15
Plan 4 Test Paper.
.MED SURG Care
LATEST UPDATE 2024.
Patient is a 80-year-old male residing at Sentara Williamsburg med-surgery unit. Patient was admitted
with hematuria onset started 8 months ago.
PAST MEDICAL HISTORY
Patient has a history of hypertension, hyperlipidemia, type 2 diabetes, coronary heart disease, gout, GI
bleeding, anemia, kidney disease stage 3, BPH, diverticulosis.
CURRENT ORDERS
DIET: Diabetic
ACTIVITY: Daily physical therapy, patient needs no assistance with ADL’s and is
independent. TREATMENTS: Patient will continue to receive everyday medications at
appropriate times.
DEVELOPMENTAL ASSESSMENT
ERIKSON’S STAGE: Ego integrity vs. Despair (Lillis, Taylor, Lemone & Lynn, 2011).
EVIDENCE: Patient is very independent and needs little to no assistance. Patient is aware that he is
independent and is wants to continue to be.
P a g e 1 | 24
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PHYSICAL ASSESSMENT
(Complete head to toe assessment. WNL is not accepted. Please be specific.)
Neurologic: LOC, pain assessment, GCS score Alert & Oriented to person, time, place, answers
questions appropriately, verbal communication
appropriate. Patient reports no discomfort. ROM
active in patient’s upper and lower extremities.
GCS 14
Respiratory: Rate and O2 saturation Lung sounds clear bilaterally to all lung fields.
Symmetrical chest expansion. Respirations: 18,
not labored, regular rhythm. Mucous membranes
are moist and pink. No cough. O2 level 100.
Cardiovascular: HR, BP, JVD, peripheral pulses, BP: 139/63 Peripheral Pulse: 57 Temp: 97.5.
capillary refill Radial pulse rate: 59 rhythms normal. Cap refill
<3 sec, brisk. Apical pulse: no audible murmur,
no JVD
Gastrointestinal: Last BM and description Abdomen round, soft. No discomfort on abdomen
during palpation and no pain. Normal bowel
sounds x 4 quadrants. Last BM 18MAR13, stool
large, soft, brown, with heavy odor.
Genitourinary: Continent. Urine is yellow, no odor. Negative for
bladder distention.
P a g e 2 | 24
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Musculoskeletal: Hand grips strong bilaterally. Right leg and left
leg push/pull strong.
Integumentary: Scalp no visible lesions hair is black. No pitting
edema present. Hands warm to touch. Patients
back and buttocks are light pink. No bruises, or
open areas present. Patients skin intact but dry.
Psychosocial: Patient was pleasant and cooperative. Enjoyed
talking about his family and work. No past history
of smoking or drinking.
Nutritional: Include % of each meal consumed Diet diabetic. Patient consumed 100% of
breakfast and lunch.
MEDICATIONS
Please include trade & generic name, dosage, action, reason your patient is receiving this medication,
major side effects, and nursing implications. Include your source citation for each med.
Trade Name: Lipitor Drug Action: Is Dose Adverse Reactions: Nursing
Lowering of total Appropriate? Implications:
Generic Name: and LDL cholesterol Dizziness,
Atorvastatin and triglycerides. Yes headache, If patient develops
Slightly increases insomnia, muscle tenderness
Dose: PTs Weight weakness, during therapy,
HDL cholesterol.
20 mg Route: Reduction of rhinitis, CPK levels should
83.9 kg
lipids/cholesterol bronchitis, chest be monitored. If
PO Time: reduces the risk of pain, peripheral CPK levels are >10
edema, times the upper
P a g e 3 | 24
Plan 4 Test Paper.
.MED SURG Care
LATEST UPDATE 2024.
Patient is a 80-year-old male residing at Sentara Williamsburg med-surgery unit. Patient was admitted
with hematuria onset started 8 months ago.
PAST MEDICAL HISTORY
Patient has a history of hypertension, hyperlipidemia, type 2 diabetes, coronary heart disease, gout, GI
bleeding, anemia, kidney disease stage 3, BPH, diverticulosis.
CURRENT ORDERS
DIET: Diabetic
ACTIVITY: Daily physical therapy, patient needs no assistance with ADL’s and is
independent. TREATMENTS: Patient will continue to receive everyday medications at
appropriate times.
DEVELOPMENTAL ASSESSMENT
ERIKSON’S STAGE: Ego integrity vs. Despair (Lillis, Taylor, Lemone & Lynn, 2011).
EVIDENCE: Patient is very independent and needs little to no assistance. Patient is aware that he is
independent and is wants to continue to be.
P a g e 1 | 24
,15
PHYSICAL ASSESSMENT
(Complete head to toe assessment. WNL is not accepted. Please be specific.)
Neurologic: LOC, pain assessment, GCS score Alert & Oriented to person, time, place, answers
questions appropriately, verbal communication
appropriate. Patient reports no discomfort. ROM
active in patient’s upper and lower extremities.
GCS 14
Respiratory: Rate and O2 saturation Lung sounds clear bilaterally to all lung fields.
Symmetrical chest expansion. Respirations: 18,
not labored, regular rhythm. Mucous membranes
are moist and pink. No cough. O2 level 100.
Cardiovascular: HR, BP, JVD, peripheral pulses, BP: 139/63 Peripheral Pulse: 57 Temp: 97.5.
capillary refill Radial pulse rate: 59 rhythms normal. Cap refill
<3 sec, brisk. Apical pulse: no audible murmur,
no JVD
Gastrointestinal: Last BM and description Abdomen round, soft. No discomfort on abdomen
during palpation and no pain. Normal bowel
sounds x 4 quadrants. Last BM 18MAR13, stool
large, soft, brown, with heavy odor.
Genitourinary: Continent. Urine is yellow, no odor. Negative for
bladder distention.
P a g e 2 | 24
, 15
Musculoskeletal: Hand grips strong bilaterally. Right leg and left
leg push/pull strong.
Integumentary: Scalp no visible lesions hair is black. No pitting
edema present. Hands warm to touch. Patients
back and buttocks are light pink. No bruises, or
open areas present. Patients skin intact but dry.
Psychosocial: Patient was pleasant and cooperative. Enjoyed
talking about his family and work. No past history
of smoking or drinking.
Nutritional: Include % of each meal consumed Diet diabetic. Patient consumed 100% of
breakfast and lunch.
MEDICATIONS
Please include trade & generic name, dosage, action, reason your patient is receiving this medication,
major side effects, and nursing implications. Include your source citation for each med.
Trade Name: Lipitor Drug Action: Is Dose Adverse Reactions: Nursing
Lowering of total Appropriate? Implications:
Generic Name: and LDL cholesterol Dizziness,
Atorvastatin and triglycerides. Yes headache, If patient develops
Slightly increases insomnia, muscle tenderness
Dose: PTs Weight weakness, during therapy,
HDL cholesterol.
20 mg Route: Reduction of rhinitis, CPK levels should
83.9 kg
lipids/cholesterol bronchitis, chest be monitored. If
PO Time: reduces the risk of pain, peripheral CPK levels are >10
edema, times the upper
P a g e 3 | 24
