NURS 101L - Marvin Hayes Patient Profile Database PDF

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Course: NURS 101L PATIENT PROFILE DATABASE

Date: ____________________________________________________________________________________ Student Name: Julie Pineda Faculty Name:

Professor Sylvain

1. ADMISSION INFORMATION Date of Pt. Name: Admission Ag Gend Growth and Ethnicit Occupatio Spiritual Care: Marvin Date: e: er: Development (Erikson): y: n: N/A Beliefs: Hayes 09/29/20 43 Male White Christian Medical Diagnoses History: (Present and past diagnoses, Reason for Surgical Physician’s History and Physical notes in the chart, nursing intake Procedures/Date: Hospitalization/Chief assessment, with length of history if possible) Underwent a Complaint (in pt’s own laparoscopic words): Mr. Hayes experienced weight loss, abdominal perineal resection with a increasing fatigue, and permanent sigmoid narrowing stools with colostomy 3 days ago blood for rectal cancer. History of Present Illness: Rectal adenocarcinoma Admitting Medical Diagnosis: Colorectal Cancer ADVANCE DIRECTIVES (Nursing Admission Assessment): Durable Power of Attorney: ☐ Yes ☐ Code status : ☐ Full Code ☐ Living Will: ☐ Yes ☐ No No DNR (Do Not Resuscitate) 2. MEDICATIONS ALLERGIES: Drug Classificatio Dosage Route Frequency Purpose Nursing n (time due) Considerations Omeprazole proton 40mg PO 0900 To protect the Avoid alcohol an pump lining of the foods that cause inhibitors stomach irritation (PPI) Enoxaparin Anticoagula 40mg SQ 0900 Prevents blood Monitor for nt clot bleeding Hydrocodone/ Narcotic 10/325mg PO PRN For pain Monitor for Acetaminophen analgesics orthostatic hypotension 3. LABORATORY DATA Test

Norms

WBC Hemoglobin Hematocrit Platelets PT INR aPTT HA1c BNP

11 11 33 200 N/A N/A N/A N/A N/A

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On admission 10 11.5 34 180 12 N/A 30 N/A N/A

Current value

Test

Norms

8.9 11.8 35 212 N/A N/A N/A N/A N/A

Sodium Potassium Calcium BUN Creatinine Magnesium Blood Glucose Urinalysis Cultures

136 4.1 N/A 15 0.9 N/A 108 N/A N/A

On admission 140 4.5 N/A 12 0.8 N/A 90 N/A N/A

Current value 138 4.4 N/A 12 0.8 N/A 88 N/A N/A

Course: NURS 101L PATIENT PROFILE DATABASE

blood/sputum DIAGNOSTIC TESTS Chest X-ray: N/A

EKG: N/A

Abnormal studies: N/A

Abnormal studies: N/A

Abnormal studies: N/A

Abnormal studies: N/A

4. PHYSIOLOGICAL DATA-VITAL SIGNS Vital Signs: Temp______99___ oF / oC ☐Axillary ☐Tympanic ☐Oral ☐ Core ☐Rectal Pulse__95____ ☐Apical _______ ☐Radial Respiratory Rate__18____ ☐Even/regular ☐Labored/SOB ☐Dyspnea on Exertion BP __132____/__86_____ ☐Supine ☐Sitting ☐Standing 5. NEUROLOGICAL/SENSORY Orientation: ☐Time ☐Place ☐Person ☐Purpose

Admission weight:____75kg_______ Yesterday’s weight___________ Today’s weight______________ Height__________

Sensation: ☐Normal ☐Impaired ☐Absent

Pain: Grade __1__ /10 Scale used: ☐0-10 Numeric ☐FLACC ☐ Wong-Baker FACES Pain Location:__Abdominal __________ Character: ☐ Sharp ☐Dull ☐Ache ☐Heavy ☐Pinprick ☐Cramp ☐Other______________

What makes the pain worse: Movement, sneezing. What makes the pain better: Position and medication.

