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JACKSON COMMUNITY COLLEGE
NUR 171 SUPPORTIVE EDUCATIVE NURSING
PREPARATION FOR SAFE PATIENT CARE
Student Name: Stephanie A. Close
Date: 03/31/16
Rev 06.25.2012
DAY ONE PREPARATION - Critical Thinking Summary
Patient Room Number 204 _______ Age 94 _____ M/F F ___ CODE Status DNR LTD __________
Primary Medical Diagnosis Reason for Admission
Pain Control
Secondary Medical Diagnoses List all that impact patient’s care
Dementia; HTN; Arthritis; Constipation
Nursing Care Plan for PRIORITY Physiological Nursing Diagnosis
Nursing Diagnosis in PES Format Patient Expected Outcome
(measurable and with time frame)
Individualized & Prioritized Nursing
Interventions with Referenced Evidence/Rationale
P: Pain Use self-report pain tool to identify 1.Assess pain intensity level in a client using a valid and reliable self-report
Current pain level and establish a pain tool, such as the 0-10 numerical pain rating scale.
Comfort-function goal by 04-28-16. Rationale: Single-dimension pain ratings are valid and reliable as
measures of pain intensity level. (Ackley pg. 586)
E: Right Hip Fracture (Inoperable)
2.Describe the adverse effects of persistent unrelieved pain.
Rationale: Pain can have physiological and psychological consequences
S: Non-weight bearing, 2 Person Bed that facilitate negative client outcomes. Unrelieved pain can result in sup-
Mobility, Hoyer Lift pressed immune function, which can lead to infection, increased tumor growth,
AEB and other complications. (Ackley pg. 586)
Defining Characteristics Use Ackley text
book – did you pick the correct diagnosis? Use of a numerical pain rating scale,
Asking the client to rate the level of 3.Assess the client for the presence of pain routinely; this is often done at the
Pain is a subjective experience and its Pain from 0 to 10. Self-report is same time as when a full set of vital signs are obtained in the inpatient setting.
presence cannot be proved or disproved. Considered the single most reliable Assess pain during both activity and rest.
Self-report is the most reliable method of Indicator of pain presence and Rationale: Pain assessment is as important as physiological vital signs.
evaluating pain presence and intensity. Intensity. Pain Should be assessed both at rest (important for maximum comfort) and
R/T actual or potential tissue damage; (Ackley pg. 585) during movement (important for maximum function). Regular assessment of
clients with chronic pain is critical because changes in the underlying pain
diagnostic and therapeutic procedures; condition. Presences of comorbidities and changes in psychosocial circumstances can affect pain intensity. (Ackley pg. 586)
central or peripheral nerve injury (neuro- 4.Ask the client to maintain a diary (if able) of pain ratings, timing,
pathic pain) precipitating events, medications, and effectiveness of pain management
(Ackley pg. 584) interventions.
Rationale: Systematic tracking of pain has been demonstrated to be an
Important factor in improving pain management. (Ackley pg. 586)
Potential Complications If this patient’s condition were to worsen, what would be the most likely reason?
-Worsening pain -Worsening UTI
-Worsening HTN -Patient develops skin breakdown -Worsening dementia w/behavioral issues
-Constipation
-Decreased respirations
How will you be vigilant in monitoring for and preventing this complication?
-Vitals q 3 hrs -Pain scale q vitals and 30 mins post
Administration of analgesic -Response to analgesic -Monitor Labs
-Report anything that I’m uncomfortable With doing to ensure patient safety -Head to Toe assessment q shift
What will you do if it happens?
Call Bill and report to primary nurse.
SCHEDULE PROCEDURES CARE PATHWAYS
How will you organize your time? (Report, medications, ambulation, bath, charting, procedures, etc.)
What procedures do you have to do?
Be ready! (Catheters, injections, blood glucose monitoring, dressing changes, etc.)
Is the patient on a Care Pathway? Attach
pathway and/or agency PMP. (What do you need to do Day 1 and Day 2 according to the path or management plan?)
