Client Initials

Client Initials

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