Demographic Information

Health History

Care Prescriptions

Age: XX

Chronic Health Conditions & Previous Health Problems:

Diet:  Regular

Gender: male

Race:  XX

Right>Left pleural effusion; Chronic A Fib; Chronic Renal Insufficiency; Hypokalemia; Constipation; Traumatic Pneumothorax x2 thoracentesis; cellulites bilateral with necrosis

›  G tube

› NG tube 

NOT APPLICABLE

Code Status:   DNR

Weight:  192 lbs.

Height:

68 in.

Activity:    ambulate with walker and assist with clinical assistant

Reason for Admission [residents own words]:

n/v for 5 days and went to the hospital and got pneumonia, and got cellulites in both lower extremities

Medical Complications:

I & O:  Client is encouraged to consume fluids. Voids while using the urinal    

Medical Diagnosis [medical terms]:

Pain in lower extremities; pain in right upper extremities.

Wound Care:  dressing change on bilateral lower extremities once a day

Acute cellulitis of bilateral lower extremities with necrosis; hyponatremia; community acquired pneumonia

Turning/Repositioning program

NOT APPLICABLE

Pulmonary care: 

Date of admission:  [date]

Nursing Diagnoses (3. prioritized)

1. Risk for infection r/t tissue destruction ABE breakdown on the sacrum
2. Risk for impaired skin integrity r/t diabetes AEB lesions and sores on lower extremities

3. Risk for ineffective tissue perfusion r/t impaired arterial circulation AEB 2+ edema bilateral on lower extremities

4. Risk for fall r/t impaired mobility AEB weight bearing pain on bilateral lower extremities

5. Risk for toileting self-care deficit r/t impaired mobility AEB need for assistance when ambulating

NOT APPLICABLE

Previous Surgeries                 When?

Tonsillectomy                      23 years old

Circumcision                        24 years old

    Med. › albuterol › atrovent 

                *other Combvient Inhaler

Allergies:

Glucometer:  Type II Diabetes

X ac/hs

X sliding scale insulin

No Known Allergies

Other: 

Discharge Plan/ Long Term Goals:

Regain strength to walk with out a walker

Name/Dose

Why does resident receive?

Major Side Effects

Nursing Implications

Acetaminaophen

500 mg tablets

2 tablets PO Q4

Mild pain and if temp reaches over 101 degrees

rash, acute poisoning, anorexia, nausea, vomiting, dizziness, lethargy, hepatotoxcity, hepatic coma, acute renal failure

monitor for signs and symptoms of hepatoxcity even with moderate acetaminophen doses, especially in individuals with poor nutrition or who have ingested alcohol over prolonged periods.

Lotrimin Cream

One application to feet BID

Acute Cellulites to bilateral feet

urogenial: vulvovaginal burning, itching, or irritation; maceration, allergic contact dermatitis

expect clinical improvement from topical application in 1-2 weeks.

Senna Plus

8.6-50 mg tablets

1 tablet PO BID

PRN

Constipation

abnormal cramps, flatulence, nausea, watery diarrhea, excessive loss of water and electrolytes

reduce dose in patients who experience considerable abdominal cramping.

the drug may alter your urine and feces color.

Glucotrol (XL)

5 mg PO Q day

Diabetis Mellitus Type 2

hypersensitivity to sulfonylureas, diabetic ketoacidosis,

observe response to initial dose, lab test to monitor liver function, check urine for sugar and ketone bodies, hypoglycemia maybe hard to detect at first.

Lasix

80 mg PO Q day

Diuetic

postural hypotension, dizziness, circulatory collapse, hypovolemia, dehydration, hyponatremia

closely and monitor blood pressure and vital signs, monitory s/s of hypokalemia, with older adults: observe periods of brisk diuresis, sudden alteration with fluid and electrolyte imbalance, lab test for frequent blood count, monitor I&O, monitor urine blood glucose in urine

Coumadin

2.5 mg PO Q day

A-fib and prophylactic

major or minor hemmerages form any organ and tissue, anorexia, nausea, vomiting, abdominal cramps,

determine PT/INP prior to initiation of therapy, obtain careful medication history prior to start of therapy, lab test for PT/INR,

Trazodone

50 mg 1 tablet PO Q bedtime

depression

drowsiness, dizziness, insomnia, headaches, agitation, hypotension, dry mouth, weight gain and loss

monitor pulse rate, monitor for change in behavior, observe patients level on activity, check for s/s of hypotension,

Uroxatral

10 mg 1 tablet PO Q day

Antispasmodic

fatigue, pain, dizziness, headache, abdomen pain, sinusitis, upper respiratory infection

monitor CV status and blood pressure, check postural vital signs to evaluate for orthostatic hypotension, check labs for baseline and periodic LFT's

Lipitor

10 mg 1 tablet PO Q day

Hyperlipidemia

back pain, asthenia, headache, constipation, diarrhea, increased liver function, rash

monitor therapeutic effectiveness which is indicated by reduction in the level of LDL-C, check labs for lipids levels, asses for muscle pain, monitor for digoxin toxicity with current digoxin use.