Level of Consciousness: ☐Alert ☐Lethargic ☐Obtunded ☐Stuporous ☐Semicomatose ☐Coma Coordination: ☐Symmetrical ☐Asymmetrical ☐Unsteady

Strength: __5__Right arm __5___Left arm __5___Right leg ___5__Left leg 0=No movement 1=Trace movement 2=Moving, not against gravity 3=Moving against gravity, not against resistance 4=Moving against gravity, some resistance 5=Full power

PERRLA : #__3__mm ☐Nystagmus

☐Brisk ☐Sluggish ☐Fixed

12 3 4 5 6 7 8mm Glascow Coma Scale: Total of all 3 columns____15______ Eyes Motor 4=Open 6=Obeys command spontaneously 5=Localizes pain 3=To speech 4=Withdraws 2=To pain 3=Flexion 1=None 2=Extension 1=None

Total___4____

Total____6____

Verbal 5=Oriente d 4=Confuse d 3=Inappro priate words 2=Incompr ehensible words 1=None Total__5_

Touch: ☐Normal Smell: ☐Normal ☐Decreased Hearing: ☐Normal ☐Tinnitus ☐HOH ☐Hearing ☐Decreased Aid ☐Deaf Vision: ☐Normal ☐Glasses ☐Contacts ☐Cataracts ☐Glasses ☐Glaucoma ☐Blurred vision ☐ Diplopia Neurosensory comments: patient AAOx4

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Course: NURS 101L PATIENT PROFILE DATABASE

Nursing Diagnosis: Acute pain related to recent abdominal surgery

6. CIRCULATORY/CARDIOVASCULAR Color: ☐ Pink ☐Pale ☐ Jaundice ☐Flushed ☐Cyanotic ☐Mottled ☐Dusky Skin:☐ Dry ☐Moist ☐Clammy ☐Warm ☐Cold ☐Hot

Capillary refill: ☐ 3 seconds Tele monitored rhythm:___NSR____________________________ Heart Sounds: ☐S1 ☐S2 Rhythm: ☐Regular ☐Irregular Implanted Pacemaker: ☐ Yes ☐No

Peripheral Edema: ☐None ☐+1 ☐+2 ☐+3 ☐+4 ☐Pitting ☐Non-pitting Location:____________________________________________ _ Peripheral pulses: Right radial ☐Present ☐Absent Left radial ☐Present ☐Absent Right pedal ☐Present ☐Absent Left Pedal ☐Present ☐Absent Circulatory Comments: Circulation within defining limits

Nursing Diagnosis: Unactable 7. RESPIRATORY/PULMONARY Breath Sounds:☐Clear ☐Diminished ☐Absent ☐ Crackles ☐Wheezes Location:☐ Throughout ☐RUL ☐RML ☐RLL ☐LUL ☐LLL Sputum: ☐White/Clear ☐Tan ☐Yellow ☐Green ☐Rusty ☐Pink ☐Red Cough: ☐None ☐Nonproductive ☐Productive ☐Suctioning required Secretions: ☐Yes ☐No Consistency: ☐Frothy ☐Thick ☐Thin Suctioning Method: ☐Oral ☐Nasotracheal ☐ETT ☐Trach ☐Bulb Respiratory Comments: respirations within defining limits Nursing Diagnosis: Unactable 8. NUTRITION/HYDRATION Diet: ☐NPO ☐Regular ☐Cl. Liquid ☐Full liquid ☐Soft ☐Pureed ☐Other____________________ Feeding Method: ☐Self ☐Assisted ☐NG ☐G-Tube ☐J-Tube Parenteral Nutrition: ☐TPN ☐PPN Tube Feeding Formula:_____________ Rate: mL/hr. Residual: ☐No ☐Yes Amt.______mL Weight: ☐Gain______# lbs./kg ☐Loss______# lbs./kg ☐No change

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Pattern: ☐Regular ☐Irregular Character: ☐Full ☐Shallow ☐Deep ☐Labored ☐SOB Amount: ☐Small ☐Moderate ☐Large Pulse Oximeter: _95_____% Oxygen: ☐Room air O2 ____L/min. or _____% Mode: ☐N/C ☐Mask ☐Trach

