Corrections RUA NR226 Clincal .docx - PATIENT ASSESSMENT STUDENT Iva Lira Date of Care Age 83-years-old Gender Female Resuscitation Status Full Code

Corrections RUA NR226 Clincal .docx - PATIENT ASSESSMENT...

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P ATIENT A SSESSMENT Age : 83-years-old Gender: Female Resuscitation Status: Full Code Allergies: Penicillin, Sulfa Reason for Admission: Dementia; diabetes mellitus type II; severe muscle ataxia; fall risk Medical Diagnoses: Hypertension, dementia; osteoarthritis, knees bilaterally; major depressive disorder; diabetes mellitus type II; severe muscle ataxia; pancreatic disease; dyslipidemia; urinary incontinence; bowel incontinence; diarrhea; gastroesophageal reflux disease; hypomagnesemia; dysphagia; anemia Surgeries/Procedures and Dates: Esophagogastroduodenoscopy (date of procedure not charted) Past medical history: Hypertension, dementia; osteoarthritis, knees bilaterally; major depressive disorder; diabetes mellitus type II; severe muscle ataxia; pancreatic disease; dyslipidemia; urinary incontinence; bowel incontinence; gastroesophageal reflux disease; hypomagnesemia; gastrointestinal bleed; hypoglycemia; clostridium difficile colitis; dysphagia; anemia Current Orders: Patient eats meals in the dining room breakfast, lunch, and dinner. Diet: Soft Mechanical Diet, Thickened Nectar Liquids Activity: Non-ambulatory; wheelchair bound with one assist transfer from bed to wheel chair, bedside commode, and toilet use. Intake: Not assessed Output: Not assessed Accu-Cheks: Three times a day, prior to meals. 8:00am, 12:00pm, 5:30pm Vital signs: No current vital sign orders were notated in the chart. Vital signs taken by nursing student during clinical. Temperature: 98.4; Pulse: 68, Radial; Respirations: 14; SpO 2 : 98%; Blood Pressure: 112/68; Height: documentation unfounded; Weight: documentation unfounded; Apical Heart Rate: 68 Where is it?? Vital signs taken by nursing student?? Please provide vital signs here Dressing changes/wound care: Patient has a right thumb skin tear. Cleanse tear with non-sterile saline, pat dry. Apply xeroform and cover with dry dressing daily. Foley : Not ordered NG/G-tube/PEG/PEJ : Not ordered IV: Not ordered Other orders: Patient is a fall risk. Bed-side rails raised while patient is in bed due to fall risk. Patient requires gait belt with 1+ assist to transfer. Patient must have access to call light prior to staff leaving the room. 1 STUDENT: Iva Lira Date of Care: 03/08/19
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No liquids to be left in patient’s room. Most recent Imaging Findings: (CXR? CT? MRI?) No imaging results in chart. Most Recent Significant /Recent Lab Results: Chemistry? Hematology? Drug Levels? Coagulation tests?) Date Lab Test Results Norms Comments 2/13/1 9 White Blood Cells (WBC) 9.01 4.8-10.8 Within normal limits. WBC’s are checked for leukocytosis (white blood cell count is elevated) which may be a result of infection, stress, necrosis, neoplasia, or inflammation. In addition, this lab test is also performed to monitor for leukopenia (white blood cell count is decreased) which indicates bone marrow failure.
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