AM Report Injections Lovenox given subq Refer to patient cardx
Check Vital signs
Pass Meds
Give Breakfast
AM Care
Head to Toe Assessment
Diagnostic Tests if any scheduled
Subjective Interview
Check Vitals
Report
PATHOPHYSIOLOGIES
Primary Diagnosis Pathophysiology: Pain it is an unpleasant sensory sensation and emotional sensation that is associated with actual and potential tissue damage. Pain is urgent and has a primitive quality, that is responsible for the psychological, cultural, social and cognitive aspects of the pain experience.
Pain can serve a purpose, although unpleasant it can warn the body of impending tissue injury and motivate the person to move the affected area. Pain can be both acute and chronic, and can cause a lot of health problems. Acute pain results from injury, surgery or from invasive medical procedures, and is usually of short duration that will resolve when the underlying problem has been corrected. Chronic pain results from arthritis, back injury, or cancer and can persist longer than might be expected reasonably after the event has been resolved, it can be sustained by both pathological and physical symptoms. (Patho Text pg. 860 & 866)
Reference – Med/Surg or Patho text (less than 5 years old):
o Textbook S&S: The most reliable indicator of pain intensity and existence is by the patient’s self-report which can be described
as sharp, stabbing, aching, burning, ripping or the worst pain ever. Pain can also be observed as facial grimace, guarding of the injured area, moaning, increased BP, increased heartrate, and in some cases increased temperature. o Patient’s S&S: Patient will cry out and reach for her right knee when it is moved. Patient state “The nurse is her pain.” Patient’s
facial expression is grimaced and she is guarding her hip area.
Secondary Diagnosis Pathophysiology: Dementia is a non-normal decline in cognition that can be caused by any disorder that damages large areas of the cerebral hemispheres or subcortical area that store memory and cognition. Common causes of dementia are Alzheimer’s disease, frontotemporal dementia, vascular dementia, Wernicke-Korsakoff syndrome and Huntington chorea. Dementia diagnosis is based on assessment of the presenting problem; history of the person that is provided by a family member or informant (someone who has known the patient); a complete physical and neurological exam; an evaluation of behavioral, cognitive and functional status; imaging and labs. The most common illness that will masquerade as dementia, is depression it must be excluded for a diagnosis of dementia to be considered. Other problems that could lead to dementia like symptoms are drugs, hypothyroidism, declining vision and hearing, infection and anemia. (Patho Test pg. 948)
Reference – Med/Surg or Patho text (less than 5 years old):
o Textbook S&S: It is characterized by impairment of short and long-term memory, impaired judgement, defects in abstract
thinking, abnormalities of speech and personality changes. The changes can be become sever enough that they interfere with
the patients day-to-day functioning.
o Patient’s S&S: Patient is not orientated to place and time. Patient states “I have four children, I went to school until 4:30 and I have been married to my husband for 83 years. Patient claims she doesn’t get many visitors (RN states friends from church
just left).
Secondary Diagnosis Pathophysiology
Reference – Med/Surg or Patho text (less than 5 years old):
o Textbook S&S
o Patient’s S&S
Use additional sheets as necessary to complete all pertinent medical diagnoses.
MEDICATION SUMMARY
ALLERGIES and usual reaction Feldene
Generic/Brand Name
and Class Normal Dose Patient’s Dose
Times to Give Drug Action Why ordered for this
patient? Items to check before giving; when to hold
Two common side effects
You know med is working when:
Alendronate Fosamax Bone resorption inhibitor; Calcium
regulator
10mg once a day in the morning or 70MG weekly
70mg tablet q week po
Inhibits bone resorption via actions on osteoclast precursors
Treat osteoporosis in post-menopausal women
Monitor chemistries (esp. serum calcium, phosphorus, alkaline,
phosphatase levels)
Back Pain Abdominal Pain
Serum calcium, phosphorus, alkaline, phosphatase levels improve
Atenolol Tenormin
Anti-hypertensive
25mg per day 25mg po daily Blocks beta1-adrenergic receptors
in cardiac tissue. Slows sinus node
heart rate, decreases cardiac output.
