PRIORITIZE (label 1-4) KEY PROBLEM NURSING DIAGNOSIS 1 Abdominal pain Acute pain 2 Poor appetite Imbalanced nutrition less then body requirements. 3 Vertigo Ineffective individual coping 4 skin Risk for impaired tissue integrity
Psychosocial:
Anxiety level:
Calm, look drowsy but verbalized concern of been in the hospital, alert and oriented x 3
Visitors/support systems:
Two children are very involved and supportive said patient.
Neurological:
Glasgow coma scale (explain any deficiencies) Total 15.
Pupils (size/ reaction/ consensual): Rt: 3mm PERL Lt: 3mm PERL
Movement of extremities:
Unable to assess for the gait at the time, patient stated she can walk to the bathroom but not at the time, however bed pan was offered to the patient before the assessment. And strongly able to move all extremities with no pain verbalized..
BIS monitor reading: n/a
Other: Patient alert to person, oriented to place, oriented to time (3/117:30), however look drowsy.
Skin and Mucous Membranes:
Color:
Pink
Temperature (route):
7:30am 98.9 Axilla
10:00am 98.3 oral
12:00am 98.7 oral. warm to touch equal
Edema (specific location and grade): No edema present on assessment.
Wounds/incisions/drains
(including location, dressing, drainage): Colostomies on the left abdomen stoma with surrounding tissue pink in color, Tx change bag every day and PRN. middle Abdominal wound surgical incision site pink in color with 10 staples intact no drainage , no odor, no swelling noted Dehiscence measurement11x 2×6.5cm. Treatment wet to dry dressing twice daily and PRN. patient albumin level 4.8g/dl
Other:
Cardiovascular:
ECG rhythm n/a
Heart sounds:
Clear on auscultation, no murmurs, rubs or gallops, no edema.
Pulses(specific location and grade):: 2+ Redial pulses bilaterally and 2+ dorsalis pulses bilaterally.
Pacemaker: rate/mA/sensitivity: n/a
IV sites (List location, type of line, dressing appearance, fluid/rate)
Periphery line to the right for arm. Site no s/sx of (infection) no redness, no swelling observed.
Other:
Gastrointestinal:
Abdomen (inspection):
Non distended, no masses/tenderness, no organomegaly, no hernias, however Colostomy on the left lower abdomen, middle Abdominal wound surgical incision site pink in color with 10 staples intact no drainage noted, Dehiscence measurement11x 2×6.5cm. Treatment wet to dry dressing twice daily. Patient albumin level 2.4g/dl.
Bowel sounds:
Present in all quadrants. Colostomy bag with gas, small loose but not diarrhea in the bag
Diet:
Apetite: Patent was on NG tube progressed to clear liquid, than just started this morning on regular diet, appetite poor, ate only 25 % breakfast, and lunch only 15% .
Tube feeding (rate and type): n/a Residuals:
Ostomy (site and appearance): Pink tissue round surrounding site.
Stools: Colostomy bag with small loose but not diarrhea in the bag
Other: n/a
Genitourinary:
Urine (color, odor, character):
Clear yellow no odor urine
Catheter:
n/a
Conduit: n/a
Dialysis access:
n/a
INTAKE/OUTPUT
(24 hour total) INTAKE: PO: about 240cc IV:n/a OUTPUT: voided x 3, bed pan offered
Respiratory:
Artificial airway: n/a
ET tube (size):
(cm/mark-taped at teeth/gumline): n/a
Ventilator settings:
n/a
O2 saturation %:
7:30am 97% room air
10:00am 98% room air (3/11/15)
12:00am 98% room air.
Supplemental O2:
2L N/C PRN, not in use at the time of assessment.
Rate/depth/pattern/effort:
Regular, Even and unlabored. RR 18-20.
Breath sounds:
Unlabored, symmetrical.
Sputum:
Moist clear white
Chest tubes (location, drainage, amount of suction):
n/a
Other: n/a
Diagnostic Tests
Include relevant normal and abnormal findings; provide complete ABGs with interpretation
Test
Norms
Baseline
Current value/date
Why
Abnormal?
Test
Norms Admission
Value/date Current
value/date
Why
Abnormal?
