NEW PROFESSIONS TECHNICAL INSTITUTE 4000 West Flagler Street…
NEW PROFESSIONS TECHNICAL INSTITUTE
4000 West Flagler Street Miami, Florida 33134
(305) 461-2223 / Fax: (305) 461-3029
STUDENT NAME: DATE:
CLIENT’S INITIALS: Mr. AV CLIENT’S AGE: 87 y/o GENDER: Male
ALLERGIES: NKA Advance Directives: None Restrains: NO DIET: Diet as tolerated.
Admitting Medical Diagnosis: Cholecystectomy (gall bladder removal).
Chief Complaint: Distended bladder. Bowel sounds detected in all quadrants. Urinary retention. Urine clear, yellow, no odor.
History of Present illness: Urinary retention r/t post operative neurogenic bladder and bladder outlet obstruction (BPH) as evidenced by measured urinary residual of 960ml, hesitancy of urination, and overflow incontinence Ineffective peripheral tissue perfusion r/t immobility, hypertension, hyperlipidemia, and diabetes as evidenced by diminished bipedal pulses (+1), bilateral pedal pitting edema (+1), and lower extremity capillary refill of 5 secs Risk for pressure ulcer r/t post surgical immobility and inadequate nutrition Risk for compromised human dignity r/t exposure of the body during frequent in and out catheterizations, language barrier (Farsi speaker), inadequate participation in decision making, and loss of control of body functions (urinary and bowel incontinence).
Past Medical History: Coronary angiogram; CAD; coronary stent; HTN; DM type 2 with complications of neuropathy, nephropathy, and retinopathy; anemia of chronic disease; benign prostatic hypertrophy; hyperlipidemia; retinal detachment and macular degeneration (right eye blindness).
Cultural and Spiritual Assessment: Lives with daughter in one story condo (3 steps to front door). Cognition intact. Nonsmoker.
Medications taken at home or before transfer: Metropolol (lopressor) 12.5mg, Lisinopril (Prinivil) 20mg PO, Repaglinide (Prandin) 2mg PO.
Summarize Pathophysiology (in our own words, include definition, etiology and physiology)
A cholecystectomy consists of excising the gallbladder from the posterior liver wall and ligating the cystic duct, vein, and artery. The surgeon usually approaches the gallbladder through a right upper paramedian or upper midline incision if necessary, the common duct may be explored through this incision.
Definition of Concurrent Diagnoses (all of them)
Correlational of all diagnoses with current condition
Signs and Symptoms: (Indicate which ones your client has)
Diagnostic test for this condition: (Indicate which ones utilized for client)
Treatment (med/surg/pharmacological)
Nursing Interventions and rationale:
Medications administered during client assignment including IVF’s, Rate, and reason for Fluids.
Generic/Trade Name Classification
Major Action
Reason Prescribed to Client
Dose Given/Normal Range
Adverse Effects
Precautions/Contraindications
Nursing Implication
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Generic/Trade Name Classification
Major Action
Reason Prescribed to Client
Dose Given/
Normal Range
Adverse Effects
Precautions/Contraindications
Nursing Implication
Generic/Trade Name Classification
Major Action
Reason Prescribed to Client
Dose Given/
Normal Range
Adverse Effects
Precautions/Contraindications
Nursing Implication
LABORATORY AND DIAGNOSTIC TESTS
WBC 12.5 ↑ (4,000 – 11,000 U/L) – infection of unknown origin (potential UTI, urine sample sent to lab)
Hemoglobin 10 ↓ (13-17 G/dL) – anemia of chronic disease
Hematocrit 34.5 ↓ (37.5 – 49.9%) – acceptable range for elderly males: 30-45% /anemia of chronic disease
CO2 22 ↓ (23-31) – increased acidity from uncontrolled diabetes/ kidney disease
Urea nitrogen 36 ↑ (5-25 mg/dL
Creatinine 1.8 ↑ (0.4-1.2mg/dL)
Glucose 189 ↑ (70-99mg/dL)
Protein 4.9 ↓ (6-8.5 g/dL)
Alkaline phosphate 196 ↑(<125u/L)
Albumin 2.5 (3.5-5.5 g/dL)
Ca serum 8.3 ↓ (8.4-10.2 mg/dL)
AST 36 ↑ (0-35 u/L)
Troponin 1 0.48:
B type naturetic peptide 527pg/ml (9-86pg/ml)
– chronic kidney disease stage IV (Severe reduction in GFR (15-29 mL/min/1.73 m2)
– chronic kidney disease stage IV (Severe reduction in GFR (15-29 mL/min/1.73 m2 )
– diabetes type 2
– poor nutrition, renal dysfunction
– commonly elevated following laparoscopic cholecystectomy
– renal dysfunction/ poor nutrition
– If the albumin is low, the measured calcium may appear low when in fact it is physiologically within normal limits. CorrCa = Measured serum Ca + [(4.0 – measured serum albumin) x 0.8]. Thus corrected Ca serum level is 9.5.
– commonly elevated following laparoscopic cholecystectomy
– experiencing unstable angina on admission (resolved with nitroglycerine)
– diagnostic for ADHF, left ventricular dysfunction. Also seen in renal disease.
Other Pertinent labs
DATE DIAGNOSTIC STUDY RESULTS SIGNIFICANCE TO PATIENT
NURSING DIAGNOSIS R/T AND EVIDENCED BY
Subjective Supportive Data: · RR 20 · SpO2 99% on room air · BP 138/70 · HR 92 · Temp 97.8 (Oral)
Objective Supportive Data: · Patient does not speak English (Farsi is first language · Appears confused at times · Responsive to commands · Moderate assistance required for ADLs and ambulation · Uses a cane or walker
NURSING ACTIONS
SCIENTIFIC PRINCIPLE/ RATIONALE
EVALUATION
MODIFICATION
NURSING DIAGNOSIS R/T AND EVIDENCED BY
Subjective Supportive Data
Objective Supportive Data
NURSING ACTIONS
SCIENTIFIC PRINCIPLE/
RATIONALE
EVALUATION
MODIFICATION
DISCHARGE PLANNING
CLIENT'S NEED FOR DISCHARGE
INTERVENTIONS RATIONALE
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