Clinical Paperwork for a simulated patient with Laryngeal Cancer and Pneumonia
Description
Clinical Packet for Third Clinical Experience
The focus of this clinical experience is to develop clinical judgement. The expectation is that you will progress throughout the semester. Clinical judgement is the ability to intervene in a developing situation to prevent any further damage to the health of a client. It is making an assessment that is broad enough to encompass the possibilities of factors effecting the health of the client and focused enough to be performed and recognized quickly. As you progress through the semester you will be asked to identify trends in vitals, labs, and other assessment factors, which could clue the nurse into the identification of detrimental factors to the client. It is important to intervene early in these processes to prevent continued deterioration. This form will develop as the semester continues requiring further development of your clinical judgement and assessment of the findings.
1. What is the pathophysiology of the current medical diagnosis? (This should be in your own words and include a reference for the source of the definition that you provide.) (20 Points)
2. List admission labs and current labs. (This should include the lab values, normal values, and why the lab is significant to the medical diagnosis. In your own words, what are we looking for by drawing this lab.) (10 Points)
3. What assessments are directly related to the client’s diagnosis? What will you be assessing for possible complications associated with the diagnosis? (20 Points)
4. What precautions are you taking to protect your patient from infection? What isolation is patient on? And why? (Isolation should include standard, contact, droplet, or air borne.) (10 Points)
5. List three physiologic NANDAs which apply to this diagnosis. (Must include the related to and as evidenced by. You must ask the instructor if you are choosing a “Risk for” diagnosis or “Pain”). (10 Points)
6. List two Psychosocial NANDAs. (Must include Related to and As Evidenced By. You may not use “Anxiety.” You cannot use deficient knowledge or hopelessness without permission from your instructor). (10 Points)
7. What medications is the client taking that directly relate to the diagnosis? What medications is the client taking to prevent or minimize the development of associated risk factors? (10 Points)
8. What comorbidities does the client have that directly impact the client’s current medical diagnosis? How do these comorbidities impact the overall health of the client? (10 Points)
