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59 views11 pagesST
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/ 11
ST. JOSEPH'S COLLEGE OF NURSING
SYRACUSE, NEW YORK
NURSING 110 CLINICAL PRACTICE GUIDE
stuent Homma Dombneki vate Ajpajas racuty Jennifer VanDyke
Ase15 — GendeM Admission Date Bare Anticipated date of discharge (ADOD) /Planned discharge date AnJH/2%
iectves (AHO) Neve Resuscitation (code) Status full code,
Advanced he
Medical History
Mie Ne Keowse oliaenieg ote Jae Weight 3 Kq Height [82-FemeMl 23 18 ka fer?
Admitting Medical/Surgical Diagnosis Anfectveerdocartitis of ackic valve
OAOMOCOCCUS Olena ol_urinalysis, ob, 121 A= yeu te
~SeMorovasculac accidenk of ce; 210 Nye KOs Loci wey Lorne k-.
“A bialons Sen Sad|2%._ tes I diabetes cob Geb mypetnycncam mpacigdema
‘Surgical History
Histoy of Present ness. ats
catered in the Vous on apg
4, 2:
the need For surge,
Undated: 5/20/2001 2
|
\
= |
Fernp: to assess for nFechon ype lNyper Mnecmia, |
MB: to assess Be perfusion or Uvculation differences from tcoseline,
RR. 40 assess Gr OMY worsening 1H Breathing Partern fain, med ay i
BP 49 assess for ony Sistolicldiostelic. pressure hOrgES Free PO. Shrgss ete |
POI Ao assess SADECAWE Poin level \
AerLoMNous Monitoring of heart
TEDS/PCDs: StQuenNal Comprescion,
exice
i > \eos. \
te prevent BVT and improve blood Flow In the ley |
NIA |
NIA |
40 beip Gel PFE CHVORIC SIEGSeaT Hype W GSS REA
Teataton.yoney aie
Alse 40 prev: “
SOLE Sea SRS nee gueamia oS.
|
7 Grevent complications of immobility
FOILS 40 alles Hor Precautions 4o be pul in place due
4 weatken extremites.
NIA
to ascees Fluid balance and WY arodsion
NIA
te restore fluid balance
NIA |
wh el Teartinaus texemeny
Cheparin drip
tHeaching oat procedure
{CHECK glucore levels,
<28piriny,
Sunselnvsive Procedure
(1ay tent had cu he aamison)
lePs hear cot]
Or) SSSR
venhnoos Helemetny,
+ maintain adequate
Aa move,
+ Sime Mo
PYHtals Frequency
+ Eee
- Geko wlooker
sneparin,
s aspirin
Furthen procedures
Invasive procedure: any procedure that was cared out by entering te bod
fo evaluate Cucrent heart
Sunemon due to endocarditis.
Wek shamed tebe” potter Sascig
blsek Gnd ot has lenginenee!
sintervene iF needed
{rough the shin or though an anatomis pening bX: PCE placeent
‘Setter the eaten of order ofthe body by incon and mnination Wh
Ws Oc tal ip arto, CABG.
Teitman + Savor
| source: fara cd5\pg-Seu-sor .9ry Data Blood Work
abc ot
| gear
[high sere uays
jPrseonn |
B8| hypeegyeemia,
Diagost Tests: Most Recent Tess Since Admision
[Be OR/EXG/Eho)
~) siesta ora]
Ala: chest x-roy-tmild edema |
—4 | |ajze: urine culture ano got
Ti. Glucose levels are || See q 4 a:enuse reactve slo2INg
igh ond can indicate | cea
= MR 4 Used bg rotons OFC
2. low doy law: Ce douse veachve |
means poor oxygen Song | Puphane
soruration ~eod OT + no evidence of
Bulow ved tid cells || ONE intracranial dieease |
con indicate anemia, ar Eoal'2 ead) sinus tochy|
peepee NEN 4/28; €CG (2 lead) + tart pecterir
Perfusion ; Faccicular BIS,
Terginenes)
= Onest x-ray 9 mid increased
Parenchymal markegs
aaa: oness acray-aingrovel cen
| |= ultrasound + chelsietniass, gail bined
Gromer g
— cnest x= roy: Feeding We in
sour Leorure 1 | rg Trt torgeainve
LE cose, Fonges
Sources EPIC
| | ener bien camo tycoon) [awoxiaba—)
‘Aspearance appropiate forage: Yes o/ No_Welhgroomed Yes ¢/ No “sineFFectve,
Ssteeneronmentcltel blow, bongs eet ef a Yen Raa tbreathirg,
|
1 tern,
aa a i :
Bhat “lig 70 |
2
|
furen_| a —_l— |
menting: C)__ Sale: Murer 30)_PANAD__dete/Owone
hen jan sent set ‘eect patter
Scenes ean genera) pow (envonea) ‘pi_denies— |
sudden, rapid tpan
genero\ SS" | |
a a ee |
Sei ae |
Parmele RonparaclgT | | |
Sensi rsa] — [erie
on [sAchwity |
oe se ee a
Crt ar ms
| —eaES wear | weak
ogee ees le 2
Ping | Pio
fara una =a rare Unresponsve see
a Po nagect
J uta,
Not equal __Absent_¥ Contracture. oe
: |__Not equal__Abse —_ “one | |
‘erst Zhe neec |
‘een: |
yes: Vision act Nerd = |
[| USRM tp tgettrneoes or — |
te a Soy
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sh al borenoh Patan we Cen —
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Sree teat Seer rea ame goo estrorae
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Treneostomy se
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Finest Yex_—No 2 Amount= Rope Good_foh_ Poor
‘Wephe SK Meh @- A OMSB. TG nace wee NZ Yo
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INlsnsing Yerad Nope: sein etarsce 0.8% /100me r=
simootanced
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>Home ye Sat em eh
Equbmen needs foréschaae: ——
Actes date of charge JO] 23 —