White blood cells
4.8-10.8 14. 9 This result is elevated due to diverticulitis (inflammation) K
3.5-5.5 4.6 Within normal limit
Blood Sugar
75-120 109 mg/dl Within normal limit Mg 1.5-2.4mEq/l 2.0mEq/l Within normal limit
Hemoglobin
12.0-15.5 9.4gm/dl This result is low due perforated diverticulitis (inflammation and vitamin D deficiency. Na
130-144 138.0mmol/l within normal limit
Hematocrit
34.9-44.5 28.2% Within normal limit Cl 98-110 108.0mM Within normal limit
Platelets
150-450 402 Within normal limit Ph
PT/INR Ca 8.10.5 8.5mg/dl Within normal limit
APTT BUN
8.26 15 mg/dl This result is elevated due to perforated diverticulitis (inflammation and vitamin D deficiency
CK-MB
Creatinine 0.4-1.2 0.40mg/dl Within normal limit
Myoglobin
Albumin 3.4-5.4g/dl 4.8mg/dl within normal limit
Troponin
Protein 6.3-8.2 5.8mg/dl This result is low due perforated diverticulitis (inflammation
OTHER:
Other:
Chest x-ray:
12 lead EKG: Other abnormal:
ABGs: (pH, PCO2, HCO3, PO2, BE)
Interpretation:
Echo:
CT: Other abnormal:
Other: Other abnormal:
Medication Medication Medication
Augmentin 875/125mg 1 tab po q12hrs x 6days for surgical sit prophylaxis.
Ondansetron (zofraninjection) 2 mg/ml injection 2ml, iv push,Q6h PRN for nausea/vomiting.
Percocet 5/325mg 2 tab po q4hrs prn for pain Ibuprofen 600mg po 1 tab 4 times daily for pain
Meclizine 12.5mg po 1 tab po tid for vertigo Phenol 1.4 %throat spray 180ml (chlorasptic GEQ) 1 spray po prn for sore throat.
Premarin 625 1 tab poqhs, For post menopausal hormone replacement.
Asprin 81mg po 1 tab dail, for cva prophylaxis.
Vitamin D2 50,000iu cap po twice a week.
For vitamin D deficiency.
Daily MVI 1 tab daily for supplement
PART II: Key Problems and Associated Nursing Diagnoses
Directions: Based on the completed, corresponding patient data profile, do the following:
1) select 4 key problems
2) select 4 associated nursing diagnoses
3) prioritize the selections
Psychosocial:
Anxiety level:
Calm, look drowsy but verbalized concern of been in the hospital, alert and oriented x 3
Visitors/support systems:
Two children are very involved and supportive said patient.
Neurological:
Glasgow coma scale (explain any deficiencies) Total 15.
Pupils (size/ reaction/ consensual): Rt: 3mm PERL Lt: 3mm PERL
Movement of extremities:
Unable to assess for the gait at the time, patient stated she can walk to the bathroom but not at the time, however bed pan was offered to the patient before the assessment. And strongly able to move all extremities with no pain verbalized..
BIS monitor reading: n/a
Other: Patient alert to person, oriented to place, oriented to time (3/117:30), however look drowsy.
Skin and Mucous Membranes:
Color:
Pink
Temperature (route):
7:30am 98.9 Axilla
10:00am 98.3 oral
12:00am 98.7 oral. warm to touch equal
Edema (specific location and grade): No edema present on assessment.
Wounds/incisions/drains
(including location, dressing, drainage): Colostomies on the left abdomen stoma with surrounding tissue pink in color, Tx change bag every day and PRN. middle Abdominal wound surgical incision site pink in color with 10 staples intact no drainage , no odor, no swelling noted Dehiscence measurement11x 2×6.5cm. Treatment wet to dry dressing twice daily and PRN. patient albumin level 4.8g/dl
Other:
Cardiovascular:
ECG rhythm n/a
Heart sounds:
Clear on auscultation, no murmurs, rubs or gallops, no edema.
Pulses(specific location and grade):: 2+ Redial pulses bilaterally and 2+ dorsalis pulses bilaterally.
Pacemaker: rate/mA/sensitivity: n/a
IV sites (List location, type of line, dressing appearance, fluid/rate)
Periphery line to the right for arm. Site no s/sx of (infection) no redness, no swelling observed.
Other:
Gastrointestinal:
Abdomen (inspection):
Non distended, no masses/tenderness, no organomegaly, no hernias, however Colostomy on the left lower abdomen, middle Abdominal wound surgical incision site pink in color with 10 staples intact no drainage noted, Dehiscence measurement11x 2×6.5cm. Treatment wet to dry dressing twice daily. Patient albumin level 2.4g/dl.
Bowel sounds:
Present in all quadrants. Colostomy bag with gas, small loose but not diarrhea in the bag
Diet:
Apetite: Patent was on NG tube progressed to clear liquid, than just started this morning on regular diet, appetite poor, ate only 25 % breakfast, and lunch only 15% .
