DATE/TIME ASSESSMENT COMPLETED: October 14, 2011 /
Cardiovascular
LOC Alert and Oriented Pupils PEARL Orientation Oriented x4 Commands Follows Speech Clear Emotional Status Agitated→Calm 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 Erikson’s 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
RLE Negative LLE Negative
Cardiac Monitor In use Cardiovascular Comment None
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 patient’s 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
Assessment completed by:
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 ADL’s and agitated by unfamiliar staff.
Signature
C. Manning, WGTC, ADNS
10/14/2011 0720 10/14/2011 0730
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 ADL’s 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 client’s current lab results
Name of Test WBC RBC Hgb Hct Mcv MCH MCHC Plt count RDW Neut% Lymph% Mono% Eos% Date Client’s 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 Client’s
Malnutrition, septicemia Infections, hx thrombocytopenia Infection, stress of
Lab Procedures, Diagnostic Tests, X-ray & Diagnostic Studies: Please list all client’s current lab results
Name of Test Baso% PT PTT INR pH pCO2 pO2 HCO3 Base Arterial Hgb Date Client’s 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 Client’s
Lab Procedures, Diagnostic Tests, X-ray & Diagnostic Studies: Please list all client’s current lab results
Name of Test Oxygen capacity Arterial/ O2 ratio Date Client’s 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 Client’s
Lab Procedures, Diagnostic Tests, X-ray & Diagnostic Studies: Please list all client’s current lab results
Name of Test Mg2+ Total bilirubin AST ALT Alkaline phosphate Creatine kinase Date Client’s 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 Client’s
Rectal bleeding, seizure, fast/slow or uneven heart rate Nephrotoxicity, bone marrow suppression pseudomembranous colitis
UTI infection
50mls@100 mls/hr
IV Q24H SCH
Mometasone Furoate/ Elocon 0.1% Hydrocodone bitartrate and acetaminophen/ Vicodin
Dry skin Pain
Promethazine hcl/ Phenergan Topical Gel
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 ADL’s.
Educational
relates to altered sensory integration, reception, and/ or transmission as evidenced by paralysis.
5)
Noncompliance as it relates to
therapeutic plan as evidenced by clients frequent hospitalizations for incurred illness related to insufficient healthcare
1)
Chronic Pain related to atrophy of
involved muscle group as evidenced by clients reporting an 8 on a pain scale of 0 to 10.
11)
Hopelessness as it relates to lack
of interest in personal care as evidenced by client’s lack of interest in performing ADL’s and eating.
4)
Deficient Knowledge as it relates
to perineal care as evidenced by recurring urinary tract infections and rash in the perineal area.
6)
Risk for Disuse Syndrome as it relates
to unavoidable musculoskeletal inactivity as evidenced by progression of muscular dystrophy.
10)
Fear related to progression of
Muscular Dystrophy as evidenced by client’s declination to receiving care.
8)
Ineffective health maintenance as
it relates to diminished gross and fine motor skills as evidenced by the progression of muscular dystrophy
3)
Impaired Skin Integrity as it relates to
patients immobility due to paralysis as evidenced by presence of stage one decubitus on client.
9)
Disturbed Personal Identity as it
relates to client changing physical appearance due to Muscular Dystrophy as evidenced by reluctance to have non family in room.
2)
Impaired Gas Exchange related to
declining respiratory function as evidenced by history of COPD and pulse ox reading of 55.9 upon admission.