Nursing Care Plan & Basic Conditioning

COMMUNITY COLLEGE DEPARTMENT OF NURSING CLINICAL discernment TOOL Subjective selective information (Basic Conditioning Factors) Student Date of aid 10/03/09 affected portions Initials P. V. Age 37 Room 3114 stratum 1Allergies Food NKA Gender FMedications NKA Environmental NKA Admitting Diagnosis Pancreatitis developmental Stage (Erickson and Havinghurst) (List Developmental stage and tasks, assess each task) 1. Selecting a mate Although persevering is single, she has legion(predicate) friends. patient of was happy to introduce her friends that came to visit.Introductions were all made as friends, no boyfriend or husband mentioned. 2. Starting a family and raising children forbearing is not interested in these aspects of life. Patient is more concerned oer her friends and their activities that they do together. 3. Managing home While the patient lives unsocial, she would prefer to have a roommate to share ho riding habitkeeping tasks and rent. 4. Taking civic responsibility Patient is not interest in helping out community. 5. Starting dividing line Patient has been a deed Researcher for two years, she claims that it is just a job to pay the bills. 6.Finding congenial social group Patient claims that she has a tight group of friends that she enjoys going out with. While the patient was agreeable, she valued to be left alone. The Erickson stage that the patient is in is matureness Intimacy vs. Isolation. I find that Miss F. V. to be in isolation, developmentally. She wanted no socialization from myself, lives alone, and works alone. She is not actively looking for a mate and was demanding to have her door shut my entire shift, which was the norm since she was admitted 20 days ago. History of present illness On 9/13/09 patient presented with severe ABD pain in ED.A computed tomography glance over (CT-Scan) of the abdomen and pelvis with contrast was performed showing severe pancreatitis with prominent pancreas demonstrating solid edema. Moderate to large amounts of ABD ascites demonstrating simple fluid attenuation was noted. Peritoneal sweetener was predominantly noted within the left ABD, reflecting significant peritonitis. No gut obstruction was noted and pancreatic necrosis was not excluded. Moderate zygomorphic pleural effusions were also noted. Past medical history Irritable gut Syndrome Anxiety DepressionCocaine economic consumption (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 Analgesic Ergocalciferol800int unitsPO daily Vitamin Complementary/Alternative Medical Practices Herbal Remedies no(prenominal) Vitamins/Minerals Daily multivitamins Meditation/Yoga None Massage None Acupuncture/acupressure None Aromatherapy NoneOther None Health Care Systems (Current orders and role of health explosive charge members) Low fat diet IV emailprotected/hr q24h Double Lumen PICC line Left AC CBC OOB sociocultural / spiritual orientation none Family system Patient has family support, however lives alone in a walk up apartment. Patterns of Living A. Employment Title Researcher B. Education Some college C. Hobbies / interest None D. ETOH / drug use Social only Environment (Conditions of living and working) Client 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. Available Resources (Economic, personal, agencies) first-string Insurance Primary Insurance is a HMO with BlueCross BlueShield. Objective judging of the USCRs Pt F. V. Room 13314 Bed 1 Jennifer Hughes Please use Y, N, NA to signal Yes, No or Not Applicable Day 1Day 2Additional Data Psychosocial Solitude v. Social Interaction or Normalcy Well train/Good hygieneY Appropriate/Full range affect Y Maintains kernel contactN Calm moodN Cooperative attitudeYAble to concentrateY Clear speech (volume/tone) Y psychomotor retardation N Tics/Tremors N Hyperactivity/Restlessness/Agitation N Hallucinations/Illusions N Suicidal/Homicidal Ideations N Activity/Rest Well-rested N FatiguedN Slept by dint of night N Neuromuscular (pr stock-stilltion of hazards) Alert and oriented Y time 3 Gait steady Y Hygiene independentN Refused AM care Primary notified Pain free NDilaudid 2mg given 6am by primary open grasp, strong and equal bilat Y Foot push, strong and equal bilat Y Smile symmetrical Y Tongue to midline Y PERL YMeets developmental task Y Cardiovascular (air or water) Palpable pedal point pulses bilaterally Y Oral mucosa tap Y Conjunctiva pink Y Capillary refill within 2 seconds Y absence seizure 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 Skin turgor WNL Y No tenting noted Skin fervent to palpation Y Cool to twin Skin intact 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 deep breathe N Chest tubesN Gastrointestinal (Food or Elimination) Abdomen softY Tender to the touch Abdomen non-distended Y catgut sounds presentYAll 4 quads Abdominal drainsN Stomach tubesN Bowel movementN Nausea/vomiting N Feeds selfY Breakfast (% consumed) 50% Lunch (% consumed) 75% Dinner (% consumed) Tube feedingN IV solution (type and rate) YTPN 83cc/hr bag 1200cc 0740 IV land site (location)YLeft AC PICC Double Lumen IV site without redness or swelling Y IV dressing prohibitionist and intact Y Chemstick n/a Gastrointestinal (food or Elimination)Voids in bedpan or bathroom Y Pt. using bathroom Foley catheterN Suprapubic tube N Urine clearY Color yellow-amber Y Yellow Amount (ccs)n/a perpetual bladder irrigation N Lab Data (explain abnormal values) RANGE white cell 4. 5 11. 0 HGB Men 14. 7 16 . 1 Women 9. 3 L12. 0 16. 0May fate anemia. HCT Men 42. 0 52. 0 Women 27. 1 L37. 0 47. 0May indicate anemia, bone marrow dysfunction, malnutrition, over hydration Platelet 490 H150. 0 450. 0 Could indicate hemorrhage or inflammatory 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 atomic number 20 8. 1 L8. 4 10. 2May indicate protein & vitamin D deficiency, malnutrition, cushing syndrome, acute 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