Académique Documents
Professionnel Documents
Culture Documents
Neuropsychological
LOC Alert and Oriented Pupils PEARL Orientation Oriented x4 Commands Follows Speech Clear Emotional Status AgitatedCalm Fontanelle N/A Gag reflex Present Swallow Present Movement RUE No movement Movement RLE No movement Movement LUE No movement Movement LLE No movement Sensation RUE Absent Sensation RLE Absent Sensation LUE Absent Sensation LLE Absent Normal Developmental Milestones N/A Eriksons Stage Generativity vs. Stagnation Neuro Comment Muscular Dystrophy diagnosed @ 18mos
Chest pain Absent Description of chest pain N/A Heart Sounds Regular Cardiac Infusions N/A Neck Vein Distention None Pulses Radial Location left Strength 2+ Pulses Carotid Location left Strength 2+ Pulses Brachial Location right Strength 2+ Edema location N/A Description N/A Capillary Refill Time Homans Sign RUE <3sec LUE <3sec RLE <3sec LLE <3sec
Genitourinary
Appearance of urine Clear yellow Incontinent Foley catheter 10/14/2011 @ 15cc Voiding Difficulties None Vaginal Discharge None Penile Discharge N/A AV Fistula None Bruit Negative Thrill Negative
Respiratory
Respirations Even, unlabored Chest Expansion Symmetrical Retractions Negative Breath Sounds (upper) Clear Quality Fine Heard on Inspiration/expiration Breath Sounds (lower) Clear Quality Fine Heard on Inspiration/expiration Cough Non-productive Sputum/Description N/A Room Air/O2/Vent/ETT Nasal Cannula O2 @ 2L Respiratory Comment Standing RT order
Gastrointestinal
Abdomen Slightly firm Abdominal girth UNK Bowel Sounds Hypoactive Nausea Intermittent Vomiting Intermittent Diarrhea N/A Constipation HX GI Comment None
Integumentary
Warm/Dry 4 Skin Intact present w/injury Wounds stage 1 decubitus left ear Dsgs/Tx N/A Braden Scale Sensory Perception 4 Moisture 2 Activity 1 Mobility 1 Nutrition 1 Friction & Shear 1 Total Points 10 Integumentary Comment Stage 1 bedsore left ear/rash perineal area
Musculoskeletal
Range of Motion:
Pain/Stiffness/Paralysis: RUE Paralysis LUE Paralysis RLE Paralysis LLE Paralysis Gait N/A Musculoskeletal Comment None
Bkft % 5
Time: 0730 T 98.7 P 88 R 16 B/P 91/55 SaO2 95 Lunch % Time: 1058 T 99.3 P 75 R _16 B/P 92/59 SaO2 95 Accucheck Time: N/A Result: N/A Intv N/A
Vital Signs
bes/Drains/IV
NGT None GT/JT None Foley October 14, 2011 Chest Tube None IV Location rt arm IV Fluid NS20MEQ KCL IV Rate 100mls/hr Condition of site Good
Pain
Scale 8 scale 0-10 Location head Palliative/Provocative dilaudid/movement Quality nausea/ aching Radiating/Referred referred/ head Timing approx. 2hrs post medication administration Pain Intervention dilaudid 2mg every 4hrs FLACC Scale: F N/A L N/A A N/A C N/A C N/A = Total N/A
Environmental
Call light within patients reach Baby monitor Bed in lowest position Yes Personal Items in reach Yes Assistive Devices in reach Yes ID bracelet in place Yes Side/Crib Rails Up x2 Isolation No
C. Manning,WGTC, ADNS
(Student Nurse Signature)
Date/Tim e
10/14/2011 0700
Student Nurses Notes At risk for skin breakdown related to limited mobility and incontinence. Client initially refused ADLs and agitated by unfamiliar staff.
Signature
C. Manning, WGTC, ADNS
10/14/2011 0900
10/14/2011 1100
C. Manning, WGTC, ADNS Assessed client and acquired vitals, client requested not to be disturbed and allowed to rest, Client state she was not able to rest the previous evening due to vomiting and pain. Fed client breakfast, morning medication was distributed by nurse C. Manning, WGTC, ADNS and alternative medication administered for pain due to low blood pressure by nurse. Client ate 5% of breakfast and fell asleep. Repositioned client and acquired a blood pressure of 127/60. NurseC. Manning, WGTC, ADNS was able to administer Dilaudid. Client requested assistance with ADLs and requested that linen not be changed. Client appeared to be improving as the day progressed.
Lab Procedures, Diagnostic Tests, X-ray & Diagnostic Studies: Please list all clients current lab results
Name of Test WBC RBC Hgb Hct Mcv MCH MCHC Plt count RDW Neut% Lymph% Mono% Eos% Date Clients Results Normal Findings 4.5-10.8 3.80-5.10 12.0-16.0 34.9-44.5 80-100 26-32 31.0-36.9 130-400 11.6-14.8 59% 34% 4.0% 2.7% Tissue stress necrosis, physiological Reason for this Abnormal Findings Yeast and UTI infections Clients
10/12/1 15.7 1 10/12/1 3.94 1 10/12/1 12.1 1 10/12/1 36.0 1 10/12/1 91.3 1 10/12/1 30.7 1 10/12/1 33.7 1 10/10/1 151 1 10/10/1 14.5 1 10/10/1 90.7 1 10/10/1 4.4 1 10/10/1 4.8 1 10/10/1 0.0 1
Lab Procedures, Diagnostic Tests, X-ray & Diagnostic Studies: Please list all clients current lab results
Name of Test Baso% PT PTT INR pH pCO2 pO2 HCO3 Base Arterial Hgb Date Clients Results Normal Findings Reason for this Abnormal Findings 0.5% 10 to 13sec 30 to 45 sec 2.0 to 3.0 7.35-7.45 35-45mmHg 80-95mmHg 22-26mEq/L (-2) (+3)mEq/L 11.7 16.1g/dL Non-smokers to 2% Smokers 10% Met hemoglobin Allen 10/10/1 0.1 1 10/10/1 positive 1 up upSmoker to hypoxemia COPD Absent of allergens Presence of anticoagulant lovenox circulating Clients
10/10/1 0.1 1 10/10/1 16.6sec 1 10/10/1 1.32sec 1 10/10/1 2.9 1 10/10/1 7.452 1 10/10/1 35.6 1 10/10/1 55.9 1 10/10/1 24.3 1 Excess10/10/1 +0.8 1 10/10/1 15 1
9.337.2micromol/L Positive
Lab Procedures, Diagnostic Tests, X-ray & Diagnostic Studies: Please list all clients current lab results
Name of Test Oxygen capacity Arterial/ O2 ratio Date Clients Results Normal Findings 15-22 Greater thanCOPD 0.75 95-99 135145mmol/L 3.5-5.0mEq/L 97-107mEq/L 22-26mmol/L 8-16Eq/L 10-31mg/dL Inadequate dietary protein COPD Reason for this Abnormal Findings Clients
10/10/1 20.3 1
Alveolar10/11/1 0.52 1 10/11/1 91.6L 1 10/11/1 135 1 10/11/1 3.5 1 10/11/1 103 1 10/11/1 24 1 10/11/1 12 1 10/11/1 6 1
Creatinine(Blood) 10/11/1 0.1 1 Glucose Osmolality Calcium 10/11/1 117 1 10/11/1 261 1 10/11/1 80 1
0.5-1.1mg/dL Decreased muscle Inadequate protein Muscular dystrophy <200mg/dL 250900mosm/kg 8.210.2mg/dL Inadequate nutrition
mass, intake,
Lab Procedures, Diagnostic Tests, X-ray & Diagnostic Studies: Please list all clients current lab results
Name of Test Mg2+ Total bilirubin AST ALT Alkaline phosphate Creatine kinase Date Clients Results Normal Findings 1.6-2.6mg/dL 0.3-1.2mb/dL 15-30units/L 7-35units/L 25 to 130 36-160units/LSmall lifestyle stature, sedentary Reason for this Abnormal Findings Clients
Medications
MEDICATION (Generic/Trade) Hydromorphone hydrochloride/ Dilaudid REASON RECEIVING Pain DOSE 1mg ROU TE NURSING INDICATIONS W/ MED IV Q3H PRN Respiratory depression, apnea, shock, cardiac arrest IV Q8H PRN Hypotension, chest pain IV Q8H PRN N/A Osteomalacia, constipation TIME
