EENT (ears, eyes, nose and throat): Patient ears were clear with no drainage; Auricles symmetrical and firm to the touch PERRLA. No presence of discoloration. Nose symmetrical and uniform in skin color. No sign of discharge or pain upon palpating. Oral mucosa pink and moist. Tongue is positioned midline. No jugular vein distention LOC: (level of consciousness) Patient was having an IV placed when arriving to room Patient alert and oriented x4. Response was congruent with statements NEUROLOGICAL: Patient’s eyes are reactive to light with no deviations. Face is symmetrical Normal eye closure and smile. MUSCULOSKELETAL:
Care Plan Patient arms and legs bilaterally were symmetrical with full coordinated movement. Patient was able to lift both hands; showed resistance to gravity Patient right foot pointed out and toes curled downward Patient has trace flicker in toes Right foot extensor spasm; dysesthesia in right foot and distal right leg Patient stated upon arrival that she felt a “Charlie horse” before foot drop occurred Patient is on Cyclobenzaprine, Diazepam, and Trospium are skeletal muscle relaxants CARDIOVASCULAR: BP was 122/60. Heart rate was 93. No murmurs or abnormal heart sounds noted on auscultation S1 and S2 noted. Radial pulse present; strong in both arms. Good expansion of chest wall. Patient on Chlorthalidone and Telmisartan for hypertension PULMONARY: Respirations were 22. Breath sounds were clear on bilateral auscultation GASTROINTESTINAL: Patient bowel sounds her in all four quadrants No tenderness or guarding Skin free of lesions NUTRITION: Patient is on a carb controlled diet Patient ate 90% of breakfast INTEGUMENTARY: Skin of extremities warm and dry. Skin turgor good.
Care Plan Capillary refill <3sec. Peripheral IV in right lateral medial forearm
Care Plan Augusta Technical College Care Plan Student Name: Rosalyan Talley Client Initials: J.P Clinical Date: 06/01/2017 Problem # 1 (Nursing Diagnosis/ NANDA) : to include subjective and objective data Acute pain relate to a physical injury as evidenced by patient self-reporting pain a 7 on a 1-10 scale General Goal Patient pain level will be a 3 on a 1-10 pain scale ( NOC) Expected Outcome Behavioral, Measurable, Observable, Realistic, & Time Limited Patient will report pain is relieved or controlled followed prescribed pharmacological regimen ( NIC) Nursing Interventions/ Rationale Patient Responses to Interventions Note patient’s attitude toward pain and use of specific pain medications, including any history of substance abuse. Patient may have beliefs restricting use of medications, may have a high tolerance for drugs because of recent or current use, or may not be able to take pain medications at all if participating in a substance abuse recovery program (Doenges, 2010, pg.
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- Spring '17
- mrs. Vargovich
- Nursing, Deglin