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NURS 4045 Adult Health Competencies II

Texas Woman's University


Patient Data Sheet
Student's name: __Uyen Do____________Date of Care: 10/14/16__________ Pt. location/Unit: _7S5__________
Pt. initials: _EP_______
Age: _67______
Gender: __F________
Ethnicity: __African American
ALLERGIES:__No medication allergy. Dust & pollen filter mask. Wheat containing product
CODE STATUS:__Full code__________________
Medical Diagnosis: _occlusion of right vertebral artery, dissection of vertebral artery, cervicalgia
_______________________________________________________________________________
Date of Admission & Course of present hospitalization:__10/13/16 _
Patient presented to outside St. Lukes facility for one week of left neck pain radiating to arm and shoulder. Was
previously admitted to methodist for 3 days earlier and did not find a cause for her main problem. MRI at St.
Lukes showed absence of right vertebral artery flow and this was also seen on MRA. Concern for vertebral artery
dissection so transferred to NICU. Denies neurological deficits. Denies dizziness or symptoms other than her
pain. Pain is described as moderate and radiated down from her left neck into her left arm. 8/10. Constant,
stabbing pain partially relieved with morphine. ___________________________________________
________________________________________________________________________________________________
Past Medical/Surg.history:_________________________________________________________________________
_Medical Hx: HTN, hypopituitarism, CAD, hypothyroidism _
Surgical Hx: 2005 cardiac catheterization, pituitary gland removal
______________________________________________________________________________________________
Social history: __Denied smoking, alcohol, drug use
__________________________________________________________________________________
Family interaction/relationship: _Daughter called today. Daughter does not live in Houston
____________________________________________________________________
Communication with patient: _Limited (patient is drowsy)
______________________________________________________________________
Isolation: Yes __ No_X_ Type: ____________ Why: _____________________________________
Oxygen Delivery: Room air:__X______ Nasal cannula: _________Facemask: ______ Other:
Ventilator settings: TV: _____ FIO2: ____ Mode:_______ rate/total: ___/___ PEEP: ____ PS: _____CPAP: _______
Nutrition: Diet: restricted sodium. Low fat. Low cholesterol ____ Feeding tube( type and location):
____________________ TPN or PPN: _____________
Chest tubes: ________________________ Drains: ________________ NGT: __________________ Foley: _______
Invasive lines/monitoring: (include location) Arterial line:______________ PA catheter _____________ IABP:___
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Central line(s):_______________ Peripheral IV(s):__R antecubital- phlebitis grade 0, intact, flushed


_______________________________ ICP monitor: __________
IV Infusions (dosage--include mcg/kg/min, mg/hr, units/min or other format as appropriate (look at the order)
PATIENT WT: ___________
Drug
infusion

Current
IV rate

Current
dose

Magnesiu
m sulfate

25 mL/
hour

2g

IV site location
(where is it
running?)
R antecubital

Drug concentration (How is


bag mixed)

Why is THIS patient


getting this infusion?

NURS 4045 Adult Health Competencies II


Patient Data Sheet- Assessment

Data

Neuro: ICP _____ CPP_____ GCS_____Sedation Assessment (RASS score)___-1 (drowsy)


____________________________
_________________________________________________________________________________________________
Musculoskeletal: __muscle strength 5/5 bilaterally. Full sensation. Strong hand grips _________________
Activity: progressive ambulation _______________________________________________________________
Cardiovascular: HR_85___ BP_96/62____ABP__N/A___ CO/CI__N/A______ PAP/PAWP _N/A_____ CVP__N/A___
SpO2___96%__________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Respiratory: Oxygen/Ventilator settings________________________________________ RR______
___________
_________________________________________________________________________________________________
GI: ______________________________________________________________________________________________
_________________________________________________________________________________________________
Renal: 24 hour I/O___Intake= 235 _____ _________________
Output= 200 _____Net= +35 mL ___________________________________________________
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_________________________________________________________________________________________________
Integumentary: T:__98.7____ F or C
_____________________________________________________________________
_________________________________________________________________________________________________
Pain Assessment: _0800 pain= 7/10 at neck, radiates to left arm, stabing _________________
1000 pain= 5/10 _______________________________________________________________
Delirium Assessment:__Alert, oriented x 4. Intact memory.
____________________________________________________________________________
Psychosocial issues:______________________________________________________________________________
Other:___________________________________________________________________________________________
o

ECG strip:
Lead: ______ Atrial/ventricular rate: ______ Regular/irregular: _______ PR interval: _____ QRS interval: _______

ECG interpretation: ___________________________ ECG Intervention:___________________________

(attach the ECG strip you analyzed above, here. Staple or tape it in place. NO NAMES or other identifying information left on strip.)

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LIST ALL VALUES that are pertinent to this patients situation. Provided all values highlighted please.

