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
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 danger to self and danger to others. He throws himself off beds and into walls to hurt himself, or randomly attacks staff. He also is constantly in restraints and seclusion because he feels safer and because of his behavior. I used FA Davis Nursing Consult the app for my resource.
This is instructor feedback for the patient profile, plus what I have for partially completed profile.
"describe path, define dx, and cite?"
"GCS and Morse Fall Scale can be assessed by looking at your patient. No hands on skills required. You must take time to look at your patient rather than rely on charts that are someone else's interpretation of what is going on. "
She wants the sloppy copy to be from maslows, from a mental health standpoint.
CONCEPT MAP – PATIENT PROFILE
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ADMISSION INFORMATION |
Student Name: Dana Priest |
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Date of Care: 2/25/25 |
Patient Initials: CEM |
Age: 31 |
Growth and Development Stage Young adult: |
Gender: M |
Admission Date: 1/12/2018 |
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Reason for care needed: DTS/DTO |
Secondary Medical Diagnoses: TBI |
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Surgical Hx: Broken femur repaair |
Isolation (type & reason): None |
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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. |
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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. |
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ADVANCE DIRECTIVES |
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Living Will: Refused |
Power of Attorney: Refused |
Do not resuscitate (DNR) order: Refused |
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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) |
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Test |
Norms |
Current Value Date |
Test |
Norms |
Current Value Date |
Test |
Norms |
Current Value Date |
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Na |
135-145 |
141 |
WBC |
4-11.5 |
10.18 |
T3 |
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K |
3.5-5.5 |
4.0 |
RBC |
3.9-5.5 |
4.88 |
T4 |
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Cl |
98-110 |
108 |
Hgb |
11.5-16.5 |
15.7 |
TSH |
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CO2 |
22-30 |
25 |
Hct |
35-49 |
47.9 |
PT |
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BUN |
7-25 |
8 |
MCV |
80-98 |
98.2 |
INR |
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Creatinine |
0.4-1.4 |
0.94 |
MCH |
27-34 |
32.1 |
HbA1c |
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Glucose |
75-110 |
97 |
MCHC |
32-36 |
32.7 |
OTHER |
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Ca |
8.0 -10.5 |
WNL |
Neuts |
40-75 |
68.9 |
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Globulin |
2.0-4.5 |
Lymphs |
14-46 |
20.90 |
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Albumin |
3.5-5.0 |
3.4 |
Monos |
4-13 |
8.8 |
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Bilirubin |
0.2-1.5 |
0.7 |
Eos |
0-7 |
1.0 |
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GFR |
>59.00 |
Baso |
0-3 |
0.5 |
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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. |
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DIAGNOSTIC TESTS |
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Chest X-ray: None |
EKG: normal |
Other abnormal reports: |
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Other: |
Other: |
Other: |
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Describe how diagnostic test relates to patient diagnosis: Much in the way of blood tests, these can indicate or pinpoint a specific condition. |
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