• To provide an organized method of client data collection. • To provide a format for researching client data.
• To provide a standard format for reporting client data. • To serve as a format for developing and evaluating a plan of care for the client.
1. This tool is to be completed as per clinical instructor’s requirements. 2. Completion is required to demonstrate clinical preparedness. You may be dismissed from clinical if this tool is not completed. 3. This tool is to be considered under HIPPA Policy; therefore, confidentiality precautions are required. Initials should be used, information should be kept in a secure location and not available for general viewing. To discard – shred or black out any client identifiers such as diagnosis, initials, room number, age, and date of admission. 4. General instructions for completion of the tool will be given during the orientation period of each clinical rotation. 5. This tool may be completed by generating the format on computer, typing, or legibly handwritten (if allowed by your clinical instructor), using black ink. Place name bottom right of each page to prevent lost loose pages. 6. There are 3 components of the tool – Assessment, Planning, Implementing/Evaluating. 7. Directions regarding dates that the tool is be completed for submission to the instructor for grading will be announced and/or identified by course instructor. 8. When the tool is submitted for grading, place the completed tool in a 9 x 12 brown envelope. Place your name, the course name, your section number, and the clinical instructor’s name in the upper left hand corner. The envelope may be used multiple times during the semester. 9. The Clinical Preparation Tool will be graded as “satisfactory” or “unsatisfactory.” 10. Please reference work using APA format.
Part 1 – Assessment
The History- Subjective Data
Client initials ____M.S_________ Age__54_____ Admission Date___1/18/2013_________
Admitting Diagnosis: Right Acetabular Fracture, Dislocation
Definition: An acetabular fracture occurs when the socket of the hip joint is broken. -- In this patient it was first fractured and repaired, and then it was dislocated in the healing processes.
Signs and Symptoms: Acetabular fractures usually produce hip pain, but may also cause diffuse pain in the groin and leg. Patient may be able to put weight on this leg but it will produce pain.
Treatment: Depending on the extent of damage to the cartilage in the joint and the degree of instability in the hip, surgery may be required. For older patients, even if the alignment of the joint is not perfect, fractures may be allowed to heal on their own, especially if the ball of the joint is still in the socket and relatively stable.
Surgical Procedure: Total hip replacement
Definition: Hip replacement surgery involves removing a diseased or injured hip joint and replacing it with an artificial joint, called prosthesis. Hip prostheses consist of a ball component, made of metal or ceramic, and a socket, which has an insert or liner made of plastic, ceramic or metal. Indications for this surgery include osteoarthritis, rheumatoid arthritis, femoral neck fractures, failure of previous reconstructive surgeries
(Smeltzer, Hinkle, Bare & Cheever, 2010)
Past medical history
(List and relate admitting diagnoses to the past history medical diagnosis.) In this case the patient had been in a car accident causing her right acetabula to become fractured and then post-surgery dislocated. The PMH does not directly correlate with the admitting diagnosis however her history of chronic renal failure could have affected her calcium levels causing her hip to fracture more easily in the car accident. At this time however her calcium levels are normal. Her history of...