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PATIENTASSESSMENTClient Age: 73 years old Gender: Male Resuscitation Status: Full CodeAllergies: NKDA Reason for Admission: LethargicMedical Diagnoses: Coronary Artery Disease (CAD), Pressure Injury to Coccyx, and Diabetes Mellitus IISurgeries/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 cardiomegalyPathophysiology 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 resistanceCurrent Orders:Diet: Low fat/ Low CholesterolActivity: One person assist with wheel chairIntake: 1800 mlOutput: 1300 mlAccu Checks: Daily at bedtime Vital signs: 98.5 (T), 103 (HR), 107/70 (BP), 20 (R), 98% on room airDressing changes/wound care: Daily wet to dry, cleanse open area to coccyx w/ NS, pat dry, and apply Allyn every other day oncoccyx area, for Stage 3 ulcer: apply BID and PRN on coccyx areaMost recent ImagingFindings:(CXR? CT? MRI?)Type of Imaging Body Area ImagedReason for testing and results of testCTChestUnremarkable no acute abnormal changesMost Recent Significant /RecentLabResults:(Chemistry? Hematology? Drug Levels? Coagulation tests?)DateLab TestResultsNormsWhy abnormal?8/5 9/18WBC13.959.55,000-10,000Infection on Coccyx9/30Glucose25260-120Diabetes8/5HGB13.612-16% (M) 12-16% (F)8/5HCT41.242-52% (M) 37- 47% (F)8/5PLT265150,000-400,000Other recent, significant procedures or tests (EKG, etc)DateTestReason for testing and results of test8/2018EchoCardiomyopathy EF: 15-20%Patient’s Developmental Stage according to Erikson: Ego Integrity vs. DespairYour assessment of this patient’s response to the opportunities and potential conflicts of this stage:1STUDENT: Harry Potter Sr._______________________Date of Care: ____09/30/2019___________