ATI response sheet David R PDF

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Download ATI response sheet David R PDF

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**Please type your answers in BLUE **Type NA if the category is Not Applicable

Date: 07/16/20 Student Name: Edylynn Quijano

ATI Health Assess Patient: David Rodriguez

1. What subjective data did you collect prior to beginning the physical assessment? ASSESSMENT DATA Comments/Responses:

Subjective: HEENT

PULMONARY

Pt states “Can’t get rid of headache… Constant throbbing pain where injury is [head]… my pain is 5 or 6/10… Head bothers me the most… head is tender where I hit it” Asked about vision, “No changes in vision” NA

CARDIOVASCULAR

NA

GI

NA

GU

NA

NEURO

Pt. reported throbbing headache and being unconscious for a couple of minutes, and upon palpation of the skull pt. Reported tenderness at the injury site of head. Pt. reported tingling on right toes and could not feel tingling sensation on left toes. Pt. rated pain at 3 on pain scale, sore. states, “Doesn’t hurt unless I move my arms” Pt stated difficulty to move toes When asked about pain Pt. stated “My leg is starting to hurt again… Pain is 4/10...Feels like my leg is achy” Pt. stated that his skin feels tight on left leg

MUSCULOSKELETAL

INTEGUMENT PAIN (use symptom analysis: PQRST)

Pt. reported headache which he described a constant throbbing pain and reported it 5 or 6 out of 10 on the pain scale. Pt. also reported leg pain which he described achy, his skin feels tight and reported 4 out of 10 on pain scale. During assessment of ROM, pt. Reported 3 out of 10 on a pain scale, reported sore and stated that it does not hurt unless movement of upper extremities.

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**Please type your answers in BLUE **Type NA if the category is Not Applicable

2. What objective data did you collect during the physical assessment? PHYSICAL EXAMINATION Objective: GENERAL SURVEY: Appearance: Body Structure: Behavior

Pt. is oriented. He is hispanic male in his 20’s, appears to have a bruise on left side of forehead, dressing on right arm due to injury, left leg appears to have bruising, edema, and elevated on pillow.

HEENT:

NA

PULMONARY:

NA

CARDIOVASCULAR:

GI:

Pulse on the right upper extremities was 1.5mmHg and on the left it was at 2mmHg. Upon palpation of pulse on the lower extremities, pulse on the left leg were absent. NA

GU:

NA

NEURO:

Pt. was alert and oriented with time and location, and was able to identify himself. Upon palpation of the skull pt. Reported tenderness at the injury site, and no lumps or bumps present. Upon assessment pt. Reported no abnormal changes in vision, and when checked for pupillary light reflex pupils constricted at 6mm bilateral. ROM on upper extremities showed difficulty when moving arms. Grip on hand strength was +3 bilaterally. ROM on lower right leg was WNL, left leg was non movable. Presence of abrasion on the forehead. Presence of scrape and bruising with dressing on the right arm and appeared swollen. Upon palpation of left leg presence of edema 2+ mm, left leg temperature was cooler and presence of bruising on left leg. Right leg had temperature of warm and dry. Capillary refill was WNL on the right lower extremities, and on the left capillary refill returned more than 3 seconds. NA

MUSKULOSKELETAL:

SKIN/MUCOUS MEMBRANES:

PSYCHO-SOCIAL: EDUCATION: What did you teach this client & family and how did they respond?

NA

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**Please type your answers in BLUE **Type NA if the category is Not Applicable

3. What did you chart in the EHR? Client’s Initials: DR DOB: 01/14/19xx Age: 21 Sex: Male Allergies: Sulfa Ht: NA Wt: NA Culture/Religion: Hispanic or Latino Marital Status: NA Family support: yes or no

ETOH use: yes or no

Tobacco: yes or no

Other disciplines/consults caring for the client (e.g. Physical Therapy, OT, dietitian, Cardiology, etc) NA Vital Signs: T NA

HR NA

R NA

SPO2: 98 Oxygen Therapy: NA Reason for hospitalization:

BP NA

Monitors: NA

Code Status: Full Code

Rate: NA

Fell while rock climbing

Clinical Diagnosis: Head, Neck, Upper and Lower Extremities Injury Nursing Problems: Impaired physical mobility r/t injured ankle aeb swollen ankle, abrasions, and difficulty moving of left leg Summarize client’s past medical history & history of present illness: (i.e. Age, gender, chief complaint, Location: Quality:Severity: Duration: Timing: Context: Modifying Factors: Associated Signs and Symptoms: Of Chief Complaints (PQRST), Past medical history, Past family history, Social History)

Admitted from ER. Pt. is a male, Hispanic 21 years old, no past medical history on record. Pt. admitted from a fall while rock climbing and complaining of headache and pain on lower extremities. Summarize hospital course/events from admission to present: (i.e. When did they arrive. Through what means? When were they admitted? Why were they admitted? Why are they still in the hospital? What is the plan of care?)

Pt. was admitted due to a fall from rock climbing and sustained head, neck, neuro and ankle injury. Pt. right leg is elevated due to pain, and edema. Upon assessment, pt. Reported pain at the injury site on lower extremities and headache. Offered the pt. Pain medication and ice pack for the swollen ankle. When assessing for ROM, pt. Reported soreness and pain during movement on upper extremities and had limited ROM on lower extremities. Pt. reported being

**Please type your answers in BLUE **Type NA if the category is Not Applicable unconscious after the fall, and upon assessment pt. Was a&o with time and location, and was able to identify himself. Pt. was also responsive during the assessment and answered all questions. Therapeutic orders for day of care:

ACETAMINOPHEN; HYDROCODONE One tablet every 6 hr PRN as needed for moderate to severe pain. Written order Dose/Frequency: 1 tablets Every 6 Hours Route: Oral IBUPROFEN One tablet every 8 hr PRN as needed for mild to moderate pain. Written order Dose/Frequency: 800 mg Every 8 Hours Route: Oral ICE PACK- Every 2 hours for 20 mins Apply to right ankle for 20 mins every 2 hr PRN as needed for pain/swelling Written order Frequency: Every 2 Hours Duration: 20 Diet: NA Activity: IV Type & Site: NA Other (dressings, etc.) NA Education needs/discharge planning: (Include client and family)

NA...