- Patient Fred Mcdonald Fm Demographic Information Admission Information Allergy Status Age 72 Male Arrived In The 1 (104.84 KiB) Viewed 84 times
- Patient Fred Mcdonald Fm Demographic Information Admission Information Allergy Status Age 72 Male Arrived In The 2 (65.33 KiB) Viewed 84 times
- Patient Fred Mcdonald Fm Demographic Information Admission Information Allergy Status Age 72 Male Arrived In The 3 (32.67 KiB) Viewed 84 times
Patient- Fred McDonald (FM) Demographic Information Admission information- Allergy Status- Age: 72. Male, arrived in the emergency department on Tuesday 1800. Chest x-ray showed right middle and lower lobe infiltrate and was admitted with pneumonia. Patient lives alone and has a neighbor for a support system at home. He is widowed x 15 years with 4 older children that live out of state. He admitted" he doesn't always have enough money for food and medication". He has no known allergies. HT. 5'7" Wt. 115 lbs. RESPIRATORY SYSTEM Patient was admitted for pneumonia and is being treated with Cefotetan 1g iv a 12 hours, first dose was administered in ED. last dose was administered at 2400. The IV dressing is cdi and the site displays no signs or symptoms of infiltrate or infection noted. As per chart-Patient has a past medical history of multiple hospitalizations for pneumonia in the past 2 years He also has emphysema, and, is a 2 pack a day smoker. Pulmonary function test was ordered by Dr Molina and per his physician note the results show worsening obstructive lung disease. Coarse crackles noted upon auscultation of lung fields, however, shift nurse reports the lung sounds are slightly less coarse. Respirations are non-labored. Respiration rate elevated at times 24-26/minute. Productive cough noted with thick yellow sputum. Current a am orders in place for BMP and ABG's and for a peak flow measurement test daily. All of which were obtained on Wednesday. Orders were also written for pulmonary rehab, ambulation TID and increase distance gradually as tolerated. Patient does get fatigued with activity. He also sleeps with 2 pillows under him to elevate head. Patient sleeps 6-7 hours nightly. Patient does state he is tired often and "too tired to do much when asked about his exercise and recreational activities. His limitations in activities of daily living requires "frequent rest periods". He takes ipratropium bromide MDI 2 puffs (metered dose) via inhalation 3 times daily, last given Wednesday at 2000. Patient had temp of 102F at 0730 and Tylenol was administered with positive effect. Temperature was rechecked at 0930 101.1F per nurse's notes. ABG's were obtained on Tuesday: 02 saturation 93, on Wednesday: 02 saturation was 92. Spo2 at 1230 Wednesday, 89% on 2 L oxygen therapy. Patient did however remove his nasal canula at 0730 Wednesday and spo2 decreased to 85% RA. Nurse replaced nasal canula and SPO2 returned to 90% on 21 oxygen. PaCo2 was 45 on Tuesday night at 2300 and increased to 47 Wednesday at 0500. PaO2 went from 72 Tuesday at 2300 and decreased to 70, 6 hours later as well. PH was 7.35 and bicarbonate level was 25 Tuesday 2300 and on Wednesday at 0500 pH decreased to 7.33 and bicarbonate level increased to 26. CARDIOVASCULAR SYSTEM Patient has had a diagnosis of HTN, which has been well controlled for 15 years (when he takes his medication). He takes atenolol 50 mg PO daily and chlorothiazide 500 mg PO daily. ED blood pressure 164/90, pulse 106 and nursing admission bp 162/90. pulse 108. Capillary refill WNL. No edema noted during physical exam per history and physical. Positive peripheral pulses to all extremities. Potassium level low 3.2. IV hydration of Dextrose 5% in 0.45% normal saline with potassium chloride 20 mEq/L IV continuous infusion at 75ml/hour was increased to 40 mEq/L in IV solution. According to the EMAR, the DSNS with KCL 20mEq is running in the left forearm peripherally. EKG-WNL NERVOUS SYSTEM/ COGNITIVE/PAIN/SENSORY ALTERATION Patient is calm, alert and oriented to person, place, time and event. Denies any pain. Has no history of seizures, stroke, fainting, blackouts, no weakness, tremors, paralysis or coordination problems, no numbness or tingling and memory is intact, and there is no history of mental health dysfunction per history physical. No Vision problems noted. No hearing problems noted ENDOCRINE SYSTEM Lymph nodes enlarged superficial cervical per nursing admission assessment. MUSCULOSKELETAL SYSTEM There is no history of arthritis or gout. Patient is independent with ADL's and has a slow and slightly unsteady gait per admission notes. His back is straight and his body is thin. No muscle pain or cramps noted. He does complain of being
tired and weak frequently after completing daily tasks, and need to rest". He becomes "unsteady at that time, and has fallen twice in the last month." He is unable to go Candlepin bowling anymore and had stopped working in his garden. GASTROINSTESTINAL SYSTEM Patient continent of bowel Last bm was yesterday, medium soft brown. + flatus, + bowel sounds 4. Abdomen is nontender, soft and nondistended. Per physical no history of hemorrhoids, dysphagia, heartburn, indigestion, or nausea and vomiting. No history of abdominal bleeding, rectal bleeding. Current diet ordered is regular with no added salt. Patient has his own teeth and has no difficulty swallowing. Per nursing admission, he usually eats twice a day, but there are times when he doesn't have enough money for food so he skips meals and often eats fast food. (Social Service Consult). Usual pattern of bowel elimination is every other morning. HT. 5'7" Wt. 115 lbs GENITOURINARY/ REPRODUCTIVE SYSTEM Patient voids without difficulty per H&P. Patient continent bladder. No history of frequency, urgency, nocturia, or dysuria. No history of urinary disease per H&P. Per nursing admission note, patient voids yellow urine 3-4 times a day. Patient is not currently sexually active. Prostate WNL INTEGUMENTARY SYSTEM Skin is clean dry and intact, warm and pink. Capillary refill WNL, >2 seconds fingers and toes. Slight tenting noted per nursing admission note. Patient is clean and well groomed. No edema and no lesions noted per H&P and per nursing admission note. IV Site in left hand. IMMUNE SYSTEM There is no record of childhood vaccinations. Patient had flu shot and Covid vaccine. TB is unknown. T- 101-102F. WBC's 15,000; IV infusing. Cefotetan 1 g IV every 12 hours.
LESSON 2- ADPIE Identify 4 purposes of Assessment: (20%) Data Collection Methods Two (2) Examples from Comprehensive Cluster Sheet for each Data Collection Method (FM) (80%) 1.(10 pts) 2.(10 pts) 1.15 pts) 1. OBSERVATION 2. (5 pts) 2. PHYSICAL EXAMINATION 1.(10 pts) 2. (10 pts) 3. (5 pts) 3. NURSING INTERVIEW 1 (10 pts) 2. (10 pts) 4. (5 pts) 4. PATIENTS CHART 1.(10 pts) 2.(10 pts)