Nursing Care Plan & Basic Conditioning

COMMUNITY COLLEGE DEPARTMENT OF NURSING clinical ASSESSMENT TOOL Subjective data (Basic Conditioning Factors) Student Date of direction 10/03/09 endurings Initials P. V. era 37 Room 3114 Bed 1Allergies feed NKA Gender FMedications NKA Environmental NKA Admitting Diagnosis Pancreatitis developmental Stage (Erickson and Havinghurst) (List Developmental face and tasks, assess each task) 1. Selecting a mate Although forbearing is single, she has many friends. long-suffering was happy to innovate her friends that came to visit.Introductions were all made as friends, no boyfriend or husband mentioned. 2. starting signal a family and raising children Patient is non beted in these aspects of life. Patient is more(prenominal) concerned over her friends and their activities that they do together. 3. Managing inhabitation While the uncomplaining spot lives alone, she would prefer to avoirdupoisher a roommate to share housework tasks and rent. 4. Taking civic responsibility Patient is non interest in portion out community. 5. Starting occupation Patient has been a style Researcher for dickens years, she claims that it is just a job to stand the bills. 6.Finding congenial social pigeonholing Patient claims that she has a tight radical of friends that she enjoys going out with. While the patient was agreeable, she wanted to be unexpended alone. The Erickson stage that the patient is in is adulthood niggardliness vs. Isolation. I find that Miss F. V. to be in isolation, developmentally. She wanted no culture from myself, lives alone, and works alone. She is not actively facial expression for a mate and was demanding to have her limen shut my entire shift, which was the norm since she was admitted 20 days ago. History of present distemper On 9/13/09 patient presented with severe ABD pain in ED.A computed tomography Scan (CT-Scan) of the abdomen and articulatio coxae with contrast was performed showing severe pancreatitis with enceinte pancreas demonstrating significant edema. Moderate to large amounts of ABD ascites demonstrating unreserved fluid attenuation was state. Peritoneal sweetener was predominantly noted within the left ABD, reflecting significant peritonitis. No bowel thwarter was noted and pancreatic necrosis was not excluded. Moderate bilateral pleural effusions were besides noted. Past medical history tender intestine Syndrome Anxiety Depressioncocaine use (1998) Smoker Past functional history none Medications Drug NameDoseRoute FrequencyClassification metoprolol Tartrate50mgPO q12hAntihypertensive Enoxaparin Sodium40mgSQ dailyAnticoagulant Esomeprazole Mag Trihy40gmPO dailyAnti-ulcer Hydromorphone hydr2mgPO PRN Opioid anodyne Ergocalciferol800int unitsPO daily Vitamin Complementary/Alternative aesculapian Practices Herbal Remedies None Vitamins/Minerals Daily multivitamins conjecture/Yoga None Massage None acupuncture/Acupressure None Aromatherapy Noneformer(a) None Health Care Systems (Current or ders and role of health care members) Low fat diet IV emailprotected/hr q24h forficate Lumen PICC line Left AC CBC OOB Sociocultural / spiritual penchant none Family system Patient has family support, all the same lives alone in a laissez passer up apartment. Patterns of Living A. Employment Title Researcher B. Education Some college C. Hobbies / interest None D. ETOH / drug use kind only Environment (Conditions of living and working) node lives alone, although the answer changed from 9/13/09 to 9/14/09 to lives with a friend.Family is supportive. Friends are supportive. purchasable Resources (Economic, personal, agencies) main(a) insurance Primary Insurance is a HMO with BlueCross BlueShield. Objective opinion of the USCRs Pt F. V. Room 13314 Bed 1 Jennifer Hughes Please use Y, N, NA to register Yes, No or Not applicable day 1Day 2Additional Data Psychosocial Solitude v. complaisant Interaction or Normalcy tumesce groomed/Good hygieneY Appropriate/ adequate range affe ct Y Maintains centerfield contactN Calm moodN Cooperative attitudeYAble to concentrateY sack up speech (volume/tone) Y Psychomotor deceleration N Tics/Tremors N Hyperactivity/Restlessness/ turmoil N Hallucinations/Illusions N Suicidal/ murderous Ideations N Activity/Rest Well-rested N FatiguedN Slept through night N neuromuscular (pr change surfacetion of hazards) Alert and oriented Y measure 3 Gait steady Y Hygiene independentN Refused AM care Primary notified Pain free NDilaudid 2mg given 6am by primary Hand grasp, strong and rival bilat Y Foot push, strong and couple bilat Y Smile symmetrical Y Tongue to midline Y PERL YMeets developmental task Y cardiovascular (air or water) Palpable pedal pulses bilaterally Y Oral mucosa knock Y Conjunctiva pink Y capillary vessel refill within 2 sonds Y Absence of edema Y apical/radial regular rhythm YRate= 94 Blood pressure YBP= 86/60 primary notified Telemetry Y Integument (prevention of hazards) Temperature YTemp= 98. 0 fur turgo r WNL Y No tenting noted Skin warm to palpation Y Cool to touch Skin full Y Incisions N Wounds N Day 1Day 2Additional Data Respiratory (air) Resps easy and even Y Lungs clear Y Secretions N Oxygen in use N Oxygen saturationY 98Cough and complex breathe N Chest tubesN gastrointestinal (Food or Elimination) Abdomen softY techy to the touch Abdomen non-distended Y bowel sounds presentYAll 4 quads Abdominal drainsN Stomach tubesN Bowel movementN Nausea/vomiting N Feeds selfY eat (% consumed) 50% Lunch (% consumed) 75% dinner party (% consumed) Tube feedingN IV solution (type and rate) YTPN 83cc/hr bag 1200cc 0740 IV position (location)YLeft AC PICC Double Lumen IV site without redness or intumescency Y IV dressing wry and intact Y Chemstick n/a Gastrointestinal (food or Elimination)Voids in bedpan or butt Y Pt. using bathroom Foley catheterN Suprapubic tube N Urine clearY tinct yellow-amber Y Yellow Amount (ccs)n/a Continuous bladder irrigation N lab Data (explain abnormal values) RANGE leukocyte 4. 5 11. 0 HGB Men 14. 7 16. 1 Women 9. 3 L12. 0 16. 0May manoeuvre anemia. HCT Men 42. 0 52. 0 Women 27. 1 L37. 0 47. 0May indicate anemia, bone kernel dysfunction, malnutrition, over hydration Platelet 490 H150. 0 450. 0 Could indicate hemorrhage or unhealthy disorder.Glucose 8370. 0 110. 0WNR Sodium 140135. 0 145. 0 WNR Chloride 10395. 0 110. 0 WNR Potassium 4. 3 3. 5 5. 1 WNR Calcium 8. 1 L8. 4 10. 2May indicate protein & vitamin D deficiency, malnutrition, cushing syndrome, bully pancreatitis Albumin 2. 6 L 3. 4 5. 0Could indicate malnutrition, ulcerative colitis, use of penicillin, sulfonamides, aspirin or ascorbic acid. BUN 127. 0 20. 0 WNR CR . 40. 3 1. 5 WNR PT Not in labs 10 12 sec PTT Not in labs 3045 sec INR Not in labs 2 3