Status _W_ Residence: Home ___Other (specify) _Nursing
home____
Reason for Admission: _Confusion and increased behavioral issues_____________
_September 27, 2012_________

Date of Admission:

Medical Diagnoses: (definitions of each to be attached to this sheet) UTI, dehydration, delirium, and acute renal
failure_________________
Surgery: (definition to be attached to this sheet) Cystoscopy with right ureteral stent placement (November
4, 2011)
__Left cystoscopy (stone extraction with stent insertion)___________ Date
of Surgery: _ April 27, 2005_____
Concurrent Medical Problems: Diabetes Mellitus Type II, Hypertension, Kidney Stones, Gout, Encephalopathy
_____________________________________________________________________________________________
Allergies: ___No Known Allergies______________________________________________________ Code Status: DNR/DNI
______
NURSING CARE:
Diet (purpose) __Diabetic 2200 calories, Sodium 2000 mg_(renal
failure)___________________________________________________
IV (purpose, solution, rate)
______IV/INT___________________________________________________________________________________________
I & O:
YES
no
to unit ambulation

VS (how often) Every Shift Activity Order: Encourage out of bed daily. Restrict

Additional Nursing Actions (wound care, foley care, O2 therapy, safety precautions, etc.) _MRSA precautions,
01-03 (RAC)

06/01

IV/INT, Walker (assist) Texas catheter, Over estimates/ Forgets limits


_______________________________________________________________________________________________________________________
Medications: (attach medication sheet)
Diagnostic Tests/Consults: (attach diagnostic tests sheet)

01-03 (RAC)

06/01

_______________________________________________________________________________________________________________________
FOCUSED ASSESSMENT
Safety-At risk for falls (mobility)
Urinary System
Adult Failure to thrive

_______________________________________________________________________________________________________________________
PLANNED NURSING ACTIONS
Assist with mobility. Monitor urine for color, odor, frequency, amount, kidney stones. Monitor lab results.

_______________________________________________________________________________________________________________________
ANTICIPATED LEARNING NEEDS/PATIENT EDUCATION
Regarding medications; adverse effects, what to report and safety precautions. Proper nutrition, fluid
intake, and exercise.

01-03 (RAC)

06/01

PATIENT: ______________________________
Prefontaine__________________________
MEDICATION

Heparin,
Sodium INJ

DOSE

5,000
units
1 mL

TIME

Three
times
per day

ROUTE

Subcutaneo
us

DATE: __October 20, 2012___________


REASON
GIVEN

NURSING
MEASURES

Prevention
&
treatment
of blood
clots

Assess vital
signs
Allergies
Review
BEERS
Monitor stool
and urine for
blood

Bleeding,
BLEEDING DISORDERS,
headache,
RECENT TRAUMA, SPINAL
dizziness,
PUNCTURE, GI ULCERS,
weakness, nausea, RECENT SURGERY,
gastrointestinal
INTRAUTERINE DEVICE,
distress, skin rash TUBERCULOSIS, PRESENCE OF
INDWELLING CATHETER,
PREGNANCY, AGE RELATED
Rash, hives,
itching, swelling
face, throat,
tongue, eyes, lips,
hands, feet,
ankles, lower legs;
hoarseness,
difficulty
breathing,
swallowing
Headache,
dizziness,
weakness, fatigue,
drowsiness &
depression

Acetamino
phen

325
mg
TAB

Twice
per day

Orally

Headaches
muscle
aches,
fever
reducer,
pain relief

Assess vital
signs
Assess for
side effects
Review
BEERS

Tamsulonsi
n

0.4
mg
Cap

Before
bed

Orally

Relaxes
muscles in
prostrate &
bladder so
that urine
flows easily

Assess vital
signs
Allergies
Review
BEERS

25 mg Before
bed
TAB

Orally

Treats
depression,
insomnia,
schizophre
nia,
anxiety

Assess vital
signs
Allergies
Review
BEERS
Assist with
Ambulation

Trazodone

01-03 (RAC)

MAJOR SIDE EFFECTS

STUDENT: Mary

Chest pain, fast &


pounding, SOB,
decreased
coordination,
weakness,
tiredness,
decreased ability
to concentrate or
remember things,
blurred vision,
nausea, vomiting

SPECIAL CONSIDERATIONS

DECREASE IN RENAL FUNCTION


(ELDERLY)
HEPATITS OR HEPATIC
DYSFUNCTION, ALCOHOLISM
OR FREQUENT USE,
PHENYLKENTONURIA, RISK OF
HEPATOTOXICITY, REPEATED
ADMINISTRATION IN PTS. WITH
ANEMIA, RENAL FAILURE

CORONARY

ARTERY DISEASE
CATARACT SURGERY
SYNCOPE (FAINTING)

