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Page View Rodou W Vancomycin 1 IV playback in 200 ml. normal saline, Infused over 60 min D Basic metabolic panel and complete blood count tests in the morning Diagnosis: Hipolar disorder Brief Summary: Sharon Cole is a 31-year-old female with bipolar i disorder who was admitted to the hospital last night for surgical repair of a right ankle fracture sustained in a fall during a mani episode. She was diagnosed with bipolar disorder 6 years ago. Prior to this incident, she had a manic episode 2 years ago as well as two earlier depressive episodes, one requiring hospitalization. She has recently stopped taking her medication She went to surgery first thing this morning. At the start of the scenario, it is early afternoon, and she is on the orthopedic unit where she has been for a couple of hours after coming back from the postoperative unit. She is manic, expressing grandiose ideas that she is needed in Washington, DC to solve some political issues. Her husband, Allan Cole, has been with her prior to surgery, but is not present now The students are expected to set limits on behavior with a patient experiencing an acute manic episode. Students are also expected to provide a therapeutic environment and identify the need for medication to manage the manicepsode. Location: Inpatient orthopedic unit Time: 14:00 Report given by charge nurse: Situation: Sharon Cole is a 31-year-old female who was admitted last night for surgical repair of a right ankle fracture. She went to surgery this morning at 08:00 and came back from the postoperative unit at 11:30 Background: Mrs. Cole sustained the injury when she fell from the stage in a bar. According to the paramedics who responded to the 911 call at the bar, she was ranting about the government and talking about how she was the only one who could help rectify Washington's problems. She jumped up on the stage and grabbed the microphone from the band leader, and in the struggle that ensued, she fell off of the stage and fractured her ankle Her husband was contacted by the emergency department, and he was here prior to her surgery. He and her sister had been searching for her for hours before the accident. He reported that she was diagnosed with bipolar disorder 6 years ago and that she had not been sleeping or eating much for the past 2 weeks. The family was worried that she was at risk of another manic episode, but she became irritable when they questioned her behavior or her compliance with her medication. Her husband reports that she is normally adherent to her medication regimen, which is lithium 600 mg twice a day. The last time she stopped her medications was 2 years ago, and she had a manic episode after that. A psychiatric consult was initiated, and her medications and diagnosis were confirmed by her regular psychiatrist Lithium will be restarted this afternoon. Assessment: She has been very loud and verbal since she came from the postoperative unit. She is somewhat oriented; she knows that she's in the hospital, but doesn't really remember the details of the fall. She knows her name and recognized her husband, but her recollection of the events of last night is inconsistent as she relays the story to different staff members. She does not know what day it is. She is having grandiose thoughts, her speech is pressured, and she is talking constantly, exhibiting a flight of ideas, with Last Updated 7/22/2021 1311
thoughts ranging from issues in Washington to suggestions about running the hospital better. She has used the call light several times, saying that she needs to get out of here, and keeps asking whether she can use the unit phone to call Washington. So far, she has responded to redirection with irritability. She has a fentanyl patient-controlled analgesia (PCA) pump for pain control. Her vital signs are stable temperature, 37.2°C (99°F); heart rate, 88 beats/min; respiratory rate, 16 breaths/min; blood pressure, 134/70 mmHg. She denies pain, but she says she never feels pain. She has threatened to take her intravenous (IV) line out to get rid of the pain medicine, which she says makes her feel like she's "not herself." So far, we've been able to talk her into keeping it. She takes small sips of water when it is directly given to her. There is a sitter present for the patient's safety
CLINICAL WORKSHEET Date Student Name: Diagnosis нси, Isolation I Type Critical Labs Other Services Age Length of stay Fall is Location: M/F Code Status Consult Consults Needed Allergies Transfer Fluid/Rate Why is your patient in the hospital (Answer in your own words and include the History of present illness)? Health History/Comorbidities that relate to this hospitalization Shift Goal/Patient Education Needs Path to Discharge Path to Death or injury
CAUCONCIMINAL HEALTHIES CLINICAL WORKSHEET Alerts: 2. What are you on Alert for with this patient? (Signs & Symptoms) 3. 1. 2 Management of Care: What needs to be done for this patient Today? 1. 3 2 What Assessments will you focus on for this patient? (How will identify the above signs & symptoms?) 1 3 4 2 5. 3 6 List Complications may occur related to dx, procedure, comorbidities 1 2. Priorities for Managing the Patient's Care Today 1. What nursing or medical interventions may prevent the above alert or complications? 2. 1. 3
What aspects of the patient care can be Delegated and who can do it? 1. 2.
