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Nursing 150 Clinical PacketPatient Assessment And Care PlanInstructions to student:1)Bring one copy of this packet with you to clinical each week.2)You will turn in a completed packet as assigned by your instructor.3)Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a Pass.
NURSING 150 CLINICAL ROTATIONCLIENT ASSESSMENT AND CARE PLANClient Initials: C.P. Room # D213 DOB: 08/15/1956 Age: 61 Years Gender: MaleAdmitted to facility Date: 11/28/2017Resuscitation Status: Full Allergies: NKDA- Demerol intolerance (nausea and vomiting) Reason for Admission: Laparoscopic Gastric Bypass _______________________________________________________________________________Social: M W S D Significant other, Next of Kin or POA for Health Care: Debra Parker________________________________________Occupation or former occupation: ___________________________________________________________________________Primary Health Care Provider(s): Christina Tecarro Consultants/Specialists: Igal BreitmanMedical Diagnoses: Diabetes Mellitus Type II, Sleep Apnea, Esophageal Reflux, heart murmur______________________________________________________________________________________________________Surgeries/Procedures and Dates: 11/28/2017: Laparoscopic Gastric Bypass _____________________________________________________________________________________________________________________________________________________________________________________Current Physician/Health Care Provider Orders (Prescriptions for Care)ITEM TYPETHIS RESIDENT’S ORDERSRATIONALEDietNPOTo avoid stomach and intestines stretchingand avoid ripping of stiches post gastric bypassActivity1 assist with walker, up in chair at least twice a dayPost : Laparoscopic Gastric Bypass I/OMonitoredMonitor fluid and electrolyte balanceVSEvery 4 hoursTo identify possible complications after surgery such as perfussionAccu-Cheks4 times a day- AC and HSMaintain control of glucose levelsFoley indwelling urinary catheterTo keep the bladder empty during surgery and to monitor output for the 1st24 hours after procedureNGN/AN/ASTUDENT: Tonia RodriguezDate of Care: 12/07/2017_________________
PEG/PEJ tubeN/AN/AWound Care / Dressing Change1stdressing change to be done by physician and change daily thereafter using clean gauze and steri stripTo prevent infection and promote wound healing.Respiratory TreatmentsIncentive spirometer 10x per hour To keep the air moving and keep the lungs health post-surgery- prevention of atelectasis Tracheostomy n/aSuctioningn/aChest Tuben/aSpecial EquipmentJackson Pratt Drainto remove fluids that build up in surgical areaLab ordersLast checked 11/08/2017 to be checked again on 11/29/2017 in the A.M.Monitor blood loss, monitor electrolyte levels and blood glucose levels, kidney andliver functionOtherSequential Compression Device (SCD) to be worn for 1st24 hours even when up in chair – per Dr BreitmanDVT prevention and promote blood flowRehab ServicesActivity or Treatment Plan & ScheduleRationalePhysical TherapyEvaluation scheduled for 11/29/2017to reduce pain, assess patients ability to perform daily activities, range of motion, function, and strength following procedure Speech Therapyn/an/aOccupational Therapy N/AIV Access:TypePeripheral Site: left handLast Dressing Change11/28/2017 Last Tubing Change:Reason for IV accessVenous access for fluid and medication administration IV fluids and medsNormal saline 0.9%, Cleocin 900 mg (once)Most recent ImagingFindings:(CXR? CT? MRI?)