Escolar Documentos
Profissional Documentos
Cultura Documentos
Student Name:
Date: 04/01/15
Age: 65
Sex: F
Weight: 181.6 kg
Frequency often
Precipitating factors: tachycardia, blood pressure changes, neuropathy. Method of relief pain medication as prn and
order
Neurological:
Orientation: awake, alert, oriented X 3
Pupils/PERRL: equal, round, and reactive to light and accommodation Size (mm) N/A
Extremity Strength (equal bilaterally?) yes
Speech: patient can speak over the tracheostomy
Gag Reflex : yes Ability to swallow: yes
Eyes, Ears, Nose, Throat:
Sclera appearance, eye drainage, vision impairment, glasses/contacts, etc: glasses needed
Ear drainage, hearing impairment, hearing devices, etc: no hearing deficit, no hearing aid device needed
Nasal drainage, nares patent, etc: no nasal drainage
Throat appearance: a tracheostomy patient
Teeth (cavities, missing teeth, dentures, etc) no dentures, no missing teeth
Cardiovascular:
Heart sounds: no murmurs
Rhythm (regular/irregular) irregular rate and rhythm
Quality of pulse (bounding, strong, normal, weak, absent, Doppler) weak
Capillary refill: delayed capillary refill, more than 3 minutes
2
Cyanosis No
Edema (location, pitting/non-pitting, grade) redness and positive + 1 edema to lower extremity bilaterally
Telemetry:
yes
Pacemaker N/A
IV access (include location, site appearance, date of insertion). Location: accessory cephalic left Date inserted 04/2/15
Site appearance: clean, dry
IV infusion (type of solution, rate of infusion) Type of fluid: Normal saline
Rate: 5ml/hr
Respiratory:
Pattern Normal
Depth Normal
Effort No
Lung sounds
Anterior: Right clear
Left
clear
Left clear
no
Vomiting No
NG/OG/Dobhoff/Peg No
Residual N/A
Hospital diet (include supplements and rationale, and route if applicable): soft, mechanical altered / chopped
Genitourinary:
Last void 0700 Appearance clear, yellow
Penile/vaginal discharge No
Dialysis: no
Incontinence No
Ostomy: no
Type/location N/A
Hemodialysis access:
Appearance N/A
AV graft
AV fistula
N/A
Dialysis Catheter
Tenckhoff
Location: N/A
Bruit No
Thrill N/A
Integumentary:
Characteristics (color, temp, condition) mild redness and thickening of the skin on the bilateral lower extremities
Turgor: loose skin turgor
General description of skin: cracked, dry
Wounds/Drains/Dressings (include location, appearance, and type) No
Musculoskeletal:
Range of Motion (full, contracted, and/or limited): patient is not mobile
RUE limited RLE limited
LUE limited LLE limited
Muscle tone (normal, decreased, increased, flaccid, atrophy, rigid, spastic)
RUE decreased
RLE decreased
no
Describe N/A
4
Ortho equipment
no
Describe: N/A
Gait (steady, unsteady, needs assistance, etc.) very unsteady gait, need assistance with all ADLs.
Discharge Planning (describe the needs of the patient during discharge planning):
Explain to Ms. T what is BiPAP for. Pt will need humidification bottle for home vent settings.
Encourage the patients to call for assistance as needed. Pt cannot perform ADLs.
Ms. T will need to reduce salt intake to help decrease blood pressure.
Clients Value
(Normal, High, Low, Critical)
HEMATOLOGY
WBC
RBC
7.5 Normal
3.62 Low
HGB
9.3 Low
HCT
COAGULATION
Platelets
31.8 Low
198 normal
PTT
N/A
PT/INR
5
CHEMISTRY
Glucose
115 High
Sodium
139 normal
Potassium
3.9 normal
Chloride
103 normal
Calcium
8.8 normal
BUN
8 normal
Creatinine
0.9 normal
Total Protein
Albumin
N/A
N/A
URINALYSIS
Color
N/A
Specific Gravity
N/A
N/A
pH
Ketones
N/A
Protein
OTHER LABS
CO2
Magnesium
N/A
Clients value
(normal, high, low, critical)
27 normal
1.5 Low
DATE
TIME
04/01/15 0900
65 yr old obese white female admitted to the ED 03/30/15 for chest pain. VS: B/P: 145/85
HR 87 RR 18 T 98.3 0 F Pulse ox 97 % on BiPAP. Alert and oriented to person, place,
day/time and situation. Pt states having pain at lower extremities. Pain level 7 out of 10 on
the pain rating scale. ----------------------------------------------------------------------------HN, FTCC NS
Pt is on 40 % of the BiPAP via trach. Pt is unable to perform any ADLs without assistance.