O2

ABGs: pH_____ pO2________ pCO2_______ HCO3___________

Aspiration Risk: ☐Yes ☐No Nausea: ☐Yes ☐No Vomiting: ☐Yes ☐No Flatus: ☐Yes ☐No

Mucous Membranes: ☐Dry ☐Moist Skin Turgor: ☐No problem ☐Tenting ☐Taut

Course: NURS 101L PATIENT PROFILE DATABASE

Intake: PO______ IV______ NG______ Blood_______ Other_______ 24 hour total_________

Output: Urine_____ NG_______ Emesis________ Stool________ Drains________ Other________ 24 hour total_________

24 hour net I/O: +/-_____

Nutrition/Hydration comments: Doctor ordered patient to advance to regular diet as tolerated

Nursing Diagnosis: Readiness for enhance nutrition: advance peraid to regular diet as tolerated

9. GI/FECAL ELIMINATION Bowel Sounds:☐Absent ☐Hypoactive ☐Active ☐Hyperactive Abdomen: ☐Soft ☐Flat ☐Distended ☐Round ☐Firm ☐Tender ☐Flatus Last BM: _______Stool: ☐Formed ☐Soft ☐Hard ☐ Liquid #_____ Fecal Elimination Comments:

Location: ☐RUQ ☐RLQ ☐ LUQ ☐LLQ ☐ Throughout Incontinence: Ostomy: ☐No ☐Yes Type: Colostomy____ ☐Yes ☐No Color: ☐Brown ☐Black/Tarry ☐Clay/Gray ☐Yellow ☐Green

Nursing Diagnosis: Risk for infection related to colostomy

10. GU/URINARY ELIMINATION Urine: ☐Clear ☐Cloudy ☐Sediment Last void: time____________

Color: ☐Straw ☐Yellow ☐Amber ☐Pink ☐Red amount

Symptoms: Frequency: ☐ Urgency: ☐

Dysuria: ☐

Catheter: ☐None ☐In/Out ☐Condom ☐Foley ☐Suprapubic Insertion date:_________________ Nocturia: ☐ Incontinence: ☐Yes ☐No mL

Urinary Elimination Comments: patient presents non-distal on tender bladder and urine yellow and clear without complaints of pain or increase frequency Nursing Diagnosis: There are no genitourinary complications 11. REST AND EXERCISE Activity: ☐ Bed rest ☐BSC ☐BRP

☐ Chair ☐ Ambulate

Functional level: ☐Independent ☐Dependent ☐Assistance ROM: ☐Active ☐Passive ☐Assistive ☐Limited ☐Full

Cast/Brace/Traction: Type: N/A

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Mobility Aids: ☐Cane ☐W/C ☐Crutches ☐Walker Gait: ☐Steady ☐Unsteady ☐Unable to ambulate Sleep Patterns: ☐Uninterrupted ☐Interrupted ☐Insomnia ☐Day time sleepiness # hrs sleep/night__________ Restraints: Type: N/A_

Course: NURS 101L PATIENT PROFILE DATABASE

Location_______________ Rest and Exercise Comments: Ambulation as tolerated

Location_______________

Nursing Diagnosis: Impaired physical mobility related to recent surgery

MORSE FALL SCALE/RISK SCREENING Variables History of Falls within last 12 No months Yes Secondary Diagnosis No Yes Ambulatory Aids None/bedrest/nurse assist Crutches/cane/walker Furniture IV or IV access No Yes Gait Normal/bedrest/wheelchair Weak Impaired Mental Status Know own limits Overestimates or forgets limits Total

Score 0 25 0 15 0 15 30 0 20 0 10 20 0 15

0+15+0+0+0+0=15 Morse Fall Score ☐ High Risk 45 and higher ☐ Moderate Risk 25-44 ☐ Low Risk 0-24

