10 Sep Catherine Owens
Date: ________ Student Name: _______________________ Clinical Site:____________________________________
Clinical Site Instructor:___________________________________ __________________________________________
Room #_405_________Client Initials: ____SR___ ____Client age: ____52 years_______ Gender: ___Male_______
Allergies: Diphenhydramine______________________________ Code Status: ___Full code______________ ________________
Diet/Nutrition: _________Regular___________________ Activity: _______________________________ Fall Risk: Yes / No Yes (High fall risk)
Use of (type/amount/frequency): Alcohol: ___________________ Tobacco (pack years): ________________________
Treatments: _______________________________ IV/Tubes/Ostomies: ______________________________________
Dressings/Wounds: (type & location) _Shoulder-healing, Back-Tegaderm and clear absorbent.__________________________________________________________________
Oxygen: (delivery method & amount) ____N/A___________________________ Dialysis: ______N/A_____________________
LAB RESULTS: (minimum of 2 labs) Why is this lab significant for this client’s condition? Write down ABNORMAL lab results and include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column. ONLY USE ABNORMAL LAB RESULTS QSEN: Informatics, Safety SLO: 3, 8
Date Test Normal Value Client Value Significance
7/24 Sodium____135-145_ 132
7/25 Hemoglobin 14-18 9.4 __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
LABS
Look at the 2 labs you looked up for this week. For each of the labs look up what body system or system(s) it tells you about, what does an elevated level mean, and what does a low level mean. Also, are there any special considerations or client education regarding prepping the client for the test? (example: fasting for 6 hours, etc.) QSEN: Informatics, Safety SLO: 3, 8
Lab Test#1: __Sodium 135-145_______________Systems affects: ______________________________________________
Elevated level: _____________________________________________________________________________
Low level: _132___________________________________________________________________________
Lab Test #2: _Hemoglobin 14-18_________________Systems affects: ______________________________________________
Elevated level: _____________________________________________________________________________
Low level: 9.4_______________________________________________________________________________
Date: ____________ Client Initials: _SR_____ Student Name: _______________________________________________
Medical Diagnosis(s): (found in paper chart)
Admitting/Primary: Motor Vehicle Accident
____________________________________ ______________________________________
Medical History (includes medical and surgical)
Acute post hemorrhagic anemia _____________________________________
Alcohol abuse ___________________________________ _____________
PTSD____________________________________
Adjustment disorder with other symptoms___________________________________ ____
Traumatic ischemia of muscle__________________________________ ______________________________________
__________________________________ ______________________________________
____________________________________ ______________________________________
____________________________________ ______________________________________
End of Shift Report or SBAR: QSEN: Informatics, Team-Work Collaboration SLO: 3
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