The University of the West Indies

The UWI School of Nursing, Mona

PRACTICE CLINICAL WORKSHEET
STUDENT NAME _Odessia_Benjamin, Nina Atkinson___________________________ DATE __March 20,2014________________________
STUDENT ID

620052267 620045347

Client Initials
A.W
Marital status
Single

Age
Sex:Female
46
Occupation: Dressmaker

Weight
Height
78.13 kg
178cm
Social History: Miss A.W is 49 years old. She lives
in the Parish of Kingston and St. Andrew with her
niece in a convenient space with modern
conveniences. She is a non-smoker and only drink
on special occasions.

Medication History
Chemotherapy and Radiation
Allergies: Tuna

Chief Complaint:
Patient complained of nausea and vomiting and feeling fatigue.
Vital Signs
Resp: 20 bpm Pulse 76bpm Bp: 150/90 mmHg T: 36.40 C Current Resp-20 pulse-78 t-36.40C bp-133/72mmHg
Current medical diagnosis
Acute Kidney Injury
Clinical Manifestations
Oliguria(less than 400ml urine/day, Vomiting, Fatigue, Weakness, Nausea, Fever, Increased urea and creatinine level in serum

Adopted with permission from Excelsior Community College School of Nursing 2008

Pathophysiology :According to Medline Plus Medical Encyclopedia(2012) acute kidney injury is the rapid loss of the kidneys ability to remove waste and help
balance fluids and electrolytes in the body. These electrolytes include calcium , sodium, chloride, magnesium and phosperous. Electrolytes affect the amount of
water in the body, acidity of the blood and muscle functions. There are three types of Acute Kidney Injury. These are Prerenal, Instrinsic and Postrenal
Acute kidney injury(AKI). Prerenal AKI occurs as a result of renal hypoperfusion which refers to decreased blood flow to the kidneys, which may be due to
dehydration, sever blood loss, shock or severe heart failure. Intrinsic AKI may result from glomerulonephritis, tubular necrosis, nephrotic drugs and severe
hypertension. In postrenal acute injury there is a obstruction of the ureter, bladder neck or urethra, Lee(2009). The primary cause of AKI include Ischemia, which
refers to inadequate blood supply to an organ or part of the body, hypoxia which refers to a deficiency in the amount of oxygen reaching body tissues. Another
common cause is nephrotoxicity; this occurs when the body is exposed to a drug or toxin that causes damage to the kidneys. Among the causes of acute kidney
injury, nephrotoxicity is regarded as being the most common cause of kidney failure and can cause temporary elevation in lab values such as Bun and creatinine
levels. This may be due to temporary dehydration. In acute kidney injury there is also a decrease in Glomerular filtration rate. This allows for excess fluid and
electrolytes to be stored in the body thereby resulting in Hypertension and decreased urinary output.

PHYSICAL ASSESSMENT
Head & Neck
Her head was normal and symmetric in shape. Black hair evenly distributed on head. Mucous membrane in eyes pink and moist. Teeth clean no cavities. No sign
of cyanosis. Nose and ears are clean. No discharge from the ears. No obstruction of the nose was seen. Trachea is symmetrically aligned. No swelling observed
upon inspection. No abnormalities were detected on palpation of lymph nodes.

Neurological
N/A

Respiratory System
Chest expansion equal bilaterally on inspection. Adequate in depth and rhythm. Vesicular breath sounds heard on auscultation of anterior and
Posterior lung fields. Respiratory rate 20 breaths per minute.

Adopted with permission from Excelsior Community College School of Nursing 2008

Cardiovascular
S1, S2 and S3 heart sounds heard on auscultation of heart. No murmurs heard. Pulsation felt in all extremities.
Abdominal
S1, S2 and S3 heart sounds heard on auscultation of heart. No murmurs heard. Pulsation felt in all extremities.

Genitalia
Normal Genitalia seen.

Musculoskeletal System and Skin:

Patient is able to complete all range of motion in required parts of the body. Power grade 5/5.
Skin is intact, no lesions noted on inspection. No hyper/hypo pigmentation noted. Skin is smoothed and moist, no masses observed, oedema was present and light
swelling upon palpation. Her skin was warm to touch.

Current Medication (Including Intravenous Fluids)

Adopted with permission from Excelsior Community College School of Nursing 2008

MEDICATION NAME
(TRADE/GENERIC)

DOSAGE/
FREQUENCY
ORDERED

ROUTE

CLASSIFICAITON

ACTION/
RATIONALE FOR
ADMINISTERING

NURSING CONSIDERATIONS

Codeine is incompatible with

soluble barbiturates.
Codeine Phosphate

60mg 3 times
daily

PO

Narcotic Analgesic

Pain relief

Lansoprazole

30mg Once daily

PO

Proton Pump Inhibitor

Inhibits the stomach's

production of gastric
acids.

Do not confuse lansoprazole with

aripiprazole (an antipsychotic)

Gravol (Dimenhydrinate)

50mg 3 times
daily

IV/IM

Antiemetic

Prevents vomiting and

nausea

Do not confuse dimenhydrinate with

diphenhydramine.

Cholestyramine

4mg twice daily

PO

Antihyperlipidemic,
bile acid sequestrant.

Absorbs, combines with

bile acids to form
insoluble complex that is
excreted through the
feces; lowers cholesterol
levels, itching is also
relieved as a result of
removing irritating bile
salts.

Always mix powder with 60-180ml

water or noncarbonated beverage
before administering.

Imodium (Loperamide)

4mg 4 times
daily

PO

Antidiarrheal

Slows intestinal motility

by acting on the nerve
endings and or ganglia in
the intestine wall. The
prolonged retention of
feces in the intestine
results in reducing the
volume of stool and
decreasing fluid and
electrolyte loss.

