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Student Nurse: Precious White Cedar Crest College Client Initials: L.T. Clinical Date: 10/26/16 Course: ____309_____ Room # 21 Clinical Site: LVHN Cedar Crest 7K Clinical Preparation Demographics 45 y.o. Female Reason for Hosp
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  Student Nurse: Precious White Cedar Crest College Client Initials: L.T. Clinical Date: 10/26/16 Course: ____309_____ Room # 21 Clinical Site: LVHN Cedar Crest 7K Clinical Preparation S   Demographics 45 y.o. Female Date of Admission: 10/23/16 Allergies: NKA Code Status: Full Code Admitting Physician: Sexton, S. Consulting Physicians: N/A Other Disciplines/Therapies involved in Client care: Urology, Case management, PT Reason for Hospitalization Chief Complaint: Right elbow pain. HPI: Pt. on her way to dinner in a rush, leaving the house and fell down 4 steps onto her right elbow. Admitting Diagnosis: Olecranon fracture, Right Define Medical Diagnosis: Fracture of the bony point on elbow. The olecranon  is the proximal extremity of the ulna which is articulated with the humerus bone and constitutes a  part of the elbow articulation. Date & Type of Surgery/Procedure: 10/23/16 ORIF-An open reduction internal fixation that is a surgical procedure to fix a severe bone fracture. B PMH/PSH /Chronic Conditions (use other side if needed) Significant abnormal Labs  Trending of Lab Values Inference of Abnormal Values PMH/PSH/CC: Anxiety, Depression, Migraines, Hyperlipidemia, Difficulty falling/staying asleep (insomnia) BUN- 5mg/dL (Low) AST- 48U/L (High) ALT- 56U/L (Hight) Increasing Decreasing Decreasing Indicates how well kidneys are working. May  be low due to patient not being able to void since the surgery. Both are blood liver tests that may indicate liver damage/injury. May be elevated also due to  patient not being able to void since surgery and Foley catheter was d/c. Definitions: A mental health disorder characterized  by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities; Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest; A headache of varying intensity, often accompanied by nausea and sensitivity to light and sound; A condition in which there are high levels of fat particles (lipids) in the blood. B   Diagnostic Procedures (ex. X-ray, Ultra Sound, CT Scan, EKG) Results Procedure Prep or Post Care 1. Elbow 2 views Right- good alignment- Post op 2. Humerus Right- partially visualized right olecranon fracture- Pre-op 3. Elbow 3+ views Right- posteriorly displaced olecranon fracture- Pre-op 4. ECG- Nonspecific T wave abnormality- Post op B   Medication Dose/Route/Time Drug Classification   Reason client Taking   Major Side Effects   Associated Labs Bactrim D 160mg tablet/ oral/ Q12H Antibiotic/ Anti-infective Suspect a UTI Fatigue, insomnia, Hepatic necrosis, Clostridium Difficile-Associated Diarrhea CBC, serum Potassium, BUN Heparin 5,000 u/mL/ IV/ Q12H Anticoagulant, Antithrombotic To prevent blood clot after surgery. Bleeding, thrombocytopenia, anemia aPTT, PT Senokot 1 tablet/ PO/ 2x daily Stimulant laxative, Stool softener Increase peristalsis after surgery for bowel movement. Cramping, diarrhea CBC, BUN, Creatinine, all Electrolytes Multivitamin 1 tablet/ PO/ daily Vitamins Optimal surgery recovery Vomiting, diarrhea, constipation, loss of appetite Iron levels, hemoglobin,  List medication patient takes at home : N/A A Vital Signs   Day of Prep   Day of Care   Vital Signs   Day of Prep   Day of Care Temp 99.4 99.7 BP 103/59 142/80 HR 68 100 Pain 9/10 9/10 RR 18 22 O2/Pulse OX 97% O2 Room Air 97% O2 Room Air A Indicate Rationale IV sol, rate, site N/A No longer had an IV on day of care Diet Regular Able to tolerate solids without restrictions Tube Feeding N/A Able to consume solid food Activity Order Per tolerance/ Encouraged Don’t want to push the pt. too much  but also need to get them mobile after a surgery PT Scheduled sessions To assist with ambulation and mobility after surgery TEDS/SCD N/A Mobile enough to not need TEDS/SCDs Finger Stick Blood Sugars N/A Not a diabetic nor have a fluctuation in glucose levels A     ASSESSMENT Day of Prep Day of Care ASSESSMENT Day of Prep Day of Care NEUMAN SYSTEMS VARIABLES   Activity/Gait 1. PSYCHOLOGICAL Cooperative but agitated and anxious Equipment/ CPM/Traction Assist x1 Assist x1 Walker/cane/crutches    N/A N/A 2. DEVELOPMENTAL Generativity vs. stagnation Pulmonary O2 amt/delivery mode N/A Room Air N/A Room Air 3. SOCIOCULTURAL Access to healthcare with adequate family support; middle class, white male, married O2 saturation 97% 97% Respiratory effort Regular, non-labored Regular, non-labored 4. SPIRITUAL  N/A Lung sounds Clear in all lung fields Clear in all lung fields Cough/Secretions N/A N/A 5. PHYSIOLOGICAL Chest Tubes N/A N/A CARDIO GI Heart Sounds: rate & rhythm Regular Regular Abdomen  Pulses: peripheral & apical All pulses +2-Regular All pulses +2- Regular Bowel sounds, tenderness, Distention?  