15

Rest and Exercise Comments: Ambulation as tolerated

Nursing Diagnosis: Impaired physical mobility related to recent surgery

12. SKIN INTEGRITY/INTEGUMENTARY Skin Condition: ☐Intact ☐ Skin tear ☐Bruise ☐Rash ☐Burn ☐Wound/Ulcer (complete documentation) Location_____________ Stage___________ ☐Incision ☐Other______________ Location#1____Abdomen_________Type of condition: surgical incision ____ ☐Drainage __N/A___ ☐Odor: N/A Location#2_____________Type of condition____________ ☐Drainage__________ ☐Odor Location#3_____________Typeof condition____________ ☐Drainage__________ ☐Odor

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Course: NURS 101L PATIENT PROFILE DATABASE

Indicate location or Intact: S Surgical site M B Burn R E Ecchymosis D F Fracture/Cast N Pe Petechaie G P Pressure ulcer & stage _______________ O Other ____________________________

I

Sensory

1. Completely limited

Braden Scale 2. Very limited

IV Site Patent Swollen Red Infiltrated

Edema Rash Dressing Inflammation Gangrene/Necrosis

A Drains None Penrose Hemovac JP

3. Slightly limited

4. No Impairment Moisture 1. Constantly moist 2. Very moist 3. Occasionally moist 4. Rarely moist Activity 1. Bedfast 2. Chairfast 3. Walks occasionally 4. Walks frequently 2. Very limited 3. Slightly limited 4. No Mobility 1. Completely immobile limitations Nutrition 1. Very poor 2. Probably inadequate 3. Adequate 4. Excellent Friction and Score of 18 or 1. Problem 2. Potential problem 3. No apparent problem Shear less = at risk IV sites: ☐ Patent ☐Swollen ☐Red ☐Infiltrated Location: Peripheral intravenous (IV) Gauge: 20G Needle Start date:__09/29/20____________ Skin Comments: No redness, swelling, infiltration, bleeding, or drainage.

Score 1 1 3 4 3 3 Total:1 5

Nursing Diagnosis: Patient skin in dry has a stoma that’s red, moist, patent and draining with no complications . 13. HORMONE REGULATION/REPRODUCTION/ENDOCRINE Thyroid Disease: ☐Yes ☐ No Estrogen Use: ☐Yes ☐ No Testosterone use: ☐Yes ☐ No Steroid use: ☐Yes ☐ No Diabetes: ☐Yes ☐ No ☐Type I ☐Type II Number of year with diabetes: _______ 14. PSYCHOSOCIAL VARIABLES Mood/Affect: ☐Cooperative ☐Cheerful ☐Angry ☐Anxious ☐Crying ☐Withdrawn ☐Flat Affect ☐Depressed ☐Fearful ☐Combative Level of education: ☐None ☐Elementary ☐High School ☐College ☐Post Understands directions: ☐Yes ☐ No Graduate Decision-making: ☐None ☐Concrete ☐Abstract Judgment: ☐Appropriate ☐Inappropriate ☐Dementia ☐Impaired History/Evidence of: N/A Recreational drug use: N/A

Alcohol use: N/A

Tobacco use: In the last 12 months ☐Yes ☐ No How often ___________ How much_____________ Recent life stress or loss: ☐Yes ☐ No

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Coping methods with current illness/hospitalization: ☐Good ☐Fair ☐Poor

Course: NURS 101L PATIENT PROFILE DATABASE

Body Image: ☐Positive ☐Negative ☐Changing

Ability to write English: ☐Yes ☐No

Braden Scale Sexuality: ☐Heterosexual ☐Bisexual ☐Homosexual ☐Transgender ☐Transsexual Ability to read English: ☐Yes ☐No

Language Barrier: ☐None ☐ESL ☐Speech Support System: ☐Yes ☐No Living Situation: Pt lives at home with his wifey Impediment ☐Intubated ☐ Trached Psychosocial Comments: Patients states having high anxiety and is worried of recent increase fatigue Nursing Diagnosis: Anxiety related to recent weight loss and increasing fatigue Narrative Charting: Head to toe assessment in words

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