Note reason for theraphy.onset,

frequency, characteristics of stool.

Assess for conditions which may

warrant lowered dose or cautious
use.

Adopted with permission from Excelsior Community College School of Nursing 2008

Adopted with permission from Excelsior Community College School of Nursing 2008

INVESTIGATIONS (Relevant to the Patients current diagnosis)

LABORATORY TEST #1

LABORATORY TEST #2

LABORATORY TEST #3

Sodium

Creatinine

Urea

Diagnostic Procedures
N/A

Results

Results

Results

Results

141

2.3 mg/L

16.9(23.15) mg/dL

N/A

Interpretation (Use Evidence to

support interpretation)

Interpretation

Normal Findings. An abnormal reading

ranges from 153 up.

Creatinine levels are abnormal as it

is higher than the normal range

Interpretation
Interpretation
N/A
Urea level normal as it ranges
from 12 to 20 grams over 24
hours.

Adopted with permission from Excelsior Community College School of Nursing 2008

Diagnosis #1
Assessment Data
Subjective/Objectives

Nursing Diagnosis

Patients Outcome

Interventions

Subjective Data

Excess Fluid Volume

With Nursing care and

Monitor and record

intake and output.

Right leg pain,

Vomiting, Diarrhea and
abdominal distention.
Objective Data
Right Leg Edema,
Increased Blood
pressure, Decreased
urine output(< 300mls
per day

Collaborative efforts
the patient will:
Maintain diet and
fluid restriction.
Maintain a normal
body weight with no
rapid changes.
Maintain normal skin
turgor
.
Exhibit normal vital
signs.
Maintain electrolyte
balance.
Exhibit normal skin
turgor without edema.

Monitor weight for

sudden loss or gain.
Gulanick,M.(2003).
Assess skin turgor and
presence of edema.
Palpate Bladder for
distention. Gulanick,M.
(2003).

Assess Blood pressure,

pulse, respiratory rate
and rhythm to provide
baseline data.

Rationales

Evaluation

Renal patients may exhibit

oliguria(,400ml/day) ,or anuria
(100ml/day).Gulanick,M.
(2003).

At the end of the shift

normal urine output
(,400ml/day was
measured and charted.

Sudden weight gain indicates

fluid.

Body weight was

maintained.
Swelling was reduced.

Edema indicates the presence of

excess fluid in interstitial
spaces. Gulanick,M.(2003).

No bladder distention.

Bladder distention indicates that

flow of urine is blocked so urine
back up into renal pelvis
resulting in anuria. Gulanick, M.
(2003).

Decreased bp.

And increase in baseline data

may be indicative of excess
fluid and electrolytes level in the
body.

Adopted with permission from Excelsior Community College School of Nursing 2008

Diagnosis # 2
Assessment Data
Subjective/Objectives
Subjective
.
Patient complained of
weakness.

Nursing Diagnosis

Patients Outcome

Interventions

Rationales

Evaluation

Imbalance nutrition less

than body requirements
related to catabolic
state,anorexia,and
malnutrition associated
with acute renal failure

Maintaining adequate
nutrition.

Offer high carbohydrate

feeding.

Carbohydrates have a
greater protein sparing
power and provide
additional calories

Adequate nutrition is
maintained.

Work collaborately with

dietician to regulate
protein intake according
to impaired renal
function.

Metabolties that
accumulate within the
blood derives almost
entirely from protein
catabolism.

Adopted with permission from Excelsior Community College School of Nursing 2008

Diagnosis #3
Assessment Data
Subjective/Objectives
Subjective data
Thirst, weight loss,
weakness
Objective data
Decreased skin turgor,
Dry mucous
membranes, Output
greater than intake

Nursing Diagnosis

Patients Outcome

Interventions

Rationales

Evaluation

Dehydration

With Nursing care and

Obtain patient history to

ascertain the probable
cause of the fluid
disturbance.

Poor turgor, dry

membranes and
excessive thirst are all
signs of dehydration.

Patient able to maintain

weight

Normotensive blood
pressure

Assess skin turgor and

mucous membranes for
signs of dehydration.

Glucose levels needs to

be reduced gradually for
the fluid balance to
omlur.

Membranes pink and

moist.

Heart rate 100 beats per

minute

Monitor temperature.

Collaborative efforts the

patient will:

Consistency of weight
Normal skin turgor.

Assess color and

amount of urine. Report
urine output less than 30
ml per hr for 2
consecutive hours.
Monitor active fluid loss
from wound drainage,
tubes, diarrhea,
bleeding, and vomiting;
maintain accurate input
and output.

Intake equal to output.

No signs of
hypoglycemia noted.

Fluid replacement is
necessary to provide
adequate circulation,
perfusion and
oxygenation of the
tissues.
Replacement is
adequate when vital
signs are back to
baseline.

Adopted with permission from Excelsior Community College School of Nursing 2008

References
Gulanick, M. & Myers, J. L. (2008). Nursing Care Plans: Nursing Diagnosis and Intervention. St. Louis, MO: Mosby
Lee, M., & American Society of Health system Pharmacist. (2009). Basic skills in interpreting Laboratory Data. Bethesda, Md :
American society of health system pharmacist.
Spratto, G., & Woods, A. L. (2008). PDR nurse's drug handbook: The information standard for prescription drugs and nursing
considerations. Clifton Park, NY: Thomson Delmar Learning.
http://allnurses.com/nursing-student-assistance/nursing-diagnosis-dehydration-293010.html

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick21.html
http://www.renal.org/guidelines/modules/acute-kidney-injury#sthash.p7O5u4tg.dpbs

Adopted with permission from Excelsior Community College School of Nursing 2008