- Patient Chart Gender Female Mrn 123546 Patient Name Barbara Nelson Age 72 Allergies Nka Dob Height 180 Cm Weight 1 (71.62 KiB) Viewed 44 times
- Patient Chart Gender Female Mrn 123546 Patient Name Barbara Nelson Age 72 Allergies Nka Dob Height 180 Cm Weight 2 (27.92 KiB) Viewed 44 times
PATIENT CHART Gender: Female MRN: 123546 Patient Name: Barbara Nelson Age: 72 Allergies: NKA DOB: Height: 180 cm Weight: 93.6 08/25/XX (72 inches) kg (206 lbs.) Admission Diagnosis: Malaise, Admission Date: Today's date Admission Provider: weakness Dr. Davis Advanced Directives: Full Location: Emergency Room Contact Precautions: Code Standard PATIENT INFORMATION Marital Status: Married Religion: Jehovah's Witness Next of Kin: Spouse, George Race: Caucasian Primary Language: English Occupation: Retired Homemaker History of Present Illness: Patient presents to the ER very anxious. She is with her husband and complains of general malaise, muscle weakness, and mild chest pain. You are nurses working in a rural ER, your provider is 15 minutes away. Past Medical History: Hypertension, Diabetes mellitus type 2, OSA, ESRD on hemodialysis 3 times/week, CHF bericht dous Immunizations: Current on immunizations Surgeries/Procedures: AV fistula to left arm in 10/2019, appendectomy, right TKA, bilateral carpal tunnel Social History: Lives with husband, has 4 children-none nearby, denies alcohol use, previous smoker of 20 pack years, quit 5 years ago. Laboratory Values Admit Date/Time: 0700 Today Complete Blood Count: Hgb HCT WBC Platelets Basic Metabolic Panel: Na+ 12.3 36 12.5 300,000 * K+ 130 7.2 119 CI HCO3 BUN Creatinine Glucose 75 20 198 *
Based on the data you have at this time: 1) What do you anticipate will be your physical priorities in this scenario and how will you manage them? (5 pts) 2) What do you anticipate will be your psychosocial priorities in this scenario and how will you manage them? (5 pts) 3) What risk factors does your patient have for the priority problem(s)? (5 pts) 4) What are the important assessments to make? (5 pts) 5) What complications is this client at risk for? (5 pts) 6) What interventions do you anticipate will help to prevent complications? (5 pts) 7) Identify any cultural or family considerations that may affect the care of this client/family. (5 pts)