1705610-78422500 Essays - Health, Medicine, RTT, Dosage Forms

1705610-78422500 Composite Clinical Nursing Report Clinical Worksheet Student's Name: Sandra Osorio Patient's Initials: JK Age: 93 Gender: F Room No.: 303 C Admitting Diagnosis: Dementia, Hemiplegia, HTN, Paresthesia. Brief discussion of Diagnosis: Dementia is not a specific disease. It's an overall term that describes a wide range of symptoms associated with a decline in memory or other thinking skills sever enough to reduce a person's ability to perform everyday activities. Lab Data as of 9/7/2017 Normal Potassium 5.1 Sodium 142 Urea Nitrogen 19 Urea n/ Creat . Ratio FFR 60 Albumin 2.9 Medical History and Chief complaints: Elderly female, resident of nursing home, with dementia, dependent on all ADLs, on PO feeds, has chronic medical illness, high risk breakdown, her family is involved in her care, checked for polypharmacy. Needs care for skin and fall precaution. Special Problems related to aging or condition: Difficulty walking, risk for falls, dependent on all ADLs Pain Assessment: Chief c/o Patient doesn't verbalize any pain. Additional Data: Allergies: Azithromycin, Moxifloxacin, Penicillin Air dye, Avelox Vital signs: T: 98.5.F P 70 R: 16 BP: 125/70 O2 Saturation: 95% Activity: Moderated IVs: None I/O: None Procedures: None Systems Assessment Neurological: Orientation/ Disoriented in AAO x 3 and situation Paresthesia and hemiplegia/ Noted HEENT Inflammation: None Mucous membranes: Pale, Moist and Intact Discharge: None Respiratory Breath sounds: No difficult to breath Secretions: None Oxygen Saturation: 95% Cardiovascular Heart rate/Rhythm: Strong heart sounds, no murmur noted Peripheral Pulses/Edema: 90 strong pedal pulses bilaterally, no edema noted. Skin Color/Capillary refill: pale skin, capillary refill 3 sec. Gastrointestinal Abdominal Description: Round and soft, no tenderness Bowel Sounds: + 4 in quadrants Stool characteristics: Soft brownish stool Genitourinary Urine characteristics: Amber color Catheter: None Discharge: No discharge noted Musculoskeletal Mobility/Gait: Difficulty walking /postural instability Range of Motion (ROM): Limited Joint Swelling: Pitting edema on knees Integumentary Color/Turgor: Pale, good skin turgor, no dehydration Rash/ Under Neck, breast armpits and coxis. Psychosocial Needs Behavior: Good mood Level of Anxiety: Moderate Social Interactions: Interact well others Nursing Notes Etiology (Instruction: Write a comprehensive Nursing Note that summarizes all sub-sections of the head to toe assessment) 06/10/2017 - 07:00am: Patient received in bed resting, VS T 98.5F, P 70, BP: 125/70, RA: 16, O2 sat: 95%, Disoriented in AAO x 3 situation. Paresthesia noted, Muco membranes pale, moist intact, no discharge noted. Normal lung sounds upon auscultation. . Strong heart sounds, no murmur noted. Pale skin, capillary refill 3 sec, ABD round and soft, no tenderness to touch, BS + in 4 quadrants, soft brownish stool. Amber color urine, no catheter, no discharge noted, difficulty walking, ROM limited, pitting edema on knees, good skin turgor, rash/lesions noted in neck, breast and armpits, good mood, interact well with others .Pt left sleeping, bed in semi-fowler position. \, Call light within easy reach. Patient endorsed to shift nurse. ---------------------Sandra Osorio LPN std Disease Process Diagram/Illustration 31432501143000 Description of the Disease Process Vascular dementia, which occurs after a stroke, is the second most common dementia type, if often incorrectly referred to as senility or senile dementia Signs and Symptoms of the Disease (Provide at least 3) Memory loos confusion Inability to speak Inability to recognize common thins anxiety Note: Cite all references WebMD (2005-2017) Retrieved from WebMD is Dementia IV. Medication Grid 48196505525770 References: Hazard, and Cynthia A. (2017) Davis's Drug Guide for Nurses (15th e.d e.d) Plus References: Hazard, and Cynthia A. (2017) Davis's Drug Guide for Nurses (15th e.d e.d) Plus CLINICAL INSTRUCTOR: Fernand de Los ReyesSTUDENT: Sandra Osorio Generic and Trade Name of Medication Classification of Medication Medication Order: Dose, Route Frequency Recommended Dose Medication Action Side Effects Reason Medication Ordered Key Nursing Implications Norvasc Amlodipine, therapeutic: Antihipertensive, pharmacologic; calcium channel blockers PO 5MG ONCE DAILY 5mg,10mg PO once a day Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, in resulting in inhibition of excitation-contraction on coupling and subsequent contraction Dizziness, fatigue, perineral edema, angina bradycardia, Hypotension, nausea Hypertension, angina pectoris and vasoplastic angina *Monitor BP and pulse before therapy, during dose. Monitor intake and output ratios and daily weight, assess for signs of HP (peripheral edema, crackles, dyspnea) Angina assesses location, duration, and intensity. Lab test considerations total serum calcium concentration Baclofen, Gablofen, Lioral. Therapeutic; antiespasticity agents, skeletal muscle relaxants PO 5mg times daily, administered with milk or