Admit Date Chief Question & Answer Guide (With Explanation)
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Original Question
Admit Date:6/9/25 Chief Complaint confusion, imbalance, possible stroke Age 66 Date of clinical: ???6/10/25 Admitting dx: RT MCA/PCA Acute/subacute stroke Gender male Allergies: No unknown allergy Code status full code Hgt 182.88cm Wgt 84.3 kg BMI ANSWER THIS Medical/Surgical History: CAD, HTN, DM, Stroke (2years ago) Social History: tobacco and alcohol abuse, medication non compliance Briefly describe the patient’s stay. Vital Signs Admission 0800/2000 1200/2400 1600/0400 T 36.3 37.1 HR 76 79 RR 18 18 BP 158/76 154/78 MAP SpO2 94 94 Neuro Alert/Forgetful/Confused Oriented X _____ Lethargic Speech: Restraints: Cardiac Skin color/temp: Rhythm: JVD: Edema/Location: Radial pulses: Pedal pulses: Respiratory Oxygen device FiO2: Lung sounds RUL: RLL: LUL: LLL: Cough: Yes/No/ Productive/Non-productive Treatments prescribed: IS/SVN/Suction GI Diet: Abd Assessment: Nausea / Vomiting: Last BM: Consistency/ Color: Ostomy: GU Voiding Y/N Urinary catheter Other: Color: Clarity: BRP / Urinal / BSC / Bedpan Intake_________ Output__________ I/O Net change______________ M/S Activity prescribed: Upper Strength _____/5 in RUE / RLE Lower Strength _____/5 in LUE / LLE Neurovascular status: Weak/ Numb / Decreased ROM / Other: Gait: Assistive devices: cane/walker/crutches/orthotics Skin Intact Wound: Location: Description: Dressing change: Precautions: Fall / Bleed / Contact / Airborne / Droplet / Neutropenic Invasive Lines Primary IV fluids/rate (Add antibiotics to Med list below) Location/gauge: Purpose: Drains (Location/Purpose) Admission Current WBC_____________ PT _____________ Albumin ____________ Hgb_____________ PTT ____________ Amylase ____________ HCT_____________ INR ____________ Lipase ______________ Plt _____________ Ca_____________ Hbg A1C ____________ Gluc __________ Mg____________ Na ___________ Phos ___________ K+ ___________ BNP ____________ Cl ___________ ALT ____________ BUN __________ AST ____________ Cr ____________ ALP ____________ Accu-Chek’s: ________________________________________________ Drug levels: _________________________________________________ WBC____5.4_________ PT _____________ Albumin ____________ Hgb______17.5_______ PTT ____________ Amylase ____________ HCT_____50.5________ INR ____________ Lipase ______________ Plt ______160_______ Ca___9.2__ Hbg A1C 9.2 Gluc ____240______ Mg______1.7______ Na ____173_______ Phos ______2.8_____ K+ ____4.2_______ BNP ____________ Cl ___________ ALT ____________ BUN _____11_____ AST ____________ Cr ______0.68______ ALP ____________ Accu-Chek’s: ________197 __________________________________________ Drug levels: ___________________________________________________ Medical Imaging Tests and Results: Other Diagnostic Tests and Results: Pathophysiology (In your own words example. Pneumonia) Complications/Potential Complications (Risk Reduction): Psychosocial Concerns (Psychosocial Integrity): Recognizing Cues: Assessment findings that warrant further investigation. VS/Subj./Obj./Labs/Diagnostics/Risk Factors/Psychosocial): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. **May have more than 10 cues Prioritize Hypotheses: These are Nursing Problem Statements. What is the highest priority?Three (3) required (e.g. Decreased cardiac output). 1. 2. 3. Take Action: These are nursing interventions. What will you do to help improve your client’s condition or prevent further deterioration? Prioritize what will you do? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. **May have more than 10 actions Generate Solutions: Planning and goal setting. What do you want as an outcome for your client? Goals should be SMART goals. Need one goal for every problem. 1. 2. 3. Analyze Cues: What do you think might be going on with the client? What does it mean? This is where you analyze the data you collected: Evaluate Outcomes: Did your actions result in the desired outcome for your client? Use additional pages as needed to include ALL medications within a 24-hour period. Medication Name (Generic) and Drug class Patient’s Dose, Route, and Frequency Why is this patientreceiving this medication? Nursing considerations (labs, assessment, etc.) Side effects & Major adverse effects Patient Teaching Insulin lispro AGHS bubQ Thiamine HCI 100 mg daily PO Multivitamins 1 tab daily PO Aspirin 81 mg daily PO Potassium 20 MEQ oncenow PO Clopidogrel 75 mg daily PO Atorvastatin 80 mg bedtime PO Nicotine 14 my daily transdermal Patient Teaching (Health Promotion, Safety and Infection Control, and Management of Care): Summary Report to Healthcare Provider/physician (SBAR Format): S- B- A- R- Please answer all and use this template so I understand where to put the answer thank you.
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