CLINICAL PAPERWOK 2 YIRELYS QUINONES.docx

CLINICAL PAPERWOK 2 YIRELYS QUINONES.docx - CLIENT DATA...

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CLIENT DATA COLLECTION ** Paperwork due in Dropbox by Thursday (Wednesday clinical) or Friday (Thursday clinical) each week you are in clinical at 23:59** Student Name: Yirelys Quinones Date: 03/01/2016 Client Initials: LH Room #: 306 Admission Date: 02/28/2016 Age: 61 Date of Birth: 08/08/1954 Sex: F Admitted From: Home________Nsg. Home________ Re-admit w/in last 30 days?___________ Tobacco: Type: N/A How Much: N/A How Long: N/A Alcohol: How Much: Not Regularly How Long: N/A Illegal Drug Use N/A Allergies & Reaction Hydrocodone/Headache, Cefzil (Cefprozil)/Diarrhea, Neosporin (neomycin, bacitracin, polimycin B)/Rash Isolation Type Standard Indication Fall precaution Glasses:_____Contacts:_____Dentures:_____Assistive Devices (specify): Walker, Wheelchair Advanced Directives:______________________________________________________________________________ Chief Complaint Osteoarthritis of multiple joints, resulting bilateral total knee arthroplasty, knee pain Admission Medical Dx:____________________________________________________________________________ Working Dx (If Applicable):_______________________________________________________________________ Past Medical History: Osteoarthritis of multiple joints, degenerative disk disease status post anterior cervical discectomy and fusion as well as posterior approach, migraine headaches, episodes of anxiety Past Surgical History: Bilateral total knee arthroplasty, C3 through C4 anterior (2010)/posterior (2014) Client’s Ordered Diet: Regular Diet Indication: N/A Description of Diet: N/A Patient Orders: N/A Peripheral IV Location #1: N/A Date of insertion: ______________ Gauge:__________ Peripheral IV Location #2: N/A Date of insertion: _______________ Gauge: __________ Central Location: N/A Date of insertion: _______________ Type:___________ DATE LAB TEST CLIENT VALUE HOSPITAL VALUE *Individualized* reason why abnormal 2/28/2016 Serum Cr. 0.5 Est 0.5-1.5 mg/dL 2/28/2016 Creatinine CL. 42.44mL/min DATE DIAGNOSTIC TEST INDICATION PATIENT RESULT Updated 1/6/2016 – Subject to change at the discretion of faculty 1
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MEDICATION NAME DOSAGE ROUTE FREQUENCY SCHEDULED TIMES Acyclovir 0.5mL PO MoWeFr 1411 Baclofen (for Lioresal) 10mg PO BID 0923/2100 Calcium Carbonate/Vitamin D (For Oscal 500+D) 1000mg (2 tab) PO qd 0924 Cholecalciferol (Vitamin D) 1000 units PO qd 0923 Cyanocobalamin (Vitamin B-12) 1000mcg/mL (1 vial) IM q14d Divalproex Sodium (Depakote Dr. Tablet) 250mg PO BID 0922/2100 Famotidine (Pepcid) 20mg PO q12h 0926/2100 Gabapentin (Neurontin) 400mg PO qid 0925/1700/2100 Meloxicam (Mobic) 7.5mg PO qd 0925 Multiple Vitamin Therapy Mineral (Theragran M) PO qd 0926 Polyethylene Glyco (Miralax) 17gm (1 packet) PO qd 0926 Prednisone 10mg PO qd 0926 Saccharomyces Boulordii (Florastor Kids) 250mg (2 packet = 500mg) PO BID 0957/1900 Senna/Docusate Sodium (Senna plus) PO HS 2100 Vitamin E PO qd 0924 Warfarin (Coumadin) 2.5mg PO qd 1600 Enoxaparin Sodium (Lovenox) 40mg/0.4mL SubQ q24h 1700 Updated 1/6/2016 – Subject to change at the discretion of faculty 2
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Nursing Physical Assessment Pre-Plan (From chart) Clinical Day Neuro: Orientation, LOC, Sensation, Pain, Pupillary Size & Response, dizziness or lightheadedness Alert & Oriented x3, No distress, Pupils equal/round/reactive to light Alert & Oriented, No dizziness/lightheadedness, Pain 5/10 Cardiac: Heart Rate #, regular/irregular, rhythm, BP, Skin Color, Heart sounds, Peripheral Pulses, Edema, Capillary refill HR 84, BP 105/63, S1 & S2 Unable to obtain HH/BP, Regular rhythm/sounds, S1 & S2, no edema, pulses normal Respiratory: Respiratory Rate #, regular/irregular, Respiratory effort, Breath Sounds, O2 Sat., RA or O2 delivery
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