NUR 2115-Final Course Project

List all of the ordered Treatments (dressings, blood sugar monitoring, TEDS/ace wraps): 1. _ Glucose checks QID (before meals and bedtime) 2. _ Check feet on the 9th of each month 3. _ Lid scrub on both eye lids BID Notch Fund 2115 Course Project, Revised 3/17 1 Rasmussen College, NUR2115- Fundamentals of Professional Nursing, Course Project 4. _ Check between toes each morning (if redness present- place lambs wool) 5. _ Diabetic nail care every Tuesday 6. – Nystatin powder to reddened areas BID PRN 7. – Biofreeze to left shoulder for fatigue from tremors BID 8. – Chapstick d/t dry lips BID 9. – Note any behaviors/tremors/mood Qshift 10. – Fax CBC results to K&S pharmacy every Tuesday ASSESSMENT SUMMARY: Documentation from your clinical day. Body System Subjective: Health History (from patient or chart) Objective: Your assessment findings Pain Level (pain scale 0- 10/location): Pain rating: 0-10: 0 Characteristic: N/A Onset: N/A Location: N/A Description (dull, aching, sharp): N/A Exacerbating factors factor(s): N/A Relieving factor(s): N/A No pain, cringing, or wincing observed Orientation Head/Eyes/Ears/Nose/Throat (HEENT): Dry eyes, dry lips, altered mental status, bipolar disorder (all from chart) Orientation (person, place, time and situation): x1 (person) Speech (clear/appropriate): unclear PERL (pupils equal and reactive to light): intact Ears (clean/dry): clean & dry Nose (clean/dry/intact): dry & intact Throat (pink, moist): pink, moist, tongue is dry Musculoskeletal: Frequent tremors (from chart) MAE (moves all extremities): slightly Weakness: lower & upper extremities Assist (transfers/ambulation): A1-2 Assistive device (walker, cane): EZ stand, Broda chair Respiratory: Respirations: even, regular Rate: 17 Lung sounds: clear bilat Cough: present/ absent/ productive, non-productive: Present, productive SOB: at rest, /with activity/ none: none Cardiac: AP (apical pulse full minute): 84 Rhythm: (regular, irregular): regular Chest pain: UTA Peripheral pulses Bilateral uppers and lowers Rt DP: Strong Rt PT: Absent Lt DP: Strong Lt PT: Absent Edema: present / absent / pitting/ non-pitting Cap. refill; RUE: brisk LUE: brisk LLE: brisk RLE: brisk Integument: Candidiasis of skin, actinic keratosis (from chart) Skin (moist, intact): moist, intact, dry patch on LLE 15x5, red blanchable area on bottom 12x8 Color (pink, pale, cyanotic): pink Wound(s): no Notch Fund 2115 Course Project, Revised 3/17 2 Rasmussen College, NUR2115- Fundamentals of Professional Nursing, Course Project Dressing(s): no Gastrointestinal (GI): Incontinent at times (from chart) Bowel sounds (x4): x4 quads Nausea/vomiting: no Pain/tenderness with palpation: slight tenderness in RLQ Last BM: 08/21/18 Continent: yes and no Genitourinary (GU): Incontinent at times (from chart) Frequency of urination (q2h, q4h, foley): Q2hr Color: Straw/yellow Dysuria (frequency, burning): no Continent: yes and no Endocrine: Diabetic- requiring insulin (from chart) Weight: UTA Diabetic/ Blood sugar: 148 at 7:45am & 227 at 11:35am Appetite (Breakfast%):_100%_Lunch %:_minimal_ Energy Level: alert throughout shift Psychosocial/Spiritual: What is resident main concern during their stay? Main concern after they discharge? Good spirits/ Pleasant Sad/ Tearful/ Anxious Anxious but cooperative, restless Utilize your assessment data and the NURSING PROCESS to create an individualized Care Plan for your patient, be specific to their needs. Nursing Diagnoses Use your Assessment data to ID clinical problems Expected Outcomes (S.M.A.R.T.) Specific, measurable, attainable, realistic, & time-oriented (ID a future time or date for reassessment/evaluation) Nursing Interventions What can you, the nurse, do to reach the goal and improve the problem? #1 Impaired verbal communication R.T. Central nervous system impairment A.M.B. Slurred speech, dysarthria The patient will… Short-term goal: Establish method of communication in which needs can be expressed by end of shift Long-term goal: Use call light to express needs at least 1 time per shift by 1 week The nurse will… 1. Use closed-ended questions that can be answered with “yes” or “no” 2. Educate the client to use her call light when she needs something 3. Place call light within patient’s reach at all times Notch Fund 2115 Course Project, Revised 3/17 3 Rasmussen College, NUR2115- Fundam