Ondansetron Nausea hydrochloride/ Zofran Sodium chloride/ Occluded IV Normal Saline flush Aluminum Heartburn hydroxide+magnesiu m hydroxide+simethicon e/ Mylanta Ipratropium Bromide/ Bronchodilator Atrovent Fluconazole/ Diflucan Yeast infection Anxiety/ depression Enoxaparin Sodium/ Antithrombotic, Lovenex low-molecularweight heparin Sodium chloride/ Occluded IV Normal Saline flush Albuterol Sulfate COPD, Shortness of breath Albuterol Sulfate COPD, Shortness of breath Senna+docusate Constipation sodium/ Senakot S Alprazolam/ Xanax
PO Q2H PRN
INH Q6H
Upper respiratory infection, pharyngitis IV Q24 SCH AST/ALT elevation, rash, abdominal pain PO BID SCH Bradycardia, tachycardia SQ Daily Hemorrhage SCH IV Q8H PRN N/A Bronchospasms Bronchospasms Dependence, perianal irritation
sodium biphosphate and sodium phosphate/ Fleet Enema Ceftriaxone sodium/ Rocephin
Constipation
1 tablet PO BID SCH (8.6mg sennosides+ 50mg docusate sodium 118ml PR 48H PRN
Rectal bleeding, seizure, fast/slow or uneven heart rate Nephrotoxicity, bone marrow suppression pseudomembranous colitis
UTI infection
50mls@100 mls/hr
IV Q24H SCH
Nausea/ vomiting
1 TOP Q4H PRN Poor wound healing, application weight gain 1 PO Q4H PRN Hepatic toxicity and tablet@10m failure, myocardial g damage hydrocodon e+400mg acetominop hen 25mg TOP Q4H PRN Epigastric distress, dysuria, thickening of bronchial secretions
Medications
NURSING INDICATIONS W/ MED Nystatin/ NY Stop Yeast infection/ 100,000 TOP TID Burning, rash Powder foot fungus units/mg irritation Metoclopramide hcl/ Nausea 10mg IV Q4H PRN Transient Reglan hypotension, diarrhea Pantoprazole/ Esophagitis 40mg IV Q12H URI symptoms, Protonix SCH pneumonia Potassium Chloride in Hydration 1000mls@10 IV Continuo Fluid volume Sodium Chloride 0mls/hr us overload, electrolyte imbalance, infiltration, phlebitis, nerve damage, circulatory overload, air embolism, systemic infection MEDICATION (Generic/Trade) REASON RECEIVING DOSE ROU TE TIME
Master List of All Identified Nursing Diagnoses Prioritize by Numbering* beginning with #1 as the Most Important Nursing Diagnosis
Identified from Nursing History and Nursing Assessment etc. *Note: There can be only one #1, one #2, one #3,
Biophysical
7)
Disturbed Sensory Perception as it
Psychosocial
12)
Readiness for Enhanced Communication as it relates to nurse/ client relationship as evidenced by clients increased willingness to communicate and express interest in ADLs.
Educational
5)
Noncompliance as it relates to
therapeutic plan as evidenced by clients frequent hospitalizations for incurred illness related to insufficient healthcare
1)
11)
of interest in personal care as evidenced by clients lack of interest in performing ADLs and eating.
4)
to perineal care as evidenced by recurring urinary tract infections and rash in the perineal area.
6)
10)
8)
it relates to diminished gross and fine motor skills as evidenced by the progression of muscular dystrophy
3)
patients immobility due to paralysis as evidenced by presence of stage one decubitus on client.
9)
relates to client changing physical appearance due to Muscular Dystrophy as evidenced by reluctance to have non family in room.
2)
declining respiratory function as evidenced by history of COPD and pulse ox reading of 55.9 upon admission.