1AMS Clinical Prep Form All information on this form should be written in your own words.

Students may not cut and paste information into this form. Patients initials: _JW____ Room #: _2102_____ Age: _42 yrs____ Sex: _M____ Allergies: NKA

Date of Admission: 03/15/12 Date of Students care: 03/17/12 Current Diagnosis (if different):
Research this diagnosis in your textbook, what expectations do you have about any patient with this diagnosis (minimum that should be included are history, diagnostic tests, labs, medications and assessment findings. Other information that you may included are medical and nursing treatments, patient teaching, etc.) Include the reference. This column should all be about the information you obtained in your book or in some other source. This column must be completed prior to clinical and should be done on all patients even if you are not doing a CPF on that patient.

Admitting Diagnosis:

After reviewing the patients chart, complete this column as it is applicable to this specific patient. This column must be completed prior to clinical and should be done on all patients even if you are not doing a CPF on that patient.

How does the research information compare with your patient? If it is different, why is it different? If it is the same, how is it the same? You can not simply say The same This column will be completed after your clinical day but prior to turning the CPF in to your clinical instructor. You do not have to do this column if you are not doing a CPF on this patient.

HISTORY (This is information that you will have found by

researching the diagnosis in your textbook or some other literature source) This information must be written in your own wards. You may not cut and paste.

HISTORY (be sure to include what brought the patient to the

hospital) Patient presented to ED with progressive symptoms pf numbess, tingling in all extremities that started 2 days ago along with diplopia, vertigo, incoordination with difficulty ambulating. Is also experiencing generalized muscle weakness. The past week the patient had an upper respiratory infection that was treated with Zpak, the cold got better but then neurological symptoms developed. Past Medical History CAD MI CVA HTN Hypothyroidism Family History: HTN CVA, MI

DM Social History: Works as a restaurant manager No tobacco history, 1-2 drinks monthly

DIAGNOSTIC TESTS (What diagnostic tests should the

patient have according to the literature?)

DIAGNOSTIC TESTS (What diagnostic tests did your

patient actually have and what were the results?) (you can add info to this column during your clinical day if additional diagnostic tests were done)

DIAGNOSTIC TESTS-(Why were the tests ordered

different then what the literature suggested? Why were any of the diagnostic tests abnormal?)

Chest xray was normal MRI of spine showed mild multilevel spondylosis, narrowing of C4-5 level MRI of brain- two right sided cerebral white matter lesions at least 3 mm (need to r/o MS) LABS (What labs should this patient have according to the
literature?)

LABS-(Why were the labs ordered different than what the LABS (What labs did your patient actually have and what were
the results?) (you can added info to this column during your clinical day if additional labs were done) Toxicology was negative Potassium decreased 3.3 Triglycerides elevated 232 HDL decreased 27 literature suggested? Why were the labs abnormal?)

MEDICATIONS (Why are there differences?) MEDICATIONS (What medication was this patient MEDICATIONS (What medications should this patient be
receiving according to the literature?) actually on?)(Dont forget your Drug Profile Sheets on each med) Home meds: Azithromycin oral packet 1 gm Diovan 160 mg q day Ibuprofen 800 mg po TID, PRN for pain Levothyroxine 125 mg PO Metoprolol 50 mg q day

All medication that is administered should be listed on the medication sheet.

Niacin 500 mg q day

ASSESSMENT (After researching this diagnosis, what

assessment findings do you anticipate?)

Plavix 75 mg PO q day Simavastatin 40 mg po bedtime Hospital Meds: Aspirin 325 mg po q day Lovenox 40 mg SQ day Niacin ER 500 mg po bedtime Plavix 75 mg PO q day Senokot 2 tablets PO at bedtime Synthyroid 0.025 mg po breakfast Zocor 40 mg PO

ASSESSMENT (Why were they different?)

PATIENT TEACHING (Based on your research, what

patient teaching might be done a patient with this diagnosis?)

PATIENT TEACHING (What patient teaching were you

able to accomplish during your clinical day? If different then what you hoped to accomplish, why?)

ASSESSMENT (What assessment findings did you actually

see?) This will be completed after you have completed your assessment.

OTHER (What other information did you find in your research

that you found interesting?)

OTHER (What other information did you discover during

your clinical day that you found interesting?)

PATIENT TEACHING (What patient teaching do you

hope to accomplish during your clinical day?)

NURSING DIAGNOSIS (Identify an appropriate nursing

diagnosis for this specific patient) (Must have at least two nursing diagnosis)

OTHER (What other information did you find when you

EVALUATION OF THE NURSING INTERVENTIONS

reviewed the patients chart that was interesting?)

NURSING DIAGNOSIS (Identify an appropriate nursing

diagnosis for this specific patient) (Must have at least two Nursing Diagnosis)

NURSING INTERVENTIONS (list at least three

nursing interventions for each Nursing Diagnosis)

EVALUATION OF THE NURSING INTERVENTIONS

NURSING INTERVENTIONS (list at least three

nursing interventions for each Nursing Diagnosis)

AMS CPF Four Questions 1. What is the most important focus of my physical assessment and why?

2.

What is the most critical medical complication that may occur/or could go wrong with the identified focus?

3.

What signs and symptoms tell me this complication is developing?

4.

What nursing interventions/assessments will I do to prevent and/or treat the identified complication?