Patient Assessment (NR 226 RUA)

Client Initials: V. J____ Age: 65 Gender: F____

Resuscitation Status Full Code_ Allergies______NKA________________

Reason for Admission: Long _Term Care__________________________________________

Medical Diagnoses_ HTN, Peripheral Vascular Disease Unspecified, Hemiplegia and Hemiparesis following Cerebral Infarction Generalized Muscle Weakness, ________________________________________________________________________


Surgeries/Procedures and Dates: ________________________________________________________________

Past medical history________________________________________________________________________________________


Current Orders:

Diet No Added Salt (NAS), Regular texture, (Thin) consistency, for Heart Healthy Diet; Low Fat, Low Cholesterol related to Essential (Primary)Hypertension__________________________ Activity________________________________

Intake _______ Output_________________ Accu Cheks______________________________

Vital signs_______________________________________________________________________________________________

Drsg changes/wound care_No wounds, no dressing changes____________________________________________________

Foley__None_________________________ NG/G-tube/PEG?PEJ_______None____________________________________

IV None_______________________________________ Reason for IV_____None_____________________________

Other orders:











Most recent Imaging Findings: (CXR? CT? MRI?)

Type of Imaging (X-Ray, CT, MRI, etc) Body Area Imaged Reason for testing and results of test
Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?)

Date Lab Test Results Norms Comments
Other recent, significant procedures or tests (EKG, etc)

Date Test Reason for testing and results of test
Review of pathophysiology:

9
You may copy and paste these tables onto the next sheet if you have more medications

Brand Name and Generic Name Normal Dosage Ranges Contraindications
Acetaminophen Tablet (Tylenol) 325-650mg In patients hypersensitive to this drug. Stevens-Johnson syndrome, Acute Renal Failure Pts
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Analgesics Give 650mg Fatigue, insomnia, nausea, vomiting, diarrhea, rash muscle spasm
Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching
Pt taking this med as needed for generalized pain PO every 6 hours as needed Many OTC and prescription products contain acetaminophen, be aware when calculating total daily dosage. Contact MD if s/s of liver damage occur.
Brand Name and Generic Name Normal Dosage Ranges Contraindications
Atorvastatin Calcium Tablet (Lipitor) 10 – 80 mg In patients with active liver disease, Renal failure caused by Rhabdomyolysis, acute myopathy
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Antilipemic/HMG-CoA reductase 40mg Insomnia, nasopharyngitis, myalgia, extremity pain, muscle pain
Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching
Pt has high cholesterol levels Give 1 tablet PO one time a day Pt should follow standard cholesterol-lowering diet before and during therapy. Obtain baseline LFT and lipid levels and during therapy and 6 -12 weeks after treatment started
Brand Name and Generic Name Normal Dosage Ranges Contraindications
Hydralazine HCL Tablet 10-100mg With pts hypersensitive to the drug, with CAD or Mitral Valvular Rheumatic Heart disease.
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Antihypertensive 10 mg as needed Palpitations, tachycardia, orthostatic hypotension, edema, flushing
Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching
Pt is hypertensive PO, give 1 tablet one time a day every 6 hours as needed for Per vital Sign Parameter related to Essential (Primary) Hypertension for SBP>180, DBP>105 Monitor BP, pulse rate, and body weight frequently, Elderly pts may be more sensitive to low blood pressure effects
Brand Name and Generic Name Normal Dosage Ranges Contraindications
Lisinopril (Zestril) Tablet 2.5-40mg Pt with history of angioedema, hypersensitive to ACE inhibitor,
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Antihypertensive/ACE inhibitor 40mg Dizziness, headache, nasal congestion, dyspepsia, impotence, orthostatic hypotension, hypotension
Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching
Pt is hypertensive PO, give 1 tablet one time a day every 6 hours as needed for Per vital Sign Parameter related to Essential (Primary) Hypertension for SBP>180, DBP>105 Monitor BP frequently, monitor glucose, electrolyte, and lipid levels during therapy, discontinue use if jaundice and elevated liver enzyme levels occur. Monitor for angioedema of face, tongue or larynx
Brand Name and Generic Name Normal Dosage Ranges Contraindications
Famotidine Tablet (Pepcid) Tablet 10-40mg Hypersensitive to drug or its derivative, QT-interval prolongation and torsades de pointes
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Antiulcer/H2-receptor antagonists 20mg Headache, dizziness, irritability, constipation, diarrhea, vomiting
Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching
Pt has GERD PO, give 1 tablet one time a day for heartburn Monitor pt for abdominal pain, assess for blood in stool, monitor pt with renal dysfunction for QT-interval prolongation
Brand Name and Generic Name Normal Dosage Ranges Contraindications
Plavix Tablet (Clopidogrel Bisulfate) Tablet 75-300mg History of sensitivity to the drug, inn pts with hematologic reaction and intercranial hemorrhage
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Antiplatelet/Platelet aggregation inhibitors 75 mg Confusion, abdominal pain, epistaxis, ulcers, myalgia, Stevens-Johnson syndrome
Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching
Pt has peripheral vascular disease PO, give 1 tablet one time a day for CVA Teach pt to avoid grapefruit juice and drug may be given without food. Advise pt that bleeding may take longer than usual to stop and to stop any activities where trauma or bleeding may occur. Notify MD if bruising or bleeding occurs.
Medications

Routine Findings Patient Variations/Abnormals
Skin –
Head and neck –
Respiratory –
Cardiovascular
Abdomen –. Bowel continence? Last BM? Bowel Plan?
Neurological
Musculoskeletal – .
Genitourinary – Urinary continence? Toileting plan?
Nursing Diagnosis #1: Imbalanced Nutrition more than body requirementsRelated to (RT): intake of nutrients that exceeds metabolic needsAs evident by (AEB): body weight (30% over ideal for height)
Planning/Desired Outcome(s):Pt will progressively lose weight/ pt will lose at least 1 pound per week until a goal of 4 pounds per month is reachedPt will eat healthy meals with fruits for snacks each day/ pt will consume 1500kcal/dayPt will show no sign of excess weight / Physical assessment findings and lab values will be within normal ranges
Implementation/Nursing intervention(s): Rationale Evaluation/Patient Response
Nurse will coordinate care with PCP, Dietitian, PT and family Coordination of nutritional care helps for a more successful outcome
Individulaized food and menue according to pt’s preferences Pt will be encouraged to eat by incorporating her food preferences
Nursing Diagnosis #2:Related to (RT):As evident by (AEB):
Planning/Desired Outcome(s):
Implementation/Nursing intervention(s): Rationale Evaluation/Patient Response
Nursing Diagnosis #3:Related to (RT):As evident by (AEB):
Planning/Desired Outcome(s):
Implementation/Nursing intervention(s): Rationale Evaluation/Patient Response
Medical Diagnoses:

Key Assessments:

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AEB

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