Treat hypertension Assess BP, apical pulse immediately
before drug is administered (if pulse
is 60mins or less w/hold med & call Dr.)
Hypotension manifested as cold
extremities Constipation
High BP comes down
Calcium Carbonate Vitamin D Oscal D Electrolyte replenisher
1,250mg 1,500mg (caltrate 600mg) 500mg TUMS
1 tablet 250mg tid Essential for function integrity of nervous, muscular, skeletal systems. Plays
important role in cardiac function
Treatment/ prevention of calcium deficiency
Assess BP EKG and Cardiac rhythm
Chalky Taste Mild Constipation
Monitor serum BMP when calcium levels go up
Enoxaparin Lovenox
Anticoagulant
30mg sub-q twice a day for 7-10 days
w/initial dose given w/in 24hrs following surgery.
30mg/0.3mL sub-q daily
Produces anticoagulation. Does
not significantly influence PT.
Prevents blood clots, patient has a right hip
fracture
Obtain a baseline CBC note platelet count
Assess potential risk for bleeding
Injection site hematoma
Nausea
Platelet count in CBC is decreased
Vitamin D2
Ergocalciferol A fat soluble vitamin
10mcg (400units) per
day
50,000 units 1 tablet
po weekly
Stimulates calcium
transport in intestines & resorption in bones
Treatment/ prevention
of osteoporosis
Monitor serum urinary
calcium levels, serum phosphate, magnesium, BUN creatine
Hypercalcemia
Decreased renal function
Serum calcium levels
increase
Lasix
Furosemide Loop Diuretic
Initially 20-
80mg/dose; may increase by 20-40mg/dose every 6-8
hours
20mg po daily Enhances excretion of
sodium chloride, potassium by direct action at ascending
limb of loop of Henle.
Treatment of
hypertension
Check vital signs esp.
BP and pulse for hypotension before administration. Assess
skin turgor
Nausea
Dizziness
High BP decreases
Insulin Type Onset
Peak
Duration
Generic/Brand Name
and Class
Normal Dose Patient’s Dose
Times to Give
Drug Action Why ordered for this
patient?
Items to check before
giving; when to hold
Two common side
effects
You know med is
working when:
Haldol Haloperidol Vial
Butyrophenone
antipsychotic
2-5mg q 4-8hrs prn 5mg/mL IM injection at bedtime
Competitively blocks postsynaptic
dopamine receptors in
brain. Produces tranquilizing effects
Patient has a history of suicidal ideation
Monitor BP, heart rate Monitor for rigidity
tremor mask like facial
expression
Blurred Vision Constipation
Interest in surroundings and
increased ability to
concentrate
Norco
Hydrocodone/ACT Opioid Agonist
2.5-5mg q 4-6 hrs 5/325mg po in the am
and HS
Binds w/opioid
receptors in CNS. Reduces intensity of incoming pain stimuli from sensory nerve
endings altering pain perception
Patient has pain due
to right hip fracture that is inoperable
Obtain vital signs if
respirations are 12/min or less w/hold medication contact physician
Constipation
Hypotension
Pain decrease per
patient’s pain score
Xalatan Latanoprost
Prostaglandin analog
0.005% drop in each eye daily before bed
0.005% drop for each eye HS
Reduction of elevated intraocular pressure
Treatment of Glaucoma
Obtain vital signs Assess for history /
presence of glaucoma
monitor development of eye pain
Eyelid crusting Redness
Patient demonstrated intraocular pressure
reading within normal
range
Lidocaine
Lidoderm Amide Anesthetic
Apply to affected
areas as needed for up to 12 hrs in a 24 hr period
5% patch 12 hrs on &
12 hrs off to affected area 1 patch only
Inhibits conduction of
nerve impulses causes temporary loss of feeling/sensation
To help treat pain in
the right hip
Baseline BP, pulse,
and respiratory rate
Burning, stinging
tenderness at application site
Patient pain score in
the right hip area decreases
Namenda Memantine Anti-Alzheimer’s agent
5mg daily, may increase dosage at intervals of at least of at least 1 week in 5mg
increments to 10mg/day (5mg bid)
5mg tablets take 2 tablets by mouth twice a day
Decreases effects of glutamate, the principal excitatory neurotransmitter in
the brain.
