The patient had laceration and abrasions on both hands, knuckles, knees and a laceration on his head. The patient had some bleeding on his face and the nurse clean it up as we assess him. The patient had some x-rays all over his body for any broken bones and the x-rays detected a fracture on his left side of his head. The nurse also told me to give ventilation to the patient. The vital signs are follow B/P-165/97,149/90,143/87,139/79, RR-10,12,12,13,15, pulse 116,109,105,106.…
M was admitted to the surgical intensive care unit of the hospital due to left-sided rib fractures 4 through 8 secondary to ground fall. During hospitalization, he seemed confused at times and was started on IV hydration due to an elevated creatinine of 2.1. And after sometimes, he experienced urinary retention with 800 mL of urine in his bladder, for which a Foley catheter was replaced. On day of discharge, He complained of pain and oxycodone was increased him to every 4 hours instead of 6 on his. He continues to work with physical therapy and required additional therapy at a skilled nursing facility.…
SC received a call from Pa’s informal CG/dtr Tina Carroll on 3/30/2016. Tina reported that the Pa fell at the front door and hit het bottom. Tina called 911 and the Pa was transported by ambulance the Penn Presbyterian Medical Center. The Pa was examined and treated in the ER and was placed under observation. Tina reported no broken bone but that the Pa is very sore and shaken-up.…
. MEDICAL UPDATE: Client continues to report arthritis in her left leg and hand, high blood pressure, stomach hernia and hip replacement surgery. Client continues to report she needs surgery and she can wait to be housed so she can schedule both surgeries stomach and hip replacement.…
At today’s visit, she is awake, alert and oriented. She reports chronic, dull, constant, sharp left hip pain. She rates her pain as 7/10. She states that the pain affects her mobility and makes it difficult to ambulate. She takes Percocet…
Initial Diagnostic Case – For Practice Edgar is a 25-year-old married man who is being hospitalized after a suicide attempt that resulted in a car crash into a lake. He has been having a depressive episode for the past six months. This is the first episode he has experienced and it has several characteristics including feelings of depression, loss of interest, weight loss, hypersomnia, poor concentration and thoughts of suicide. His casual daily drinking of 1 or 2 beers per day has increased to five to eight per day in the last two months, which is aggravating his problems. He has no evidence of psychosis but his mood is severe.…
1. Describe the primary issues presented in the case study. The case study of the doctor in the sleep study clinic represents issues with health disparities, race, poverty/socioeconomic class, ethnicity and culture. The doctor clearly puts his own needs first as well as remains at the job due to its proximity to family and friends.…
Database and Assessment Table 1 – Physical Nursing Assessment Data GENERAL: Patient is an 88 year-old Caucasian male. Vital signs stable at 97.3°F, 82BPM, 22 breaths/min, 84/54mmHg, 100% on 1.5lL O2, 0/10 pain, patient weight 58kg. SKIN/HAIR/NAILS: Skin was thin and fragile, warm and moist, skin color slightly pale, skin tear on left upper arm measuring 3 inches, no bleeding or pain.…
A review of her medical records indicates that she has chronic lower back pain that is uncontrolled. She has a history of spinal fusion and was been followed by Dr. Corner. She was living at home, but recent transferred to the ALF due to her multiple falls at home. She requires taxing effort due to her falls and increased muscle weakness and unsteady gait. She is having difficult getting to her appointments with Dr. Corner.…
Introduction Perfusion is a very important aspect to the human body. Perfusion is defined as the flow of blood through arteries and capillaries that deliver oxygen and nutrients to the cells and removing cellular waste from the body (Giddens, 2013, p. 148). For us to maintain optimal perfusion, we need are heart to generate sufficient cardiac output. This means transporting the blood through patent blood vessels to supply the tissues throughout the body. Impaired perfusion may occur when the blood supply is reduced or completely interrupted (Giddens, 2013, p. 148).…
A patient was chosen with longstanding chronic problems that included atrial fibrillation, diabetes, and hypertension. Two of the longstanding chronic problems, atrial fibrillation and hypertension, were diagnosed in 1992. One longstanding chronic problem, diabetes, was diagnosed in 2005. The patient reports that the chronic problems were managed on an outpatient basis and he has never required hospitalization until now. The patient reports that he was under the care of two physicians to manage his chronic problems, a cardiologist and an internist.…
Notified by the pt. Two pt verifier. Informed the pt this a f/u call d/t recent adminission for chest pain and left shoulder pain. The pt states that he has a history of chronic shoulder pain and that his pain was non cardiac.…
During the previous clinical rotation, I have always been accustomed to working with one patient, until I was given the opportunity to work with two. The difference between working with one patient and two is time consumption. I find myself spending more time writing information on my daily care map about two of the patients. It’s time consuming because I want to be able to gather important data in order to plan my care for the patients. I learned that using an SBAR worksheet helped me write the important information about each of my patient; thus, saving me more time.…
Primary diagnosis: Disorders of back (discogenic and degenerative) Secondary diagnosis: Other and unspecified arthropathies. Rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr The claimant was a 61-year-old woman. Alleged disability: Right leg paralysis, left leg nerve damage.…
9:10pm This undersigned witnessed patient standing in the hallway facing the nursing station when he turned around his foot was rolled over by a peer in a wheelchair. Patient observed extending his hands in front of himself when he lowered himself to the floor landing on his hands and knees. His head did not touch the floor. The patient immediately stood up and positioned himself in the medication line.…