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 ______________________________