Patient has Dementia Assess cognitive behavioral functional deficits of patient Assess renal function
Dizziness Headache
Patient’s memory improves or is not diminishing
Macrodantin Nitrofurantoin
Macrocrystal Cap Antibiotic
50-100mg q 6 hours Maximum: 400mg/day
50mg take 2 tablets po daily
Inhibits with bacterial enzyme systems,
interfering w/metabolism and cell wall synthesis
Treatment for Chronic UTI
Question for history of asthma
Evaluate baseline renal function LPT
Anorexia Nausea / vomiting
UTI Symptoms decrease
Mirlax
Polyethylene Glycoln Osmotic / laxative
17g or 1 heaping tbsp.
per day
17g daily mix in 8oz of
water or juice hold dose if having loose stools
Osmotic effect induces
diarrhea, cleanses bowel without depleting electrolytes
Treatment of
Constipation
Do not give oral
medication within 1 hr of start of therapy (may not adequately
be absorbed before GI cleansing)
Nausea
Bloating
Patient has a bowel
movement daily
Insulin Type
Onset
Peak
Duration
Note: You may choose to use hand-written or pre-printed medication cards, but be sure to STUDY and KNOW their contents!
LAB VALUES SUMMARY
Medical Diagnosis
Diagnosis #1 Diagnosis #2 Diagnosis #3 Diagnosis #4
List laboratory and diagnostic tests found in your text for admitting and secondary medical diagnoses.
Pain Dementia HTN Arthritis
CBC diff/indices CRP CBC diff
Electrolytes Renin (Angiotensin) CRP
X-ray, CT, MRI PET Scan, Monitor
SED rate
Blood glucose
during test
ANALYSIS OF LAB VALUES
Test Normal Value Admitting
date / value
Follow up
date / value 03/26/16
Cause of abnormal
finding
Implications for
care
RBC
(4.2-5.4) 3.69 L Anemia Monitor Labs
Hemoglobin
(12.0-16.0)
11.5 L Anemia Monitor Labs
Hematocrit
(37.0-47.0)%
34.9 L Anemia Monitor Labs
Platelets
WNL
WBC (diff prn)
WNL
Sodium
WNL
Potassium
WNL
Chloride
WNL
CO2
WNL
BUN
(6-20) 22 H Urinary tract
obstruction/infection
Monitor Labs
Creatinine
WNL
Albumin
(3.5-5.0) 3.2 L Poor nutrition Monitor Labs
Coagulation studies
WNL
Total Protein (3.5-5.0) 5.6 L Poor nutrition Monitor Labs
Assess amount Of food eaten
Daily
RDW-SD
(35.1-43.9)
45.4 H
Iron Deficiency
Anemia
Monitor Labs
Give Iron Supplement
ANALYSIS OF LAB VALUES Day 2 List all other pertinent normal or abnormal lab values.
