RUA NR226.docx - PATIENT ASSESSMENT STUDENT_Ariadne Abrica Date of Care_Nov 14 2019 Age_95 Gender_Female Resuscitation Status_DNA Allergies_Fragrance

RUA NR226.docx - PATIENT ASSESSMENT STUDENT_Ariadne Abrica...

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P ATIENT A SSESSMENT Age: __95__ Gender: ___Female___ Resuscitation Status ___DNA___ Allergies___Fragrance, Perfume, Cologne, Cosmetics, Cinnamon, and Caffeine___ Reason for Admission: _____Subdural Hematoma, Dementia, Malnutrition_____ Medical Diagnoses: ______Hypertension, Osteoporosis, Asthma, Anxiety, GERD_________ ________________________________________________________________________________________________________ Surgeries/Procedures and Dates: ___Unknow reason for Abdominal Surgery (Date: Unknown), Tonsillectomy to remove tonsils (Date: Unknown), Oophorectomy to remove one or both ovaries (Date: Unknown), Hemiarthroplasty on Left Hip to replace half the hip joint (Date: 2014) ______ Past medical history____Pelvic Fracture (Date: 2019) ____ ________________________________________________________________________________________________________ Current Orders: Diet_____Mechanical Soft, Thin Liquids_____ Activity_______Ambulates and eats on own_______ Intake ______N/A_______ Output______N/A_______ Accu Cheks______N/A________ Vital signs______T- 97.8 Degrees Fahrenheit, HR- 74, SpO2- 98, RR- 20, B/P- 162/48 R. arm, Pain- 0 __________ Drsg changes/wound care_______N/A________ Foley_______N/A________ NG/G-tube/PEG/PEJ______N/A______ IV ________N/A__________ Reason for IV________N/A__________ Other orders: _____4/2/19 STAT CT scan Pelvic area Reason: Patient had fallen______ _____4/7/19 Physical Therapy to Evaluate and Treat for 30 days Reason: Post-fall evaluation _____ _____4/8/19 CT scan of head Reason: Post-fall check up_____ _____10/1/19 Wanderguard in place Reason: to keep patient in the facility and to make patient is safe_____ _____10/21/19 Mechanical soft diet and thin liquids, remove dentures during meals Reason: patient was at risk for aspiration_____ _____10/25/19 Flu shot Reason: protocol of the facility and it is the flu season_____ _____10/29/19 Cleanse the Left Lower posterior leg, apply bacitracin, and cover with dry dressing Reason: to prevent skin infection due to small abrasions in the leg_____ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 1 STUDENT: ______ Ariadne Abrica ________ Date of Care: ___ Nov. 14, 2019 ___
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______________________________________________________________________________________________________ Most recent Imaging Findings: (CXR? CT? MRI?) Type of Imaging (X-Ray, CT, MRI, etc) Body Area Imaged Reason for testing and results of test CT Pelvic Are Patient had fallen Results: Pelvic Fracture CT Head Patient had fallen Results: Unknown Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?) Date Lab Test Results Norms Comments 10/7/1 9 CBC All normal except for MCHC (31) and MPV (13.4) MCHC 32-36% MPV 9.8-12.7 fL The low MCHC could be because of anemia. The slightly high MPV could be due to infection, inflammation, or heavy blood loss. 10/7/1 9 Basic Metabolic Panel All normal except for Glucose (114) Urea Nitrogen (32) GFR African American (49) GFR Others (49) Glucose 70-99 mg/dL Urea Nitrogen 8-23 mg/dL GFR African American 60- 300 GFR Others 60-300 The glucose could be due to high amounts of sugar in the blood. The high urea nitrogen could be mean that the kidneys are not working properly. The GFR being low could also be because the kidneys are not working properly.
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