Encourage patient to call for assistance as needed. Pt acknowledged understanding.HN, NS
Patient can speak over the trach and does PO med food 1+ pedal edema noted
Patient has clear lung sounds in the upper lobe bilaterally and slowly diminished
at lower lobes. No wheezing noted. Redness to lower extremities bilaterally. Pt is on the
telemetry monitor. --------------------------------------------------------------------------- ---HN, FTCC SN
Bowel sounds are present. Last bowel movement at 0700, normal. ---------------HN, FTCC SN
0910
ACCUCHECK: 115 mg/dL ------------------------------------------------------------------------------- HN, FTCC SN
0915
Monitor signs and symptoms for pain. Administer pain medication as prn and order. HN, FTCC SN
0930
Administering medications, see MAR ---- ------------------------------------------------------------ HN, FTCC SN
1200
Remains on BiPAP via trach at 40 %. Trach supplies at the bedside. Pt is resting, offer no complains.
Sa O2 98 % at BiPAP, no respiratory distress noted. Respirations are even and unlabored. Telemetry
Call bell is in reach. Bed is in low position for safety. ------------------------------ -------------- HN, FTCC SN
Printed Name: HANH NGUYEN
NURSES NOTES
7
Medication Worksheet
Drug Name
Classification
Mechanism of
Action
Anticoagulant/thro
mbolytic
Inhibits Vitamin K
dependent coagulation
factor synthesis
2 mg po
daily
Lipid-lowering
agents
catalyzing an early
step in the
synthesis of
cholesterol.
Blocks stimulation
of beta
1(myocardial)
10 mg PO
TAB every
day
(trade/generic)
Warfarin/Coum
adin
Lipitor
antihypertensiv
es
Metaprolol
Antidiabetics,
hormones
Lower blood
glucose by
stimulating
glucose uptake
antidepressants
Selectively inhibits
the reuptake of
serotonin in the
CNS.
Insulin Lispro
(Humalog) 3
ML
citalopram
Dose,
Rationale for
Route,
taking drug
Frequency
50 mg PO
tab twice
a day
151 to
200 2
units
201 to
250 4
units
251 t0
300
6 units
301 to
350 8
units
351 t0
400
10 units
2000 mcg
PO TAB
Adverse side
effects
Nursing
consideration
s
Atrial Fibrillation
Hemorrhage:
reverse with
administration of
Vit K
Monitor PT/INE,
Plt
Lowering of
total and LDL
cholesterol and
triglycerides
Decrease BP
and heart rate
Abdominal
cramps,
constipation
heartburn
Fatigue,
weakness,
dizziness,
drowsiness,
insomnia
Erythema,
lipodystrophy
swelling,
allergic
reactions
including
anaphylaxis
monitor liver
function tests,
assess muscle
cramps
Monitor BP,
ECG and
pulse
frequently
Confusion,
drowsiness,
insomnia
Assess
suicidal
tenderness
Control of
hyperglycemia
in diabetic
patients
Antidepressant
action.
Assess for
symptoms of
hypoglycemia
Nursing diagnosis: chronic pain related to neuropathy as evidenced by verbalizing that pain is present, pain is
rated 7/10, crying at times, need assistance with ADLs, irritable with family members and caregivers
Patient goal: patient will demonstrate decrease in pain.
Nursing Interventions:
- Administering Tylenol 650 mg PO tab every 4 hour if needed, not more than 4 gm in 24 hours.
- Ask the patient to describe prior experiences with pain, effectiveness of pain management intervention
and response to pain medications including side effects, ask patient about pain intensity level using
numerical pain rating scale
- Keep monitoring signs and symptoms of pain.
Documented Rationale:
- Provide the basis to determine effectiveness of the individualized pain management plan.
Evaluation: patient verbalized pain rated 3/10 on a numeric rating scale.
APA References:
Ackley, B. J., & Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
(10th ed.). St. Louis, MO: Mosby/Elsevier
Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: Patient- centered collaborative care
(7th ed.). St. Louis, MO: Elsevier.
Pagana, K. D., & Pagana, T. J. (2010). Mosbys manual of diagnostic and laboratory tests (4th ed.). St. Louis,
MO: Mosby/Elsevier.
10