Test Normal Value Admitting date
/ value
Follow up date
/ value
Cause of
Abnormal finding
Implications for
care
CBC
03/29/16
RBC
(3.70-5.30) 3.51 L Anemia Monitor Labs
Give Iron
Hemoglobin
(11.8-16.0) 11.1 L Anemia Monitor Labs
Give Iron
RDW-SD
(35.1-43.9) 45.8 H Iron Deficiency Monitor Labs
Give Iron
Hematocrit
(35.0-48.0)% 33.2 L Anemia Monitor Labs
Give Iron
CMP
03/29/16
Albumin
(3.5-5.0) 3.1 L Malnutrition Monitor Labs
Asses Pt Intake
Total Protein
(6.0-8.0) 5.6 L Malnutrition Monitor Labs
Assess Pt
Intake Daily
Student Name _____Stephanie A. Close _______________________________________ Date ___03/31/16________
Patient Age/Sex __94/F________ Medical Diagnosis: R. Hip Fx (inoperable), pain control Code Status: DNR LTD _____
MENTAL STATUS
LOC and orientation X3 Oriented x 1
Appearance Appropriate
Cognition Answers questions inappropriately
PAIN
Location, severity, quality, radiation, duration, precipitating/alleviating factors, associated symptoms
R. Hip, 0/10, pain observed with movement, facial grimacing, Norco
Given for pain control
HEAD AND NECK
Hair and skin Clean, Dull, white, evenly distributed
Eyes: sclerae, conjunctivae, pupil reactivity White, pink, no exudate noted, pupils non-reactive pt on pain meds
Eyes: vision/aids Wears glasses
Ears: lesions, hearing/aids No lesions noted, hearing aids present
Nose: symmetry, mucosa, drainage Symmetrical, pink, moist, no drainage noted
Mouth: mucosa, tongue, dentation, lesions Pink, dry, midline
Swallowing/ Appetite No dysphasia, appetite poor
Trachea position Midline
JVD at 45 degrees No JVD noted @ 45 degrees
UPPER EXTREMITIES
Skin Pink, dry, warm, no lesions noted
Pulses (brachial, radial) +2, regular, equal bilaterally
Capillary refill >3 seconds
Strength/ROM Right hand stronger grip than Left hand
Turgor/edema Elastic, Edema noted Left forearm
CHEST/BACK
Shape AP: Transverse Diameter 1:2, symmetrical
Respiratory effort/SpO2 No use of accessory muscles, non-labored breathing, 95% RA
Cough/sputum No cough noted
Lung sounds anterior and posterior Bilateral anterior upper lobes clear and equal, anterior right lower lobe clear, anterior left lower lobe unobtainable
Skin condition/integrity Pink, warm, dry, no varicosities noted
Heart sounds Unobtainable
Apical pulse rate/rhythm (auscultate full min) 92bpm
ABDOMEN/PERINEAL AREA
Contour, symmetry Soft, Distended, symmetrical
Bowel sounds in 4 quadrants Active present in all 4 quadrants
Tenderness Unobtainable
Urinary pattern/color Foley Catheter noted, yellow, clear
Bowel pattern/character/last BM 03/31/16
Perineum (if appropriate) N/A
LOWER EXTREMITIES
Skin color/integrity Pale, pink, dry, warm, no lesions noted
Edema Present bilateral lower legs +2 bilaterally
Pulses (femoral, popliteal, PT, DP) Dorsalis Pedis + 1, regular, equal bilaterally, All others N/A
Capillary refill >3 seconds
Strength/ROM N/A
EQUIPMENT
Pumps N/A
Tubes Foley Catheter
DURING SHIFT
Vital signs/time 1030: HR 92, RR: 12, BP 146/67, Temp: 97.6 oral, Pain 0/10
Blood glucose monitoring results/insulin N/A
Intake and output
Food intake/Appetite/Nausea Ate >25% of breakfast, poor appetite
IV solution and rate/hourly checks N/A
Significant lab results High BUN, RDW-SD; Low RBC, Hemoglobin, Hematocrit, Albumin, Total Protein
Support system/SO involvement Daughter and Son; staff states they visit often
Patient education completed Unobtainable
NURSING DIAGNOSIS
Chronic Pain, r/t inoperable right hip fracture, aeb: patient gives facial grimaces with movement of right leg.
___________________
______
SOAP NOTE (on above nursing diagnosis only)
S= Patient is in end stage Alzheimer’s disease, states “You people are always wanting to look at belly,” as she tries to pull her
hospital gown down. ______
O= VS: BP: 146/67, Pulse: 92 bpm, RR: 12, Temp: 97.6 oral, Pain level 0/10. CV: Edema noted Left forearm and bilateral lower legs.