Lab

Normals

Results/Date

WBC

4.0-10.0
K/L
4.00-5.00
M/L
150-430
K/CU MM
N/A

7.2

N/A

N/A

12.0-15.0
GM/DL
36.0-45.0
%
136-145
meq/L
3.5-5.1
meq/L
98-107
meq/L
N/A

13.8

7-21
mg/dL
0.57-1.25
mg/dL
70-105
mg/dL

17

RBC
PLT
PT/I
NR
PTT
HgB
Hct
Na
K
Cl
Osmolality
BUN
Creatinine
Glucose
Albumin

Rationale and/or importance for this patient

4.77
280
N/A

37.9
131
5.4
102
N/A

1.91
75
N/A

Ca (Serum or Ionized?)

9.6

Mg

8.5-10.5
mg/dL
1.2

CK

N/A

N/A

CK-MB

N/A

N/A

1.2

Troponin

4.69

Arterial : pH

0.03

PaCO2

N/A

N/A

PaO2

N/A

N/A

HCO3

N/A

N/A

BE

N/A

N/A

Ventilator settings
for the blood gas
Urinary: pH

This is required for blood gases.

N/A

6.0

Specific gravity

1.015

sodium

N/A

N/A

osmolality

N/A

N/A

Creat. clearance

N/A

N/A

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GFR

32

Amylase and
Lipase
Liver
transaminases

N/A

N/A

N/A

N/A

Protein, urine

0-14

12

Uric acid

2.5-8

6.8

Lipid profile
Cholesterol
Triglyceride
HDL
LDL
Hemoglobin A1C

<200
<150
>=60
<100
4.3-6.1

210
183
33
140
5.3

Vitamin B12

213-816

580

Folate

>=7

13.2

TSH

0.35-4.94

0.01

Free T4

0.7-1.48

1.08

PTH

15-90

74.4

ANA

Negative

Negative

Ds DNA Ab

Negative

Negative

C3 complement

82-193

144

C4 complement

15-57

41

Hepatitis B surface
Ag
Hepatitis C Ab

Nonreactiv
e
Nonreactiv
e

Nonreactive
Nonreactive

Positive Culture Reports?


Date
Site

Result

Additional Notes/ Comments:


_10/13/16 MR orbit face neck without IV contrast: Long segment right cervical
level vertebral artery vasculopathy and flow compromise
10/13/16 MR neck without IV contrast: No visible flow right vertebral artery,
chronicity and specific etiology unknown.
10/13/16 MR head without IV contrast: No visible right vertebral artery flow.
Otherwise negative MRA head
08/05/15 Protein electrophoresis: Gamma globulins increased in a diffuse fashion.
This indicates a chronic immune or inflammatory
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response._____________________________________________________________
_08/05/15 Urine electrophoresis: Urine electrophoresis shows no evidence of
monclonal proteins or free light
chains________________________________________________________________
_04/15/15 DEXA Bone Density
These findings are consistent with a normal BMD of the lumbar spine
and bilateral femoral necks. There is no increased risk of an
osteoporotic fracture as compared to the young adult population__]
_05/01/15 _Ultrasound right breast_____
There is no sonographic evidence of malignancy.
The 5 mm oval cyst in the right breast is benign. A 1 year screening mammogram
is recommended
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________________________

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Scheduled Medications-Include all IV Medications. Infusions are listed on first page.


Medication
Time
Dose Frequency Route Why Patient is
Major Side Effects
Name
getting
(must have)
0600 1200
81
Daily
PO
0700 1300
Aspirin
mg
0800 1400

Atorvastatin
(Lipitor)
Clopidogrel
(Plavix)
Enoxaparin
(Lovenox)
Famotidine
(PF)
Famotidine
(Pepcid)
Gabapentin
(Neurontin)
Hydrocortis
one (Cortef)
Magnesium
sulfate IVPB

Spironolact
one
(Aldactone)

0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100

1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700

0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100

1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700

80
mg

Q night

PO

75
mg

Daily

PO

30m
g

Q 24 h

Sub
Q

20m
g/2m
L

2 times
daily

IV

20m
g

2 times
daily

PO

300
mg

3 times
daily

PO

20m
g

Daily

PO

2g in Once
50m
L
steril
e
wate
r
25m Daily
g

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IV

PO

revised 10/14/16

PRN Medications
Medication
Dosag
e
Morphine
1mg
injection
10 mg

Frequenc
y
Q4 hour

Rout
e
IV

Why patient is
getting.
Severe pain 7-10

Q 6 hour

IV

N/V

Major Side Effects

Prochlorperazine
(Compazine)

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Problem list
List 5-10 problems, ranking them in order of importance. The most important items become
your care plan focus.
1.
2.
3.
4.
5.
6.
7.
8.
9.

10.

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NURS 4045 Adult Health Competencies II


Patient Data Sheet Patient Care Plan
Primary Nursing Diagnosis (1) with related information and evidence:

Secondary Nursing Diagnosis (2) with related information and evidence:

Intervention(s) and Evaluation(s):


Diagnosi
s#

Interventions (What did you do?)

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Evaluation (How did it work)

revised 10/14/16

Diagnosi
s#

Interventions (What did you do?)

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Evaluation (How did it work)

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