Health & Medical

Patient history: The patient has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity / hemiplegia of left side of the body.

Admission diagnosis: altered mental status.

Discharge diagnosis summary: AMS / possible acute toxic encephalopathy, and SIRs.

Ola was 40yrs he presented to the hospital with Altered mental status, he was lethargic and not following commands in hospital. She was admitted for AMS (altered mental status) .he was Keppra loaded as she appeared post-ictal . placed on seizure precaution with neuro checks overnight in the ICU and he improved and was transferred to floor. His mentation continued clear. Blood cultured drawn 12-22 returned positive for staph epidermidis times 2 -> most likely contaminant. He did meet SIRS(Systemic Inflammatory Response Syndrome) criteria with CBC < 4 and heart rate > 90, although upon review of his medical record his leukocytosis is chronic. he was given dose of vancomycin and BCx redrawn with NGTD -> ID evaluated patient and antibiotic were deescalated. TSH elevated normal T4.

Date: ________ Student Name: ____________________________ Clinical Site/Unit: ___________________________

Clinical Site Instructor:__ ____________________________Previous Shift Report: ____________________________

Client Initials: _______ Client age: _______   Gender: _____________ Height: __________ Weight: ______________

Allergies: ________________________________ Code Status: _________________ Transfer Status: ______________

Marital Status: _____________ Religion: _________________ Occupation: ___________________________________

Cultural Background: ____________________________     Primary Language: _______________________________

Diet/Nutrition: ____________________________   Activity: _______________________________ Fall Risk: Yes / No

Use of (type/amount/frequency): Alcohol: _____________ Tobacco (pack years): ______________________________

Medical Diagnosis(s):

Admitting Diagnoses to Acute Care Facility

1.____________________________________ 2.______________________________________

Primary Diagnoses for Admission to TCU/LTC

1._____________________________________ 2._____________________________________


Secondary Diagnoses

                                                1.______________________________________ 2.____________________________________

3._______________________________________ 4.___________________________________

Surgical History 1.______________________________________ 2.___________________________________

                                                3._______________________________________ 4.___________________________________

Treatments: _______________________________  IV/Tubes/Ostomies: ______________________________________

Dressings/Wounds: (type & location) ___________________________________________________________________

Oxygen: (delivery method & amount) _______________________________ Dialysis: ___________________________

Recent 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.

Date          Test                     Normal Value                   Client Value                       Significance

_____WBC _     4.0—11.0           4.1 ________________________________________________________________ RBC           3.80 -5.40          4.95 ____________________________________________________________HEM_                    35.0 -47.0           37.5           _____________________________________________________________ MCV               80-100                   76     __

 MCH                  7-34                     22

_PLT                                                                                      238                  

HEMOGLOBIN 12-16                  11.1          __________________________________________________



Recent 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. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




For the primary admitting diagnosis to the acute care facility and primary diagnosis for the TCU/LTC, provide a 3-5 sentence explanation of the pathophysiology of the problem. Then complete an ATI template for the above two diagnoses (2 total).  Use the “Active Learning Template: Systems Disorder” template from ATI Active Learning templates.  Complete, print, and attached to paperwork.


For the top two secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization. 

If your client is post-surgical, what problems or complications could possibly occur? What nursing assessments would you need to include in your post-operative or post-procedure monitoring

                                                        To be completed the day of clinical

Vital Signs

Pain: Pain is normal for him due to his TBI 8 out of 10

Neurological: The patient oriented times 4, his speech is clear and appropriate and slow .Head: No rashes , no lesion and symmetrical round. Pupils: PERRLA. Ears: no drainage, no lesion and hearing intact. Nose: clean, no drainage. Throat: moist intact, No JVD, no difficulty in swallowing, no lumps. Mouth: oral mucosa is pink and moist, no gum bleeding.

Cardiac Rate 88. Radial pulse: 2+ bilaterally equal. Chest pain: no chest pain. Peripheral Pulses: palpable present in all extremities. Edema: no edema.

Capillary refill: less than l second on finger and toes.

Respiratory: Respiration: even and relaxed. Respiratory rate: 16. Lung sounds: Breath sounds clear no crackles and wheezing. Cough : no cough . SOB: No.

Gastrointestinal: Abdomen: round and soft. Bowel sound: active times 4. Nausea and vomiting: not present. Pain:  no pain upon palpation. Last BM: This morning, usually once a day . Continent: continent.

Genitourinary: Urination: Q 2h . color: clear.  Dysuria: no pain. Continent: continent.

Integument: dry, no bruising, no broken. Color: appropriate for color. Wounds/ location: no wound. Dressing /location: no dressing. Upper extremities/ lower extremities: warm and moist, no bruises and wound  on top of toes , between the toes and heel.

Musculoskeletal: Strength of upper extremities: strong on left arm but the right arm is flaccid. Strength of lower extremities: strong on left leg but not right leg. Weakness: yes, paralysis  on right side of the body due TBI . Assist with transfers: yes, Hoyer devices use to transfer from bed to wheel chair.  Assistive device: wheel chair

BP_________   HR _________  RR _________ Temp ________ O2 Sat _______%  RA/LPM ________

Pain is normal for him due to his TBI

                                                                 PRN Medications List


(Include dose, time, route, & frequency)


What nursing considerations should

you include with this medications?

Buspar  15mg

Baclofen 20mg

Cymbalta 30mg

Levetiracetam 1000mg

Omeprazole 20mg

Robafen 100mg /5ml

Senna 8.6mg

Tizanidine hcl 2mg

Xarelto 20mg

Oxycodone HCL 5mg


Medication Data Sheet

List all scheduled medications for your shift

Drug Name and Classification, Normal Adult Dose, Route & Schedule

Indications for Use and Expected Actions

Side Effects/ Adverse Reactions

Drug and Food Interactions

Nursing Administration Considerations

Client education &

Evaluation of Medication Effectiveness




Gabapentin 300mg(Neurontin).  

Venlafaxine 75mg ( Effexor)



Write 2 complete Nursing Diagnoses based on your client problems you noted on your assessment for this day.

Nursing Diagnosis #1:


Client Goal: ________________________________________________________________________________________

List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.

1.       _______________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

2: _________________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

Nursing Diagnosis #2:


Client Goal: ________________________________________________________________________________________

List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.

1.       ______________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

2. ________________________________________________________________________________________________

Rationale: ________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

Documentation by exception of head to toe assessment:

SBAR communication:






Student self-evaluation of clinical performance:

Please describe any procedures/skills you performed/ observed during the clinical experience. Also, include your assessment of how well the day went.

Post-Clinical Education:

Provide the group with education on a topic you learned about preparing for your client/clinical packet.  For example a medical diagnosis, intervention, medication, lab value, treatment method, etc.  Use this space to write your speaking notes and reference(s).

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