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holistic assessment labs

holistic assessment labs

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Published by Mags

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Published by: Mags on Dec 15, 2009
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07/02/2014

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Client’s Initials _LG__ Adm. Date _9/24/09___ Date Surgery _9/24/09__  Type of Surgery _exploratory laparoscopy with extensive lysis of adhesions _ Diagnosis & Relevant History Dx: small bowel obstruction; hx: vertigo, syncope,Seizures “passing out seizures” , stroke, cataract surgery, macular degeneration, hypertension,Hypercholestermia, myocardial infarction, CHF, varicose veins, bowel obstruction,Cholecystectomy, reflux disease, bowel resection, appendectomy, ovarian cyst removal,Carpal tunnel, arthritis, depression.Social History Pt is widowed for past 26 years. Lives at home with daughter and daughter’s family. Pathophysiology: Attach and cite source with APA format (USE SEPARATE SHEET)Analysis of Assessment: (use only abnormal and significant normal findings)0800 VS: T 98.1 P 60 R 18 B/P 132/68 RUA saO
2
98% RAI.Psychological Variables pt is very calm and cooperative. She is anticipating her dischargehome, which is still unplanned. She discussed her admission as a “bummer” since she isstill very active and this was a disruption to her daily plans. She pleased that her health isimproving and that she is not experiencing pain anymore.II.Sociocultural Variables widowed homemaker, has 4 children and 13 grandchildren. Shelives with one of her daughters and her family. Pt said that this makes her feel safer and that sheloves being able to help taking care of her grandchildren. Her family is very important to her andhas been visiting her at the hospital every single day which she says is a great comfort to her.III.Developmental Variables , list current Erickson Integrity Despairstage & “X” task line and explain reason Xopen about life and life experiences, discusses life as lived well, discussed childrenin good tone and spoke of their accomplishmentsIV.Spiritual Variables religion is important, she prays daily and goes to church. She has beenseeing the chaplain while hospitalized.V.Physiologic VariablesA.Respiratory airway patent; lung sounds clear in all areas bilaterally; 18RR, regular,eupnea, unlabored breathing, symmetrical chest movement, no cough. 98% onroom air. Instructed to use incentive spirometer , coughing and deep breathingexercises. IBE 750mL.B.Cardiovascular Apical 60; regular. On telemonitor- sinus rhythm with PACs. Nopacemaker. Peripheral pulses palpable 2+ in all extremities. Skin pink, warm anddry to touch. bilateral ankles edema 2+ pitting. Bilateral lower extremities moderatenon-pitting edema. (legs elevated). Capillary refill <2sec in all extremities. BP132/68; current treatment of CHF. EBL 200ml.C.Neurological awake/alert. Oriented to person, place, time, situation. Languagenormal for age. Speech clear. Judgment appropriate. Hx of possible seizures, ptdescribes them as “passing out seizures” and states that she’s not sure if she evenhas seizures and no final diagnosis available, she is treated prophylactically withlevetiracetam 500mg bid, last possible episode 6/09. Symmetrical facial
9/09
Female
  __ Married __ Single __ Divorced _X_ WidowedAge _ 
91
 __ 
 
movements. Full sensation in all extremities, denies numbness or tingling. Extremitymovement present. Emotion: calm, coping. Behavior: cooperative.D.Musculoskeletal Right and left hand grasps strong, symmetrical. Right and leftplantar flexion strong. No c/o any pain in right knee currently, previously the painwas “aching all the time, inside my knee” no radiating, alleviated by ice, rest, meds;movement aggravates pain, pt using orthopedic shoe while walking, 10/10/09 1%lidocaine and methylprednisolone was injected intraarticularly into the right kneeafter trace fluid (nonpurulent) was aspirated from intraarticular space of right knee.Performs good active range of motion and strength of bilateral UE for ADL. LEdecreased AROM.E.Gastrointestinal abd soft non-tender, BSx4, normal, no abd discomfort, passingflatus, no constipation, no diarrhea, last BM 10/12/09, no nausea or vomiting.F.Genitourinary toileting: BRP , urine: yellow, clear. Foley catheter removed 10/12/09430, pt voided 0730 100ml clear yellow urine, no c/o burning or discomfort. Novoiding problems. No bladder distension. (2300 10/11-0430 10/12: 650 mL)G.Integumentary warm, color normal for ethnicity, elastic/no tenting, dry to touch.Mucous membranes pink, moist. 1 surgical incision: abdomen, medial, ~10 incheslong, well approximated, by staples, open to air. No discharge from site. Skin aroundincision warm, pink around edges. Pt denies direct wound pain. Staples removed myNP 10/12/09 @1030. Pt tolerated well.
VI.
Discharge Planning AssessmentPt states she will be staying with her youngest daughter who will be helping her with herADLs. She will need PT and OT rehab outpatient. No definite plans of discharge yet.VII. Neuman Wheel
M
EDICATIONS
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 D
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ADMINSTRATION
levofloxacin
(Levaquin )1300-antibiotic postop-allergies to levofloxacin,other fluoroquinolones-s glucose-renal/hepatic-hypersensitivity rxns (skinrash, urticaria, pruritus)
9/09
 
Key for Neuman wheel:Phy-PhysiologicalPsy-PsychologicalSoc-SocioculturalDev-DevelopmentalSpi-Spiritual
 
Phy psysocdevspi
 
-250mg /D5W50ml-admin over 60min-Q24H-IVPB-wound site-n/v/d-abd pain-dizziness, drowsiness,light-headedness-h/afunction tests-CBC-WBC-changes/ulcerations in oralmucosa-mod to severe diarrhea-new or increased fever 
clindamycin
(Cleocin)-600 mg/D5W50ml-admin over 30min-Q8H100018000200-antibiotic-allergies to clindamycin,lincomycin, aspirin-abd pain-n/v/d, BM pattern-wound site--WBC-CBC-renal/hepaticfunction tests-hypersensitivity rxns (skinrash, urticaria, pruritus)-changes/ulcerations in oralmucosa-mod to severe diarrhea-new or increased fever 
heparin sodium
-5000 units-Q12H-subQ injection09002100-anticoagulant-poss hemorrhage (LOC,BP, P,-injection sites for excessive bleeding-peripheral pulses-skin for ecchymosis, petechiae-gums for erythema,gingival bleeding-hematuria-PTT-Hct-platelets-AST-ALT-urine and stoolfor occult blood-poss hemorrhage (dec BP, P,LOC, c/o abd/back pain,headache)
methylnaltrexone bromide
(Relistor)-12mg-Q24H-subQ injection1800-opioid inducedconstipation-BM pattern-abd pain-n/v/d-orthostatic hypotension
guaifenesin
(Robitussin)-400mg-tid-PO090014002200-expectorant-lung sounds-type, severity, frequencyof cough-any improvement of cough-fluid intake-dizziness-h/a-rash-n/v/d-abd pain
diclofenac
(Flector patch)-1 patch-Q12H0900analgesicanti-inflammatory-onset, type, location,duration of pain,inflammation-any improvements-inspect appearance of affected joints for immobility, deformities,skin conditions-BUN-creatinine-K -hepatic-renal-headache-dyspepsia-overdose may result in acuterenal failure-rashes
omeprazole
0900reduces gastric acid -n/d abd pain-lytes-headache
9/09

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