NR 226 RUA......docx - PATIENT ASSESSMENT STUDENT_Jaspreet...

This preview shows page 1 - 5 out of 11 pages.

P ATIENT A SSESSMENT Age: ______85 years____ Gender: _____Male_____ Resuscitation Status ____DNR_____ Allergies________Fish, Ampicillin ______________ Reason for Admission: __________________Generalized body weakness, inability to care for self d/t forgetfulness.__ ______________________________________________________________ Medical Diagnoses: ___Iron deficiency Anemia, Dementia, Generalized anxiety disorder. Surgeries/Procedures and Dates: _________________Aortic valve replacement in 2017, Partial colectomy for colon cancer, knee replacement. Past medical history__________h/o colon cancer s/p partial colectomy, erosive esophagitis, diverticulosis, T1T2 fracture, Atrial fibrillation, diverticulosis, hypertension, hyperlipidemia, dizziness. Current Orders: Diet________Regular diet___________________ Activity_______light activity as tolerated_____________________ Intake ____________50-75% of the meals_______ Output_________________ Accu Checks____Not diabetic____ Vital signs_______________Bp-130/84 mmhg, temperature-98.4, O2 saturation-98%, RR-16/min, Pulse rate- 80/min________________________________________________________________________________ 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: _Check and record weight monthly, Blood labs every month, provide assistance with ADL’s as needed. ______________________________________________________________________________ __________________________________________________________________________________________ ____________ 1 STUDENT: ___________ Jaspreet Singh Dahia __________________ Date of Care: _______2/7/2020________
__________________________________________________________________________________________ ____________ __________________________________________________________________________________________ ____________ __________________________________________________________________________________________ ____________ __________________________________________________________________________________________ ____________ __________________________________________________________________________________________ ____________ __________________________________________________________________________________________ ____________ __________________________________________________________________________________________ ____________ __________________________________________________________________________________________ ____________ 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 N/A N/A N/A Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?) Date Lab Test Results Norms Comments 12/2/201 9 Na 138 135-145 High (high intake of Na or impaired renal excretion) 12/2/201 9 K 4.1 3.5-5.5 Normal 12/2/201 9 Cl 106 97-111 Normal 12/2/201 9 Blood glucose 85 70-120 Normal 12/2/201 9 Serum Creatinine 1.2 0.6-1.3 Normal 2
12/2/201 9 GFR 61 60(mean for age) Slightly elevated (Impaired renal function) 12/2/201 9 Serum albumin 4 3.5- 5.5 Normal 12/2/201 9 Total Protein 6.6 6.8-8.1 Slightly less (Can be due to decreased intake or poor absorption from GI tract) 12/2/201 9 LDL 66 89-212 Low (decreased risk for CVA) 12/2/201 9 WBC 8600 4000-11000 Normal 12/2/201 9 RBC 4.59 million 4.5-5.5 million Normal 12/2/201 9 Hct 41.4 42-52 Low (Anemic) 12/2/201 9 Platelet 160000 1.5-400000 Normal 12/2/201 9 Urine Analysis N/A N/A N/A Other recent, significant procedures or tests (EKG, etc) Date Test Reason for testing and results of test Based on the information on these pages and your assessment of this patient, what is your FIRST or PRIORITY concern and why? 3
Medications You may copy and paste these tables onto the next sheet if you have more medications Brand Name and Generic Name Normal Dosage Ranges Contraindications Lisinopril (zistril) 2.5-30 mg Allergies to ACE Inhibitors, Pregnancy Pharmacotherapeutic Class Dosage Ordered Adverse Reactions Ace inhibitor 10 mg Itching, blistering, nausea, vomiting, loss of appetite Why is patient receiving this med?

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture