PROBLEM LISTOrder DescriptionThis care plan problem list i s based on a patient which information of the patient will be providing on the patient DATA PROFILE and please MUST USE for this assignment. also I will be providing EXAMPLE FROM THE TEACHER, BUT NOT THE SAME PROBLEM. also A BLANK TEMPLATE WITH FOUR PROBLEMS WITH THE NURSING DIAGNOSES as stated inside the template. 1 ABDOMINAL PAIN 2 POOR APPETITE 3 VERTIGO 4 SKIN. PRIORITIZE the answer when doing./COMPLETED Clinical Assignment due within ONE week of the date of care.
Points will be deducted for late submissions.
Clinical Assignment Number: _2 _
Student Name: CHINYERE JULIET OGUAYO _
Date of Submission: __3/17 /15_
12, please see comments, need correction to key problems and nursing diagnoses. Date of Admission: _3/11/15__
FROM: ER_807_ Unit _800_
Other facility: __PG HOSPITAL_______
Date of Care:
Patient Initials: G M Age: 75 Gender: FEMALEReason for Hospitalization:
Abdominal pain, Perforated Diverticulitis
Surgical Procedures with dates: post day 4 Exploratory laparotomy, with sigmoidectomy, colostomy on the left abdomen, and Hartmanns procedure/end colostomy. 3/8/15, Post menopausal hormone replacement at the age of sixty.
Admitting Medical Diagnosis: Abdominal pain, Perforated Diverticulitis Vitamin D deficiencyCurrent Medical Diagnosis: Abdominal pain, Perforated Diverticulitis. Vitamin-D deficiency, vertigo,Past Medical & Surgical History: CVA, 3 years ago, post menopausal hormone replacement at the age of sixty one 14 years ago. vertigo
Smoking History: Formal smoker, quit more than one year agoAllergies: Patient stated no drug or food allergies known.Psychosocial and Cultural AssessmentMarital Status: 0 married 0 single 0 divorced 0 partnered 0 widowed
Occupation (if retired, list previous): Was Elementary school teacher for 36 years. Retired 15 years ago.
Mood/Affect: calm but looks drowsy.
Ethnicity: African American.
Other relevant psychosocial and cultural data: Has two children, one is a medical doctor, (OBGYN), with one daughter that is in pre med school. Another is a college chemistry professor, also has one daughter and two grand children. Her husband died of colon cancer 5 years ago at the age of 77 years old, also was a retired social worker and a deacon at the church. Her both parents died at the earlier age. Has one brother with the hx of CVA, HTN, and Never use any ETOH/substance abuse.Advance Directives (Nursing Admission Assessments)Do not resuscitate (DNR) order: 0 yes 0 no Living will: 0 yes 0 noPhysical Assessment Data?RANGE OF FINDINGS (ESPECIALLY IF UNSTABLE)
ASSESSMENT PARAMETER FINDINGS
Temp:
7:30am 99.9
10:00am 98.7 (3/11/15)
12:00am 98.3
HR
7:30am 76
10:00am 84 (3/11/15)
12:00am 86
RR:
7:30am 18
10:00am 18 (3/11/15)
12:00pm 20
SpO2 (pulse oximetry):
7:30am 97% room air
10:00am 98% room air (3/11/15)
12:00am 98% room air.
BP:
7:30am 136/67 position lying l/arm
10:00am 128/ 59 position sitting l/arm (3/11/15)
12:00pm 124/60, position lying l/arm
PAIN Assessment:
TYPE OF PAIN SCALE: (Note location, intensity etc.) At the time of assessment patient verbalized no pain round the stoma and surgical site pain 0/10. patient stated the nurse gave me Percocet an about one and half to two house ago this am ok for nowHeight 66.0 method wing span. Weight: 166lbs 11 oz (75.60kg) lying down bed scale. 3/11/15
BMI: 26.8
CHANGE from BASELINE? How much? + or Mrs GM is overweight. Normal weight range would be from 115to 150 pounds.
Hemodynamic Monitoring
(IF APPLICABLE) n/a
Swan Ganz catheter:
location, waveform, dressing, readings: n/a
Arterial line:
location, waveform, dressing, Allens sign: n/a
Balloon pump:
location, dressings, settings, distal pulses n/a
REVIEW OF SYSTEMS
Briefly describe assessment finding in the areas outlined below.
Include any aIDitional abnormal findings that are not listed below.Physical Assessment Data?RANGE OF FINDINGS (ESPECIALLY IF UNSTABLE)
Psychosocial:
Anxiety level:
Calm, look drowsy but verbalized concern of been in the hospital, alert and oriented x 3
Visitors/support systems:
Two children are very involved and supportive said patient.
