Medical HistoryStudent Name - Marchelle Minor Date - 10-02-09Client’s Initials - mn Room - 405 Client’s Diagnosis: Pancreatitis, New onset Diabetes Mellitus ________________________________________________________________________ * * Write out the findings of your physical assessment. Use proper narrative phrasing including the following data:1.
Admitting Medical Diagnosis:
Pancreatitis - new onset Diabetes mellitus II
Obese Hispanic female, age 28 is admitted to the hospital, communicates well in English. She expresses all overabdomen pain and is guarding. She is moaning with pain, upon palpation there is rebound activity with facialgrimacing. Patient denies nausea or vomiting stated her last meal was yesterday morning and caused abdomenpain and bloating feeling. Last menstrual cycle was 4 days and regular every 2 weeks. Last bowel movementwas 3 days ago. She acknowledges change in appetite and weight gain. She is without dizziness or night sweats.Her weight is 215lbs, Blood pressure is 138/86, pulse 100, respirations 22, 99.0 99% saturating on room air. Noknown allergies. Patient states this is her first time in the hospital and prior to moving here she lived with hermother and father in El Paso. Both are alive and healthy.
Current surgery / surgical history;
is denied.
Past
medical history
No history is available
Home medications
. None
Disease/preventive care
. Patient denies; infectious
History of Present Illness: Drug use:
Cannaboid user weekly past 8 years;
Support systems:
Father and mother
IMPRESSIONS:
Severe Pancreatitis, Severe Dehydration, Leukocytosis , Hyperglycemia, Cannaboid use,
constipation
PHYSICAL EXAMINATIONGeneral overall condition:
Awoke in semi- fowler position, has bilateral 22 gage wrist/hand IVs’ with 24 hoursreplacement time/ restart negative for signs or symptom of infiltrate. Right is capped – Left has 0.9ns infusing at250cc. Robust female, alert x3 respirations are even non-labored. Skin warm dry and intact color is withinnormal limits.1.
Vital Signs
T 97, Bp, 121/76, P 101, R202.
Head:
Normal symmetrically, scalp clean without lesion, no dandruff 3.
Ears:
No earache, deafness, tinnitus, no vertigo or discharge4.
Eyes:
No diplopia, itching, dry eyes, eye pain or photophobia, orbits normal5.
Nose
: Normal membrane pink and moist.6.
Throat:
Flexible. Normal pulsations, no palpable thyromegaly, no palpable Lymph nodes, tracheacentral, no JVD7.
Nails:
Normal, Good capillary refill8.
Skin:
Skin is warm dry and intact
,
color wnls.
9.
Neuro
Sensation is intact, Cranial nerves II – XII intact10.
Musculoskeletal
WNLS No pedal edema Peripheral pulses normal negative joint swelling11.
Respiratory
Normal contour of the chest with symmetrical motion. Clear to auscultation bilaterally, Nodyspnea, No pleural rub.12.
Cardiovascular
Tachycardia. Normal S1, S2 No murmurs.13.
Gastrointestinal
No Scars, Hypoactive bowels sound, 4 quadrants. Pt is very tender in the right upperquadrant and mid epigastrium, she is complaining of tenderness all over her back and abdomen. Murphyis negative.14.
Genitourinary
Urine positive for cannabis,
Foley - Lab
15.
Mouth
Normal lips, Buccal mucosa is dry, Normal looking teeth and gums16.
Nose
Normal external, septum and turbinates(3)
Use SCAR charting meNURSES NARRITIVE : Use correct documentation technique. Document subjective and objective dataat least every two hours. Chart the care and responses of the client during your care. Please includean opening and ending statement. Sign after each entry
.
Preceptor and SN; Initial observation:
08:30a.m.
NPO:
The patient is alert and able to state her nameand date of birth.
She is sitting in a semi- fowlers position with TV on. I introduced myself. as a Sn and stated Iwould be working the her nurse: Noted bilaterally 22g peripheral IVs taped, secure and intact, no s/s of rednessor infiltration Left hand heplocked, Right has 0.9ns infusing @ 125cc via pump. Foley to gravity with 300 cc of light urine. Q4 hr Finger sticks, 264; administered : 4 units of regular insulin per s/s, given sq in right upperarm. Pantoprazole 40mg IVP. Abdomen large taunt. Daily Vitals signs completed. Noted abdomen large tauntpatient denies pain at this time. Observed patient guarding her stomach with facial expression of pain. I askedthe patient if she would like to have some pain medication and from 1 to 10 what was her pain level? She statedit was at a 7. Administered Morphine 5 mg Ivp for pain. (alcohol wipe – ns flush before and after medadministered______________________________________________________________________________________MMinor:sn
SN
: 09:00 Returned to observe patient; when asked about the pain she stated it was “much better and itdidn’t hurt anymore.” Ice chip at her bedside. Bed in low position- side- rails up x2 call-bell in reach _____________________________________________________________________________________________MMinor:sn
Preceptor and SN;
09:15a.m. Assessment of patient reveals she is no longer in pain, talking on her phone
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Nursing Care Plan PackageC
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| Upload Date: | 10/17/2009 |
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