RENAL

FAILURE, PREGNANCY,
VASODILATING OR
ANTIHYPERTENSIVE DRUGS

06/01

Allopurinol

Asprin
enteric
coated

Sertraline

Polyethyle
ne Glycol
3350
Powder

I-Vite
Protect

POLYVINYL
ALCOHOL
01-03 (RAC)

100
mg
TAB

Four
times
per day

Orally

Treats
gout,
seizures

Assess vital
signs
Allergies
Review
BEERS

Upset stomach,
drowsiness,
diarrhea, painful
urination, blood in
urine, unexpected
weight loss

MAINTAIN

325
mg
TAB

Daily

Orally

Prevent
blood clots

Assess vital
signs
Allergies
Review
BEERS

Nausea,
heartburn, blood
loss, bleeding
abnormalities,
ringing in ears,
mental confusion

CONCURRENT

50 mg Every
Mornin
TAB
g

Orally

Depression
, OCD,
panic
attacks,
PMS
dysphoric
disorder

Assess vital
signs
Allergies
Review
BEERS
Assess skin
Assess
kidney
function(test
s)

1
Packe
t

Daily
as
needed

Orally

Constipatio
n

2
TABS

Two
times
per day

Orally

Supplemen
t
multivitami
ns &
minerals

Assess VS
Monitor stool
for blood
Review
BEERS

Tooth staining,
increased
urination, stomach
bleeding, uneven
heart rate,
confusion, muscle
weakness

AVOID MILK AND OTHER DAIRY


PRODUCTS, ANTACIDS THAT
CONTAIN CALCIUM

1
DROP

EVERY

DRY EYE

ASSESS

TEMPORARY

EXTERNAL

FOUR

BOTH
EYES

FLUID INTAKE TO
YIELD MORE URINE OUTPUT AT
LEAST 2 L PER DAY

USE OF
ANTICOAGULANTS,
RHEUMATOID ARTHRITIS,
ALLERGY TO SALICYLATES AND
OTHER NSAIDS

Drowsiness,
DIABETES MELLITUS
dizziness,
PREGNANCY/BREAST FEEDING
excessive
ST. JOHNS WORT
tiredness, pain,
burning, tingling
of hands or feet,
nervousness,
uncontrollable
shaking of a part
of the body,
blurred vision,
seizures, abnormal
bleeding
Assess for
Nausea, bloating,
PREGNANCY, BOWEL
possible
cramps, gas,
OBSTRUCTION, ULCERATIVE
contraindicati diarrhea, hives,
COLITIS, GASTRIC RETENTION,
ons or
abdominal
cautions
distension
Gather
baseline data

EFFECTS

SIDE

PAIN

EYE

USE ONLY
PREGNANT/BREAST FEEDING
06/01

SOLN
OPH

BLURRED

HOURS
AS
NEEDED

Glipizide

2.5
mg
TAB

Fosinopril
NA

Orally

Stimulates
insulin
making

Assess VS
Assess for
anorexia
Assess skin

Hypoglycemia, GI
distress, vomiting,
anorexia, skin
reactions,
increased risk of
cardiovascular
mortality, blisters

LOWER

10 mg Every
mornin
TAB
g

Orally

Hypertensi
on
Diabetic
nephropath
y

Reflex
tachycardia, chest
pain, heart failure,
ulcers, renal
failure, photo
sensitivity

ELDERLY HYPERSENSITIVITY,
HISTORY OF ANGIOEDEMA,
BILATERAL RENAL ARTERY

Insulin
Regular
INJ

Slidin
g
Scale

Three
times
per day

SubCutaneo
us

Review
BEERS
Baseline VS,
assess VS,
Assess for
adventitious
breath
Assess VS
Assess skin

Redness, swelling,
pain at injection
site, weight gain

AGE,

Insulin
Glargine
INJ

10
units

Before
bed

SubCutaneo
us

Assess VS
Assess food
intake
Assess skin

Redness, swelling,
pain at injection
site, weight gain,
constipation, skin
rash, hives, SOB,
trouble breathing,
low blood
pressure, swelling,
abnormal heart
beat, difficulty
swallowing

DIARRHEA, MALABSORPTION,
FEVER, INFECTION, RENAL OR
HEPATIC IMPAIRMENT,
HYPOTHYROIDISM SURGERY,

01-03 (RAC)

Every
day

VISION

Diabetes

Diabetes

DOSAGE FOR ELDERLY.


HEPATIC IMPAIRED, BETABLOCKER USE, HERBAL
THERAPIES

STENOSIS

HYPOTHYROIDISM,
HYPERTHYROIDISM SURGERY,
PREGNANCY

PREGNANCY

06/01

PATIENT: ______________________________
DIAGNOSTIC TEST

01-03 (RAC)

DATE

DIAGNOSTIC TESTS/CONSULTS
NORMAL

PATIENT RESULTS

NURSING SIGNIFICANCE

06/01

CONSULTATIONS: (List type, date and results if available)

01-03 (RAC)

06/01