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.

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 / NoUse of (type/amount/frequency): Alcohol: _____________ Tobacco (pack years): ______________________________Medical Diagnosis(s):Admitting Diagnoses to Acute Care Facility1.____________________________________ 2.______________________________________Primary Diagnoses for Admission to TCU/LTC1._____________________________________ 2._____________________________________3._____________________________________4._____________________________________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. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PATHOPHYSIOLOGY: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.PATHOPHYSIOLOGY CONTINUED: 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 clinicalVital Signs Pain: Pain is normal for him due to his TBI 8 out of 10Neurological: 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 chairBP_________   HR _________  RR _________ Temp ________ O2 Sat _______%  RA/LPM ________Pain is normal for him due to his TBI                                                                 PRN Medications List                    Medication(Include dose, time, route, & frequency)       ClassificationWhat nursing considerations shouldyou include with this medications?Buspar  15mgBaclofen 20mgCymbalta 30mgLevetiracetam 1000mgOmeprazole 20mgRobafen 100mg /5mlSenna 8.6mgTizanidine hcl 2mgXarelto 20mgOxycodone HCL 5mgibuprofenMedication Data SheetList all scheduled medications for your shiftDrug Name and Classification, Normal Adult Dose, Route & ScheduleIndications for Use and Expected ActionsSide Effects/ Adverse ReactionsDrug and Food InteractionsNursing Administration ConsiderationsClient education &Evaluation of Medication EffectivenessTicagrelorAtorvastinPantoprazoleGabapentin 300mg(Neurontin).   Venlafaxine 75mg ( Effexor).NURSING PROCESS 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:S:B:A:R:Notes: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).