Capillary Refill >3 seconds in upper and lower extremities. Brachial, and radial pulses +2 regular and equal bilaterally. Dorsalis Pedis
pulses +1 regular and equal bilaterally. No JVD noted @ 45 degrees. RESP O2 SAT: 95% RA. Anterior upper lobes clear and equal
bilaterally, right lower lobe clear, left lower lobe unobtainable, breathing is non-labored, no use of accessory muscles noted. GI:
Bowel sounds active and present in all four quadrants. Abdomen is soft, distended and symmetrical. Bowel movement reported
03/31/16. Normal diet, >25% food eaten, poor appetite. GU: Catheter noted, yellow clear urine noted. SKIN: Pale pink, warm and
dry. No lesions or breakdown noted. NEUR: Client oriented x 1, patient has dementia, PERRLA not present. Grasps stronger on right
hand then left hand. MUSC: Patient is a two person assist with a Hoyer lift, at risk for falls and a bed alarm is present. ______
A= Provide a warm blanket for patient to cover upper chest when abdomen has to be exposed for examination. _________________
P=Continue_nursing_care, administer_warm_blanket_prn_with_examination_and_with_medication_administration. ____________
END OF SHIFT CHECK-OUT
Patient safe and comfortable Meds administered Reported off to RN and instructor
I&O documented MAR signed Student signature ______________________________
DAY TWO PREPARATION
EVALUATION
Did you choose the appropriate nursing diagnosis for Day One? □Yes □No
What would have been a better choice?
Were your objectives and interventions appropriate? □Yes □No
What would have been more appropriate?
Nursing Care Plan for SECOND PRIORITY Nursing Diagnosis
Nursing Diagnosis in PES Format Patient Expected Outcome (measurable and with time frame)
Individualized & Prioritized Nursing Interventions with Referenced Evidence/Rationale
P Constipation Maintain passage of soft, formed 1.Check for impaction; if present, perform digital removal of
Stool every 1 to 3 days without Stool per provider’s orders.
E r/t use of opioid pain medications Straining by 04/07/16. Rationale: An impaction is hard stool that is too large to move
through the sphincter and must be removed manually.
(Ackley, 2014. Pg 241)
S abdominal distention, lack of activity 2.Provide prune or prune juice daily.
due to inability to ambulate. Rationale: Each 100 g of prunes contain about 6 g of fiber, 15 g of
AEB: Sorbitol, and 184 mg of polyphenol; all have laxative effects.
Defining Characteristics (from book – did
you pick the correct diagnosis?)
Elimination pattern/stool soft and (Ackley, 2014. Pg 241)
Formed/Passage of stool without 3. Provide privacy for defecation. If not contraindicated, help the
Decrease in normal frequency of defecation, Aids/Ease of stool passage. Client to the bathroom and close the door.
Accompanied by difficult or incomplete passage (Ackley, 2014. Pg 239) Rationale: Bowel elimination is a private act in Western cultures, and
Of stool and/or passage of excessively hard, dry A lack of privacy can hinder the defecation urge, thus contributing to
Stool. (Ackley, 2014. Pg 238) Constipation. (Ackley, 2014. Pg 242)
4.Use Opioids cautiously.
Rationale: Opioids cause constipation. (Ackley, 2014. Pg 243)
Student Name _____Stephanie A. Close_______________________________________ Date _04/01/16____________
Patient Age/Sex ___94/F_____ Medical Diagnosis: R. hip fracture (inoperable) pain control Code Status DNR LTD_____
MENTAL STATUS
LOC and orientation X3 Oriented x 1
Appearance Appropriate
Cognition Answers questions inappropriately
PAIN
Location, severity, quality, radiation, duration, precipitating/alleviating factors, associated symptoms
0/10, right knee, uncomfortable, patient shouts out and reaches for
The right knee with movement, Norco given @ 1:45am, 6:45am and
10:20am to keep pt comfortable.
