The sloppy copy needs to be done based on this example. The patient is a man with schizophrenia, schizoaffective disorder, seizure disorder and TBI. He is a

ADMISSION INFORMATION

Student Name: Dana Priest

Date of Care:

2/25/25

Patient Initials:

CEM

Age:

31

Growth and Development Stage

Young adult:

Gender:

M

Admission Date:

1/12/2018

Reason for care needed:

DTS/DTO

Secondary Medical Diagnoses:

TBI

Surgical Hx:

Broken femur repaair

Isolation (type & reason):

None

Primary Medical Dx (describe pathophysiology, define the diagnosis, cite reference):

Schizoaffective disorder, schizophrenia and seizure disorder

List all signs and symptoms (subjective/objective data) possible with diagnosis – Highlight those your patient exhibits :

Hallucinations , delusions, depression, bizarre behavior , manic moods, personal care management , disorganized thoughts.

History of present illness:

Patient has auditory and visual hallucinations, can become aggressive very suddenly and has become a danger to self and others who trigger psychosis. Currently a 2:1 because he threw himself off of his bed and broke his arm intentionally.

ADVANCE DIRECTIVES

Living Will: Refused

Power of Attorney: Refused

Do not resuscitate (DNR) order: Refused

LABORATORY DATA:

Reason why it pertains to patient. Indicate with an “L” if low or “H” if high. (Change Norms so it is consistent for your facility’s lab data)

Test

Norms

Current Value

Date

Test

Norms

Current Value

Date

Test

Norms

Current Value

Date

Na

135-145

141

WBC

4-11.5

10.18

T3

K

3.5-5.5

4.0

RBC

3.9-5.5

4.88

T4

Cl

98-110

108

Hgb

11.5-16.5

15.7

TSH

CO2

22-30

25

Hct

35-49

47.9

PT

BUN

7-25

8

MCV

80-98

98.2

INR

Creatinine

0.4-1.4

0.94

MCH

27-34

32.1

HbA1c

Glucose

75-110

97

MCHC

32-36

32.7

OTHER

Ca

8.0 -10.5

WNL

Neuts

40-75

68.9

Globulin

2.0-4.5

Lymphs

14-46

20.90

Albumin

3.5-5.0

3.4

Monos

4-13

8.8

Bilirubin

0.2-1.5

0.7

Eos

0-7

1.0

GFR

>59.00

Baso

0-3

0.5

Describe how lab value being high or low relates to patient diagnosis:

When the numbers are either too high or too low, it can be symptomatic of a disease, or the cause of a disease. The exact arrangement of values can be linked to specific conditions.

DIAGNOSTIC TESTS

Chest X-ray: None

EKG: normal

Other abnormal reports:

Other:

Other:

Other:

Describe how diagnostic test relates to patient diagnosis:

Much in the way of blood tests, these can indicate or pinpoint a specific condition.

ALLERGIES/PAIN

Allergies: NKDA

When was the last pain medication given? None given

Where is the pain? No pain

How much pain is the patient in on a scale from 0-10? 0

TREATMENTS

Treatments: Patient is being supervised with 2:1 monitors.

What are the treatments for? DTS/DTO

Support services: 2:1 monitors

Consultations:physical therapy, dietary and psychiatry

DIET/FLUIDS

Type of Diet: HH

Rationale: to meet patient needs

Restrictions: None

Gag reflex intact: Yes

Appetite: Poor

Intake (% each meal)

Breakfast: <50%

Lunch: : <50%

Dinner: : <50%

What types of foods are included in this diet and what foods should be avoided? No restrictions.

Fluid Intake in mL:

(Oral & IV)

Not monitored

Highlight the problems experienced by your patient below:

Problems: None

(Swallowing, Chewing, Dentures)

Needs assistance with feeding:

None

Nausea or Vomiting: None

Overhydrated or Dehydrated: None

Tube Feedings: None

Type and Rate: None

Belching: None

Other:

Is the patient’s intake greater than output? Not monitored Calculate: Not monitored

INTRAVENOUS FLUIDS (IV Therapy Record)

IV lines: WDL Location: Not mentioned

Type and Rate: Not mentioned

IV dressing dry: yes

Edema: No

Redness: No

Other:

ELIMINATION

Foley/Condom catheter: Not monitored

Last bowel movement and characteristics of stool: Not monitored

Characteristics of urine: Not monitored

24-hour Urine Output: Not monitored

Highlight the problems experienced by your patient below:

Bowel: constipation, diarrhea, flatus, incontinence, belching: continent, not monitored

Urinary: hesitancy, frequency, burning, incontinence, odor: continent, not monitored

Other:

ACTIVITY

Ability to walk (gait):

Independent

Type of activity orders:

None

Use of assistive devices (cane, walker, crutches, prosthesis):

None

Bed modifications: None

Weakness: None

Trouble sleeping: None

VITAL SIGNS:

BP: Refuse

Pulse: Ref

O2 Sat: Ref

Respirations: 16

Temperature: Ref

Weight: Ref

Height: Ref

Other Assessments Learned throughout program that applies to patient?

Glasgow Coma Scale Nott monitored

Braden Scale 23

Morse Fall Scale 0

Other (specify) Nott monitored

Other Assessment or Treatment Information not included above:

None tsken