Neurological:
Glasgow coma scale (explain any deficiencies) Total 15.Pupils (size/ reaction/ consensual): Rt: 3mm PERL Lt: 3mm PERL
Movement of extremities:
Unable to assess for the gait at the time, patient stated she can walk to the bathroom but not at the time, however bed pan was offered to the patient before the assessment. And strongly able to move all extremities with no pain verbalized..
BIS monitor reading: n/a
Other: Patient alert to person, oriented to place, oriented to time (3/117:30), however look drowsy.Skin and Mucous Membranes:
Color:
Pink
Temperature (route):
7:30am 98.9 Axilla
10:00am 98.3 oral
12:00am 98.7 oral. warm to touch equal
Edema (specific location and grade): No edema present on assessment.
Wounds/incisions/drains
(including location, dressing, drainage): Colostomies on the left abdomen stoma with surrounding tissue pink in color, Tx change bag every day and PRN. miIDle Abdominal wound surgical incision site pink in color with 10 staples intact no drainage , no odor, no swelling noted Dehiscence measurement11x 26.5cm. Treatment wet to dry dressing twice daily and PRN. patient albumin level 4.8g/dl
Other:
Cardiovascular:
ECG rhythm n/a
Heart sounds:
Clear on auscultation, no murmurs, rubs or gallops, no edema.
Pulses(specific location and grade):: 2+ Redial pulses bilaterally and 2+ dorsalis pulses bilaterally.
Pacemaker: rate/mA/sensitivity: n/a
IV sites (List location, type of line, dressing appearance, fluid/rate)Periphery line to the right for arm. Site no s/sx of (infection) no redness, no swelling observed. Ondansetron (zofraninjection) 2 mg/ml injection 2ml, iv push,Q6h PRN for nausea/vomiting.
Other:
Gastrointestinal:
Abdomen (inspection):
Non distended, no masses/tenderness, no organomegaly, no hernias, however Colostomy on the left lower abdomen, miIDle Abdominal wound surgical incision site pink in color with 10 staples intact no drainage noted, Dehiscence measurement11x 26.5cm. Treatment wet to dry dressing twice daily. Patient albumin level 2.4g/dl.
Bowel sounds:
Present in all quadrants. Colostomy bag with gas, small loose but not diarrhea in the bag
Diet:
Apetite: Patent was on NG tube progressed to clear liquid, than just started this morning on regular diet, appetite poor, ate only 25 % breakfast, and lunch only 15% .
Tube feeding (rate and type): n/a Residuals:
Ostomy (site and appearance): Pink tissue round surrounding site.
Stools: Colostomy bag with small loose but not diarrhea in the bag
Other: n/a
Genitourinary:
Urine (color, odor, character):
Clear yellow no odor urine
Catheter:
n/a
Conduit: n/a
Dialysis access:
n/a
INTAKE/OUTPUT
(24 hour total) INTAKE: PO: about 240cc IV:n/a OUTPUT: voided x 3, bed pan offered
Respiratory:
Artificial airway: n/a
ET tube (size):
(cm/mark-taped at teeth/gumline): n/a
Ventilator settings:
n/a
O2 saturation %:
7:30am 97% room air
10:00am 98% room air (3/11/15)
12:00am 98% room air.
Supplemental O2:
2L N/C PRN, not in use at the time of assessment.
Rate/depth/pattern/effort:
Regular, Even and unlabored. RR 18-20.
Breath sounds:
Clear and Unlabored, symmetrical.
Sputum:
Moist clear white
Chest tubes (location, drainage, amount of suction):
n/a
Other: n/aDiagnostic Tests
Include relevant normal and abnormal findings; provide complete ABGs with interpretationMedication Medication Medication
Augmentin 875/125mg 1 tab po q12hrs x 6days for surgical sit prophylaxis.
Ondansetron (zofraninjection) 2 mg/ml injection 2ml, iv push,Q6h PRN for nausea/vomiting.Percocet 5/325mg 2 tab po q4hrs prn for pain Ibuprofen 600mg po 1 tab 4 times daily for painMeclizine 12.5mg po 1 tab po tid for vertigo Phenol 1.4 %throat spray 180ml (chlorasptic GEQ) 1 spray po prn for sore throat.Premarin 625 1 tab poqhs, For post menopausal hormone replacement.Asprin 81mg po 1 tab dail, for cva prophylaxis.Vitamin D2 50,000iu cap po twice a week.
For vitamin D deficiency.Daily MVI 1 tab daily for supplementPART II: Key Problems and Associated Nursing Diagnoses
Directions: Based on the completed, corresponding patient data profile, do the following:
1) select 4 key problems
2) select 4 associated nursing diagnoses
3) prioritize the selectionsPRIORITIZE
(label 1-4) KEY PROBLEM NURSING DIAGNOSIS1
Abdominal pain Acute pain2
Poor appetite Imbalanced nutrition less then body requirements.3
Vertigo
Risk for falls4
Skin (Patient has colostomy and abdominal surgical incision) Risk for impaired tissue integrity