HEAD AND NECK
Hair and skin Clean, dull, white, evenly distributed
Eyes: sclerae, conjunctivae, pupil reactivity White, pink, some exudate noted before am care, PERRLA not present
Eyes: vision/aids Wears glasses
Ears: lesions, hearing/aids No lesions noted, hearing aids present
Nose: symmetry, mucosa, drainage Symmetrical, pink, moist, some drainage noted
Mouth: mucosa, tongue, dentation, lesions Pink, dry, midline
Swallowing/ Appetite No dysphasia, appetite poor, patient thirsty
Trachea position Midline
JVD at 45 degrees No JVD noted @ 45 degrees
UPPER EXTREMITIES
Skin Pink, some excessive dryness, warm, no lesions noted
Pulses (brachial, radial) + 2, regular, equal bilaterally
Capillary refill >3 seconds
Strength/ROM Right hand stronger than left hand
Turgor/edema Elastic, no edema noted
CHEST/BACK
Shape AP: Transverse Diameter 1:2, symmetrical
Respiratory effort/SpO2 No use of accessory muscles, non-labored breathing, 91% RA
Cough/sputum No cough noted
Lung sounds anterior and posterior Bilateral upper lobes clear and equal, right lower lobe clear, Left lower lobe unobtainable.
Skin condition/integrity Pink, dry, no varicosities noted, warm, large moles noted between breasts, and access powder noted under bilateral breasts
Heart sounds Unobtainable
Apical pulse rate/rhythm (auscultate full min) 72bpm
ABDOMEN/PERINEAL AREA
Contour, symmetry Distended, soft, symmetrical
Bowel sounds in 4 quadrants Hypoactive in all 4 quadrants
Tenderness Unobtainable
Urinary pattern/color Foley catheter noted, yellow, clear
Bowel pattern/character/last BM 04/01/16 runny, green/brown, incontinent
Perineum (if appropriate) N/A
LOWER EXTREMITIES
Skin color/integrity Pale, pink, excessive dryness, left leg cool, left foot & right leg warm
Edema No edema noted
Pulses (femoral, popliteal, PT, DP) Dorsalis Pedis +2 bilaterally
Capillary refill >3 seconds
Strength/ROM N/A
EQUIPMENT
Pumps N/A
Tubes Foley Catheter
DURING SHIFT
Vital signs/time BP: 139/79, HR 56, RR: 16, Temp: 98.4 oral, Pain: 0/10 Time: 1055
Blood glucose monitoring results/insulin N/A
Intake and output 20oz apple juice
Food intake/Appetite/Nausea ¼ banana raw, 1 cookie
IV solution and rate/hourly checks N/A
Significant lab results High RDW-SD; Low RBC, Hemoglobin, Hematocrit, Albumin, Total Protein
Support system/SO involvement Daughter and Son; Staff says they visit often
Patient education completed N/A
NURSING DIAGNOSIS
Constipation r/t opioid pain medications, aeb: abdominal distention, lack of activity due to inability to ambulate. ______
SOAP NOTE (on above nursing diagnosis only)
S: Patient at risk of constipation due to opioid pain medications, aeb: lack of activity due to inability to ambulate.
O: VS: BP: 139/79, HR: 56, RR: 16, Temp: 98.4 oral. CV: No edema noted, capillary refill >3 seconds x 4. Brachial and radial pulses +2,
regular, equal bilaterally. Dorsalis pedis pulses + 2 regular, and equal bilaterally. No JVD noted @ 45 degrees. RESP: O2 Sat: 91% RA,
Lungs clear and equal bilaterally upper lobes, right lower lobe clear, left lower lobe unobtainable, non-labored breathing, no use of
accessory muscles noted. GI: Bowel sounds hypoactive in all 4 quadrants. Abdominal distention noted, abdomen is symmetrical, ___
palpation unobtainable. Bowel movement noted runny, green/brown, incontinence noted. GU: Foley catheter noted, urine yellow
and clear. Skin: Pink, warm, with excessive dryness on bilateral hands and feet. No lesions or breakdown noted. NEUR: Oriented x 1,
PERRLA not present due to pain medication, strong grasps on right hand, left hand weaker. MUSC: Patient is a two person assist with
a Hoyer lift, at risk for falls, and has a bed alarm in place. ______
A: Patient tolerating stool softeners well and is defecating in small amounts daily.
P: Continue stool softeners as order for patient and push fluids.
END OF SHIFT CHECK-OUT
Patient safe and comfortable Meds administered Reported off to RN and instructor
I&O documented MAR signed Student signature ______________________________
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