ASSIGNMENT 4 CUINICAL CARE PLAN WORKSHEET 2 TT 130 Minute This activity creates an opportunity for you to prepare for a virtual clinical experience. This activity provides you with the opportunity to manage patient care, prioriture interventions, and identity aspects of care that could be delegated STUDENT LEARNING OUTCOMES At the end of this, student will be able to 1. Describe pathological events associated with the patient's disease process or condition 2 Create a plan of care that is prioritized and is based on the patient's care needs. 3. Identifies path to healing or health and path to death or injury Describes aspects of care that can be delegated and appropriate personnel to complete delegated tasks ASSIGNMENT COMPLETE CLINICAL WORKSHEET Patient Details Patient Data: Female, Hispanic, 31 years old. Weight: 61 kg: Height: 168 cm Date of Birth: 3/15/XX Allergies: No known Past Medical History: Bipolar disorder diagnosed 6 years ago Episodes of mania at the time of diagnosis and 2 years ago The episode 2 years ago was triggered when she discontinued her medications. During this episode, she accumulated credit card bills that totaled over $12,000. She has also had two episodes of depression, one 8 years ago and another 4 years ago. The episode 4 years ago required Inpatient hospitalization She has been seeing the same psychiatrist for the past 2 years and has been well managed on lithium 600 mg twice a day when she is adherent. She has also been on fluoxetine, paroxetine, and allorasole in the past Provider's Orders Admit to the orthopedic unit Vital signs every 4 hours Activity as tolerated Intake and output Clear liquids, advance to regular diet as tolerated Normal saline 30 ml/h Fentanyl PCA pump at 10 mc/h 0 Patient controlled dose: 10 mcg Lockout 15 minutes o Maximum of 1200 mcg per 24 hours including continuous infusion Uthium 600 mg orally twice daily - start in the afternoon Lorazepam 2 mg orally every 8 hours as needed for agitation Risperidone 2 mg orally daily 12 Last Updated 7/22/2021
Vancomycin 1 IV playback in 200 mt normal saline, Infused over Date metabolic panel and completed counters in the morning Diagnosis Bipolar disorder Brief Summary Sharon Cole is a 31-year-old female with bipolar disorder who was admitted to the home at night for surgical repair of a right ankle fracture sustained in a fall during a manic episode. She was diagnosed with bipolder years ago. Prior to this incident she had a manic episode 2 years ago as well as two earlier depressive episodes, one routing haluation. She has recently stopped taking her medication She went to surgery first thing this morning. At the start of the scenario, it is early afternoon, and she is on the orthopedic unit where she has been for a couple of hours after coming back from the postoperative unit. She is manit, expressing grandiose ideas that she is needed in Washington, DC to solve some political issues. Her husband, Allan Cole has been with her prior to wrgery, but is not present now. The students are expected to set limits on behavior with a patient experiencing an acute mani episode. Students are also expected to provide a therapeutic environment and identify the need for medication to manage the manic episode Location: Inpatient orthopedic unit Time: 14:00 Report glven by charge nurser Situation: Sharon Cole is a 31-year-old female who was admitted tast night for surgical repair of a night ankle fracture. She went to surgery this morning at 08:00 and came back from the postoperative unitat 11:30 Background: Mrs. Cole sustained the injury when she fell from the stage in a bar. According to the paramees who responded to the 911 call at the bar, she was ranting about the government and talking about how she was the only one who could help rectify Washington's problems. She jumped up on the stage and grabbed the microphone from the band leader, and in the struggle that ensued, she fell off of the stage and fractured her ankle. Her husband was contacted by the emergency department, and he was here prior to her surgery. He and her sister had been searching for her for hours before the accident. He reported that she was diagnosed with bipolar disorder years ago and that she had not been sleeping or eating much for the past 2 weeks. The family was worried that she was a risk of another manic episode, but she became irritable when they questioned her behavior or her compliance with her medication. Her husband reports that she is normally adherent to her medication regimen, which is lithiurn 600 mg twice a day. The last time she stopped her medications was 2 years ago, and she had a manic episode after that. A psychiatric consult was initiated, and her medications and diagnosis were confirmed by her regular psychiatrist. Uthium will be restarted this afternoon Assessment: She has been very loud and verbal since she came from the postoperative unit. She is somewhat oriented; she knows that she's in the hospital, but doesn't really remember the details of the fall. She knows her name and recognized her husband, but her recollection of the events of last night is inconsistent as she relays the story to different staff members. She does not know what day it is. She is having grandiose thoughts, her speech is pressured, and she is talking constantly, exhibiting a flight of ideas, with 131 Last Updated 7/22/2021
thoughts ranging from issues in Washington to sugestions about running the hospital better. She has the times, saying that she needs to get out of here, and keeps asking whether she can the hotel Washington Seter, the has responded to redirection with irritability. She has a tentanyl patient-controlled analgesia IPC puma for pain control. Herve signs are stable: temperature, 37.2°C 199°F): heart rate, 8 beats/min respiratory rate, 16 breath blood pressure, 134/70 mmHg. She denies pain, but she says she never feels pain. She has threatened to take her intravenous line out to get rid of the pain medicine, which she says makes her feel like she's not herselt sotar, we've been able to tell her into keping 2. She takes small sips of water when it is directly given to her. There is a sitter present for the patient's safety Updated 7/22/2021
thoughts ranging from issues in Washington to suggestions about running the hospital better. She has used the call light several times, saying that she needs to get out of here, and keeps asking whether she can use the unit phone to call Washington. So far, she has responded to redirection with irritability. She has a fentanyl patient-controlled analgesia (PCA) pump for pain control. Her vital signs are stable temperature, 37.2°C (99°F); heart rate, 88 beats/min; respiratory rate, 16 breaths/min; blood pressure, 134/70 mmHg. She denies pain, but she says she never feels pain. She has threatened to take her intravenous (IV) line out to get rid of the pain medicine, which she says makes her feel like she's "not herself." So far, we've been able to talk her into keeping it. She takes small sips of water when it is directly given to her. There is a sitter present for the patient's safety
CLINICAL WORKSHEET Date Student Name Dugo HP holation Type Am Langth of stay Folk M: Code Status: Comed Cons: Transfer wate: Alleres Why is your patient in the hospitalin on words and include the hory Health History/Comories aretate to this options Shifto/Patient Education Med 1 2 3. 4 Path to Discharge Path to Death or injury Las CUNICAL WORKSHEET Alerts: What we you on Alert for with this patients & Symptom