Unit/Room Number:
Not listed for HIPPA purposes Date of Admission: July 2016
Age: 82 years old Ethnic/Cultural Preferences: Caucasian
Gender: Male Allergies: Adhesive
Eriksons Developmental Level: Code Status: DNR- Hospice
Despair
Co-morbidities: Cellulitis (right and left lower leg), anxiety, depression, insomnia,
lymphangitis, heart failure, atrial fibulation, hypertension, hyerlipidemia, anemia,
diabetes mellitus, chronic pain, GERD, gout, benign prostatic hyperplasia.
Discharge Plan (add day of clinical): Patient is present for hospice and will be at GSS
for the remainder of his life. Patient is present for pallative care.
Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
Diet (Type): Regular/Normal IV (Fluid type, rate, access type): None
I&O (MD order/Nursing Order/Frequency):
CBG (Yes/No, frequency): Yes, Q6H
Not measured or recorded
Fall Risk/Safety Precautions (Yes/No): Activity (What is ordered):
Yes Up in W/C or assisted with FWW.
Oxygen (Yes/No, Delivery method, how much):
Wound Care (Yes/No):
Yes, 2 LPM; nasal cannula, PRN in the
Yes, please see below ***
event that CRT is longer than 3 seconds.
Last BM: Patient has not had a BM since
Drains (Yes/No, Type): No
Sunday.
Other Tubes: Foley Catheter in place
ASSESSMENTS
(Include Subjective & Objective Data)
Thorax/Lungs:
Cardiac:
Musculoskeletal:
Gastrointestinal:
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CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Intended
Nursing
Action/ Adverse
Implications
Generic & Dose/Route/ Therapeutic reactions (1
Classification Onset/Peak for this client.
Trade Name Rate if IV use. Why is major side
(No more than
this client effect)
one)
taking med?
DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays,
CT, MRI, U/S, etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be
different.
Interpretation as
Lab Test Patient Values/ related to
Date
Normal Values Date of care Pathophysiology cite
reference & pg #
Sodium
8/29/16 135 145 mEq/L
141
Potassium
8/29/16 3.5 5.0 mEq/L
5.1 H CKD
Chloride
8/29/16 97-107 mEq/L
107
Co2
8/29/16 23-29 mEq/L
25
Glucose
8/29/16 118 H DM
75 110 mg/dL
BUN
8/29/16 8-21 mg/dL
49 H CKD
Creatinine
8/29/16 0.5 1.2 mg/dL
2.96 H CKD
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
8/29/16 8.2-10.2 mg/dL
9.2
Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
8/29/16 0.4
0.3-1.2 mg/dL
Total Protein
8/29/16 6.0-8.0 gm/dL
4.7 L CKD
Albumin
8/29/16 3.4-4.8gm/dL
3.2 L CKD/CHF
Cholesterol
<200-240 mg/dL
Alk Phos
8/29/16 25-142 IU/L
91
SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
8/29/16 4.5 11.0
7.3
RBC
8/29/16 male: 4.7-5.14 x 10 3.12 L CKD
female: 4.2-4.87 x 10
HGB
8/29/16 male: 12.6-17.4 g/dL 9.5 L CKD
female: 11.7-16.1 g/dL
HCT
8/29/16 male: 43-49% 29.6
female: 38-44%
MCV
8/29/16 85-95 fL
95.0
MCH
8/29/16 30
28 32 Pg
MCHC
8/29/16 33-35 g/dL
32
RDW
8/29/16 11.6-14.8%
16.9 L CKD
Platelet
8/29/16 male: 12.6-17.4 g/dL 9.5 L CKD
female: 11.7-16.1 g/dL
HCT
8/29/16 male: 43-49% 29.6
female: 38-44%
MCV
8/29/16 85-95 fL
95.0
MCH
8/29/16 30
28 32 Pg
MCHC
8/29/16 33-35 g/dL
32
RDW
8/29/16 11.6-14.8%
16.9 L CKD
Platelet
8/29/16 150-450
87 L CKD
DIAGNOSTIC TESTING
Interpretation as
related to
Date UA Normal Range Results Pathophysiology
cite reference &
pg #
Color/
8/24/16 Straw
Appearance
8/24/16 pH 5-9 5
8/24/16 Spec Gravity 1.005-1.030 1.018
8/24/16 Protein NEG NEG
8/24/16 Glucose Normal Normal
8/24/16 Ketones NEG NEG
8/24/16 Blood NEG NEG
Interpretation as
Other
related to
(PT, PTT, INR,
Date Normal Range Results Pathophysiology
ABGs, Cultures,
cite reference &
etc)
pg #
7/21/16 PTT 11.8-13.6 16.0 H ?
7/21/16 INR 1.4 0.8-1.3 H ?
Interpretation as
related to
Date Radiology Results Pathophysiology
cite reference &
pg #
There are no
fractures or
dislocations
identified. No
radiopaque
foreign bodies
or significant
soft tissue
findings are
AP Pelvis seen.No specific
8/24/16 X-Rays
1 or 2 views or significant
Interpretation as
related to
Date Radiology Results Pathophysiology
cite reference &
pg #
There are no
fractures or
dislocations
identified. No
radiopaque
foreign bodies
or significant
soft tissue
findings are
AP Pelvis seen.No specific
8/24/16 X-Rays
1 or 2 views or significant
degenerative
abnormalities
are identified.
Intramedullary
nail in the right
femur.
No significant
osseous
abnormalities.
Scans
EKG-12 lead
Telemetry
Data-
My patient passed today. When I arrived to clinicals, he had been demonstrating
Cheyenne-Stokes breathing. The charge nurse reported that he had been bed
ridden since yesterday. Sunday, he was mobile, but in a severe amount of pain.
Monday, patient stayed in bed and was sleeping, but responsive. Tuesday, patient
was completely unresponsive.
Action-
As a student nurse I took care measures, including: sitting with patient and talking
to him, reading to patient, applying lip balm PRN, wetting down mouth with lemon-
glycerin swabs.
Response-
While sitting with patient, his breathing changed to an agnal pattern, and he began
to vomit. I turned him on his side while a fellow student nurse ran to get a charge
nurse. At this time, patient opened his eyes briefly as I felt him pass.
This experience was very hard, but I am honored to have spent his last hours with
him.
I took this opportunity to work with the patients hospice nurse to perform post
mortem care. We cleaned him up, prepared his family, and assisted the gentleman
from the morgue in getting him to the van for transport. This was an invaluable
learning experience. I am glad that I could ease some suffering and help him in his
final moments.