P
ATIENT
A
SSESSMENT
Client Age:
73 years old
Gender: Male
Resuscitation Status:
Full Code
Allergies:
NKDA
Reason for Admission:
Lethargic
Medical Diagnoses:
Coronary Artery Disease (CAD), Pressure Injury to Coccyx, and Diabetes Mellitus II
Surgeries/Procedures and Dates:
CABG x 4, 25 years ago, Automated Implantable Converter Defibrillator (AICD), 1
year ago
Past medical history: Hypertension, Hyperlipidemia, Type II Diabetes, and ischemic cardiomegaly
Pathophysiology Review: CAD is when plaque which is made of cholesterol builds up in the arteries. Pressure injury
results from inadequate blood supply into the tissues. Diabetes Mellitus II results in hyperglycemia from insulin resistance
Current Orders:
Diet: Low fat/ Low Cholesterol
Activity:
One person assist with wheel chair
Intake:
1800 ml
Output: 1300 ml
Accu Checks:
Daily at bedtime
Vital signs: 98.5 (T), 103 (HR), 107/70 (BP), 20 (R), 98% on room air
Dressing changes/wound care: Daily wet to dry, cleanse open area to coccyx w/ NS, pat dry, and apply Allyn every other
day on
coccyx area, for Stage 3 ulcer: apply BID and PRN on coccyx area
Most recent
Imaging
Findings:
(CXR?
CT?
MRI?)
Type of Imaging
Body Area Imaged
Reason for testing and results of test
CT
Chest
Unremarkable no acute abnormal changes
Most Recent
Significant
/Recent
Lab
Results:
(Chemistry?
Hematology?
Drug Levels? Coagulation tests?)
Date
Lab Test
Results
Norms
Why abnormal?
8/5
9/18
WBC
13.95
9.5
5,000-10,000
Infection on Coccyx
9/30
Glucose
252
60-120
Diabetes
8/5
HGB
13.6
12-16% (M) 12-16% (F)
8/5
HCT
41.2
42-52% (M) 37- 47% (F)
8/5
PLT
265
150,000-400,000
Other recent, significant procedures or tests (EKG, etc)
Date
Test
Reason for testing and results of test
8/2018
Echo
Cardiomyopathy EF: 15-20%
Patient’s Developmental Stage according to Erikson:
Ego Integrity vs. Despair
Your assessment of this patient’s response to the opportunities and potential conflicts of this stage:
1
STUDENT:
Harry Potter Sr._______________________
Date of Care:
____09/30/2019___________