Tube feeding (rate and type): n/a Residuals:
Ostomy (site and appearance): Pink tissue round surrounding site.
Stools: Colostomy bag with small loose but not diarrhea in the bag
Other: n/a
Genitourinary:
Urine (color, odor, character):
Clear yellow no odor urine
Catheter:
n/a
Conduit: n/a
Dialysis access:
n/a
INTAKE/OUTPUT
(24 hour total) INTAKE: PO: about 240cc IV:n/a OUTPUT: voided x 3, bed pan offered
Respiratory:
Artificial airway: n/a
ET tube (size):
(cm/mark-taped at teeth/gumline): n/a
Ventilator settings:
n/a
O2 saturation %:
7:30am 97% room air
10:00am 98% room air (3/11/15)
12:00am 98% room air.
Supplemental O2:
2L N/C PRN, not in use at the time of assessment.
Rate/depth/pattern/effort:
Regular, Even and unlabored. RR 18-20.
Breath sounds:
Unlabored, symmetrical.
Sputum:
Moist clear white
Chest tubes (location, drainage, amount of suction):
n/a
Other: n/a
Diagnostic Tests
Include relevant normal and abnormal findings; provide complete ABGs with interpretation
Test
Norms
Baseline
Current value/date
Why
Abnormal?
Test
Norms Admission
Value/date Current
value/date
Why
Abnormal?
White blood cells
4.8-10.8 14. 9 This result is elevated due to diverticulitis (inflammation) K
3.5-5.5 4.6 Within normal limit
Blood Sugar
75-120 109 mg/dl Within normal limit Mg 1.5-2.4mEq/l 2.0mEq/l Within normal limit
Hemoglobin
12.0-15.5 9.4gm/dl This result is low due perforated diverticulitis (inflammation and vitamin D deficiency. Na
130-144 138.0mmol/l within normal limit
Hematocrit
34.9-44.5 28.2% Within normal limit Cl 98-110 108.0mM Within normal limit
Platelets
150-450 402 Within normal limit Ph
PT/INR Ca 8.10.5 8.5mg/dl Within normal limit
APTT BUN
8.26 15 mg/dl This result is elevated due to perforated diverticulitis (inflammation and vitamin D deficiency
CK-MB
Creatinine 0.4-1.2 0.40mg/dl Within normal limit
Myoglobin
Albumin 3.4-5.4g/dl 4.8mg/dl within normal limit
Troponin
Protein 6.3-8.2 5.8mg/dl This result is low due perforated diverticulitis (inflammation
OTHER:
Other:
Chest x-ray:
12 lead EKG: Other abnormal:
ABGs: (pH, PCO2, HCO3, PO2, BE)
Interpretation:
Echo:
CT: Other abnormal:
Other: Other abnormal:
Medication Medication Medication
Augmentin 875/125mg 1 tab po q12hrs x 6days for surgical sit prophylaxis.
Ondansetron (zofraninjection) 2 mg/ml injection 2ml, iv push,Q6h PRN for nausea/vomiting.
Percocet 5/325mg 2 tab po q4hrs prn for pain Ibuprofen 600mg po 1 tab 4 times daily for pain
Meclizine 12.5mg po 1 tab po tid for vertigo Phenol 1.4 %throat spray 180ml (chlorasptic GEQ) 1 spray po prn for sore throat.
Premarin 625 1 tab poqhs, For post menopausal hormone replacement.
Asprin 81mg po 1 tab dail, for cva prophylaxis.
Vitamin D2 50,000iu cap po twice a week.
For vitamin D deficiency.
Daily MVI 1 tab daily for supplement
PART II: Key Problems and Associated Nursing Diagnoses
Directions: Based on the completed, corresponding patient data profile, do the following:
1) select 4 key problems
2) select 4 associated nursing diagnoses
3) prioritize the selections
PRIORITIZE
(label 1-4) KEY PROBLEM NURSING DIAGNOSIS
1
Abdominal pain Acute pain
2
Poor appetite Imbalanced nutrition less then body requirements.
3
Vertigo
Ineffective individual coping
4
skin Risk for impaired tissue integrity
PATHOPHYSIOLOGY REVIEW NURS 424
Student Name:______________________________ Clinical Assignment #:_____
Pathophysiology Review
PATHOPHYSIOLOGY REVIEW NURS 424
Student Name:______________________________ Clinical Assignment #:_____
Pathophysiology Review