Toprol XL

50 mg PO Q day

Hypertension

red rash, fever, headaches, muscle aches, sore throat, dizziness, fatigue, insomnia, bradycardia, heartburn, shortness or air.

apical pulse and blood pressure because admin of drug, take several blood pressure readings, monitor I&O, daily weight,

Potassium Chloride

20 mcg 1 tablet PO BID

Hypokalemia

nausea, vomiting, diarrhea, abdominal distension, pain, mental confusion, irritability

monitor I&O ratio, check lab for serum, electrolytes are warranted, monitor for and report signs of GI ulceration, monitor potassium, , also patient has a risk of hyperkalemia.

Test

His Value

Normal Value

Na

138

136-146 mEq/L

K

3.3

3.5-5.0 mEq/L

Cl

105

98-106 mEq/L

Glucose

150 mg/dl

70-110 mg/dl

BUN

45 mg/dl

10-20 mg/dl

Creatine

0.7mg/dL

0.6-1.2 mg/dl

Calcium

5.4mg/dL

4.5-5.6 mg/dl

Bilirubin

0.5mg/dL

0.3-1.0nmg/dl

Albumin

3.7g/dL

3.5-5.0 g/dl

WBC

5,500 mm3

5,000-10,000 mm3

Hemoglobin

15 g/dl

14-18 g/dl

Hematocrit

0.48 SI units

0.42-0.52 SI units

Platelet ct

200,000 mm3

150,000-400,000 mm3

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

. Client states that he is weak and tired all the time. Client states that he has pain when walking around and that his legs stay swollen and that there are cracks/sores on both feet.

Objective

 Cellulitis with necrosis bilaterally to lower extremities.

3+ edema in left lower extremities and 2+ edema in the right lower extremities.

Type II Diabetes,.

Lesions on bilateral lower extremities.

Problem:

Risk for impaired skin integrity

Long Term:

Verbalize a personal plan for preventing impairs skin integrity on [date] at 1130.

For a client with limited mobility, monitor condition of skin covering bony prominences.

Rationale: pressure ulcers usually occur over bony prominences, such as the sacrum, coccyx, and heels. This is a result of unrelieved pressure between the prominences and support surface (Maklebust & Sieggreen, 2001; WOCN, 2003).

Teach the client skin assessment and ways to monitor for skin breakdown.

Rationale: early assessment and intervention helps prevent the development of serious problems. Basic elements of a skin assessment are assessment of temperature, color, moisture, and intact skin (Baranoski & Ayello, 2003).

Client will be taught what a part of his body is at most risk for skin break down. He will also be taught how to do a simplified skin assessment and what to look for if there is a breakdown or change in skin.

Nursing student observes the material being taught and made sure it was taught in a simple manner so that it was not to complex for the client. Nursing student will observe the client doing his own simplified skin assessment.

R/T

Diabetes

Short Term:

Client will be able to report any altered sensations or pain on bilateral lower extremities after teaching on [date] at 1630.

Monitor skin conditions at least once a day for color or texture changes, or lesions. Determine whether the client is experiences loss of sensation or pain.

Rationale: systematic inspection can identify  impending problems early (Ayello & Braden, 2002; Krasner, Rodeheaver & Sibbald, 2001).

Limit the number complete baths to two or three per week, and alternate them with partial baths. Use a tepid water temperature (90 and 105 degrees) for bathing.

Rationale: excessive bathing, especially in hot water, depletes again skin of moisture and increases dryness. The ability to retain moisture is decreased in the skin and starts to diminished amounts of dermal proteins. One of the most common age-related changes to the skin is damage to the stratum corneum (Baranoski, 2000; Ayello & Braden, 2003).

I

Client will be taught what to look for and how to inspect his own legs and will be able to demonstrate a self inspection of his lower extremities and be able to report is pain on a scale from 0-10.

Nursing student observes the client in doing a self inspection of his lower extremities. Client was able to report his findings and knows to report is there are any new ones.

Client also understood the importance of a pain scale and new how to implement it on a scale from 0-10.

AEB

Lesions and sores on bilateral lower extremities