Normoactive in all quadrants, nontender, round and soft  Normoactive in all quadrants, nontender, round and soft Edema N/A N/A Appetite/% eaten 0% 55% Capillary Refill <3 seconds <3 seconds Nausea/vomiting None None Jugular Vein Distention N/A N/A Tube feeding: type/site N/A N/A Skin Other tubes/drains N/A N/A hematocrit, plasma folic acid Ferrous Sulfate 1 tablet/ PO/ 2x daily before meals Antianemics, iron supplement Prevention/treatment of iron-deficiency anemia. Hypotension, nausea, constipation, dark stools, epigastric pain, skin staining Hemoglobin, Hematocrit, reticulocyte Oxycodone 5mg 1 tablet/ PO/ PRN Q4H Opioid analgesics Pain Confusion, sedation, respiratory depression, constipation Plasma amylase and lipase levels Acetaminophen 1 tablet 325-600mg/ PO/ PRN Q6H- dose dependent on the total amt. of acetaminophen in conjunction with oxycodone; not to exceed 4,000mg/day Antipyretics, nonopioid analgesics Pain Hepatic failure, Renal failure, rash Serum bilirubin, AST, ALT, LDH, PTT  Color/Temp Pink/Warm Pink/Warm GU  Turgor/Moisture    No tenting of skin/Dry  No tenting of skin/Dry Urine description  N/A N/A Mucous Membranes   Pink and moist Pink and moist Catheter Foley Catheter N/A IV site   Patent, non-tender N/A Bladder scan N/A N/A Braden score/stage 16 16 INTAKE   NEURO  Type Amt IV and oral 2100 mL LOC Awake and Alert Awake and Alert Orientation X4 X4 OUTPUT   N/A Follows commands Yes Yes Type Amt PERRLA Pupils are equal, round and reactive to light and accommodate  bilaterally Pupils are equal, round and reactive to light and accommodate  bilaterally Last BM: 10/22/16 Description & frequency of stools Brown, soft and formed Swallow/Speech W/o difficulty/ Clear W/o difficulty/ Clear Safety Issues Musc-Skeletal  Restraints N/A N/A Extremity Strength Weak on RUE Weak on RUE Fall precautions Bed rails up, Fall Risk  bracelet Bed rails up, Fall Risk Bracelet Movement/ Sensation Moves slowly/ Sensation intact Moves Slowly/ Sensation intact HOH N/A N/A ROM Passive and limited ROM on RUE Passive and limited ROM on RUE Vision Can easily read newspaper print Can easily read newspaper print Other Fall Score 13 13 R    Dressings & Wound Care N/A Plan of Care (Your Concept Map) ATTACHED Other Treatments (ex. Chest tubes, feeding tubes)  N/A Teaching Goals Coping methods to reduce anxiety/ depression, pain medication limits, nutrition Discharge Plan: N/A    Ct. Stage of dev. Generativity  vs. Stagnation Medical Diagnosis: Right Olecranon Fracture Cc: Right elbow pain HPI: Fell down 4 steps, landing onto point of elbow. Flexible line of defense Normal line of defense   Lines of Resistance Basic Structure/Central Core   S “I’m just not hungry.” “I don’t feel like eating.”   O 0% food eaten, pain 9/10 right elbow, not in the mood to order food, lethargic, agitated.  A Imbalanced Nutrition: less than body requirements R/T insufficient dietary intake  AEB 0% food eaten, lethargic & agitated.   P Patient will consume adequate nourishment. S “This feels like torture.”   O pain 9/10 right elbow, grimacing face, gripping bed rail, taking oxycodone Q4H, HR 100, RR 22, BP 142/80, x-ray positive of right olecranon fracture.  A  Acute pain R/T surgery of elbow AEB pain 9/10, grimacing face, gripping bed rail & using oxycodone Q4H. P Patient will state relief of pain. S “I feel like I have to go, but I just can’t.”   O D/C Foley catheter, no urinary output since surgery, low BUN of 5, distended bladder, sensation of full bladder, anxiety regarding the situation and circumstances.  A Urinary Retention R/T the disruption of nerve impulses between the brain and bladder  AEB sensation of full bladder but not being able to void & no output since surgery. P Patient will void after the urge to do so. S “How am I supposed to do anything  with this cast?”   O Full right arm cast, assist x1, fall score 13, lethargic, urge to void.  A Risk for Falls R/T postoperative conditions. P Patient will remain free of falls. Physiological Stressor # 1 Physiological Stressor # 2 Physiological Stressor # 3 Other Stressor # 4 Positive Variable  Aiding Defense   Patient’s husband comes every day after  work to visit . Positive Variable  Aiding Resistance  Patient receiving adequate ROM for corrected right olecranon fracture. Cedar Crest College Student Concept Map, p1 Life threatening stressors penetrate Core  Abnormal Symptoms penetrate normal line of defense Stressors penetrate flexible line of defense & ^ risk for penetration of NLD P R E C I O U S  W H I T E 11 21 16
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