Motor pt was able to grip with their hands push foot

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Motor: Pt was able to grip with their hands, push foot against nurses hand, and was able to wiggle their toes. Vision: Pt is legally blind. Hearing: Pt hearing appeared in tact. No assistive devices noted. Cardiovascular Heart Sounds: S 1 and S 2 present, strong and regular. No extra heart sounds or murmurs noted. Rate: 83 Rhythm: strong and regular PMI: Short, gentle tap located at the apex. Pulses (R/L): Temporal: Strong and regular bilaterally Carotid: Strong and regular bilaterally Brachial: Strong and regular bilaterally Radial: Strong and regular bilaterally Femoral: Strong and regular bilaterally Popliteal: Strong and regular bilaterally Posterior Tibialis: Strong and regular bilaterally Dorsalis Pedis: Strong and regular bilaterally Capillary Refill (<1-3 sec>): < 2 secs Pulse Deficit 72 bpm Pulse Pressure: strong and regular Skin color/temp: pale bilaterally, cry, warm. Edema (+/0; pitting/non-pitting): 0 Pulmonary Respirations: Rate 17 Rhythm: Even Depth: Symmetrical chest rise and fall Effort/Ease: Unlabored and effortless Breath Sounds (bilateral comparison) R/L – Diminished, Absent, Clear : Lungs clear bilaterally, No adventitious lung sounds noted. Oxygen Therapy: None noted. Gastrointestinal Diet: Diabetic Diet Intake (% of food): 1800 kcal Liquids: Intake: 2540+ N/V? No Mouth: Pink and moist.No lesions noted. Teeth/Dentures: Pale yellow, No cavities or broken teeth noted. Abdomen: (soft, distended, ascites, stomas): Skin tone is even, consistent with ethnic background, no lesions noted, skin is smooth an even. Normal is round. Abdomen is symmetrical. Umbilicus is
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CASE STUDY DATA FORM (HOSPITAL) 6 midline. no signs of inflammation, or hernia. Piercings are present/not present. No aortic pulsations are noted. Bowel sounds: Present Location: All four quadrants. Activity: Regular Last BM: 24 hours ago Stool Characteristics: NA Genitourinary Urine: Output Output: 1800+ Characteristics: Dark yellow, cloudy. Catheter (type): None Childbearing History (if applicable): Had one child, son, natural birth. 6. Clinical Manifestation of Current Condition: Expected Manifestations according to Literature for medical diagnosis (What are the expected signs and symptoms for this patient’s diagnoses; cite these findings) Full thickness skins involving damage to or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. (Bhattacharya & Mishra, 2015, p. 4) Presents clinically as a deep crater with or without undermining. (Bhattacharya & Mishra, 2015, p. 4) May present with lower extremity pain, calf tenderness, and lower extremity swelling. (Kesieme; Jebbin; Irekpita; Dongo, Assessment on Day of Admission or Health Care Visit According to Chart (How did the patient present to the hospital. Review ER notes, Nursing admission form, History & Physical and nursing narrative notes from day of admission). Include any expected manifestations from the first column that were present upon admission.
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  • Spring '16
  • Kim Hutapea
  • Gangrene, Bedsore

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