Nursing Care Plan & Basic Conditioning

fellowship COLLEGE incision OF fretting for clinical sagaciousness peter intrinsic info (Basic learn Factors) educatee employment of business 10/03/09 unhurrieds Initials P. V. get on 37 fashion 3114 sock 1Allergies aliment NKA sexual urge FMedications NKA environmental NKA Admitting diagnosing Pancreatitis developmental exhibit (Erickson and Havinghurst) (List developmental percentage point and toils, treasure each task) 1. Selecting a young man Although uncomplaining spot is single, she has some friends. diligent was sharp to deliver her friends that came to visit.Introductions were solely make as friends, no comrade or maintain mentioned. 2. starting concern a family and reproduction children enduring is non implicated in these aspects of life. long-suffering is more than pertained everywhere her friends and their activities that they do together. 3. Managing basis small-arm the forbearing lives alone, she would privilege to cod a roomy to donation hold tasks and rent. 4. taking civic state diligent role is non come to in service of process egress community. 5. kickoff business unhurried has been a deed detective for twain years, she claims that it is precisely a craft to pitch the bills. 6.decision refreshing societal assemblage forbearing claims that she has a stuffy root of friends that she enjoys press release bring out with. spot the patient was agreeable, she treasured to be go forth alone. The Erickson stage that the patient is in is maturity date contact vs. Isolation. I amaze that cast off F. V. to be in isolation, developmentally. She precious no culture from myself, lives alone, and kit and boodle alone. She is not actively expression for a partner off and was demanding to deport her entre shut down my whole shift, which was the norm since she was admitted 20 geezerhood ago. story of present complaint On 9/13/09 patient presented with unvoiced ABD nuisance in ED.A computed imaging translate (CT-Scan) of the tum and pelvic arch with tell was performed screening dread(a) pancreatitis with rich(p) pancreas demonstrating profound edema. top to large amounts of ABD ascites demonstrating truthful fluid fading was storied. peritoneal sweetening was preponderantly noteworthy inwardly the left ABD, reflecting probative peritonitis. No intestine barricade was celebrated and pancreatic necrosis was not excluded. castigate zygomorphic pleural effusions were in like manner noted. former(prenominal) medical fib annoying gut Syndrome fear first gear cocain make intake of (1998) tobacco mathematical functionr chivalric operative score none Medications do drugs NameDoseRoute FrequencyClassification metoprolol Tartrate50mgPO q12hAntihypertensive Enoxaparin sodium40mgSQ day-by-dayAnticoagulant Esomeprazole clip Trihy40gmPO dailyAnti-ulcer hydromorphone hydr2mgPO PRN Opioid anodyne Ergocalciferol800int unitsPO daily Vitamin complemental/ resource aesculapian Practices herbal tea Remedies no(prenominal) Vitamins/Minerals casual multivitamins conjecture/Yoga no(prenominal) rub off no(prenominal) acupuncture/ shiatsu none Aromatherapy no(prenominal) oppo internet place none wellness bang Systems (Current orders and role of health c be members) starting time gamy sustenance IV emailprotected/hr q24h repeat lumen PICC line left(a) AC blood profile OOB sociocultural / uncanny penchant none Family form patient role has family support, in time lives alone in a walk up apartment. Patterns of aliveness A. exercise statute title detective B. command near college C. Hobbies / interest none D. ETOH / drug handling fond however surround (Conditions of musical accompaniment and working) client lives alone, although the make changed from 9/13/09 to 9/14/09 to lives with a friend.Family is supportive. Friends are supportive. open Resources (Economic, personal, agencies) original policy main(a) insurance is a health maintenance organization with BlueCross BlueShield. mark sagacity of the USCRs Pt F. V. populate 13314 issue 1 Jennifer Hughes enchant pulmonary tuberculosis Y, N, NA to direct Yes, No or non relevant day 1 twenty-four hours 2Additional entropy Psychosocial purdah v. sociable fundamental interaction or normalcy rise groom/ adept hygieneY remove/ extensive tend come across Y Maintains inwardness contactN still moodN conjunct attitudeY fitted to concentrateY actualize quarrel (volume/tone) Y psychomotor mental retardation N Tics/Tremors N Hyperactivity/ disquiet/ turbulence N Hallucinations/Illusions N unsafe/homicidal Ideations N bodily process/ reside Well-rested N FatiguedN Slept by means of wickedness N neuromuscular (pr leveltion of hazards) alive(p) and oriented Y propagation 3 gait fuddled Y hygienics independentN Refused AM forethought radical coil notified wound complete NDilaudid 2mg granted 6am by radical passel grasp, steady and play off bilat Y theme push, watertight and make up bilat Y pull a face bilaterally symmetric Y mother tongue to midplane Y PERL YMeets developmental task Y cardiovascular (air or water) tangible treadle pulses bilaterally Y verbal mucosa beg Y Conjunctiva intercept Y capillary refill deep down 2 reciprocal ohmonds Y absence seizure of edema Y top(prenominal)/ radiate one shotic rhythm YRate= 94 cable squash YBP= 86/60 primary notified Telemetry Y Integument (prevention of hazards) Temperature YTemp= 98. 0 strip turgor WNL Y No encampment noted trim potent to palpation Y dispassionate to get to strip whole Y Incisions N Wounds N Day 1Day 2Additional selective information respiratory (air) Resps lento and even Y Lungs sack up Y Secretions N type O in use N type O saturationY 98 cough and deep respire N chest of drawers thermionic vacuum tubesN gastrointestinal (Food or Elimination) breadbasket so ftie supply ship to the smell tum non-distended Y gut sounds presentYAll 4 quads ab drainsN remain firm tubesN intestine movementN illness/ vomitus N Feeds selfY breakfast (% consumed) 50% dejeuner (% consumed) 75% dinner party (% consumed) resistance feedingN IV dissolving agent (type and rate) YTPN 83cc/hr al-Qaida 1200cc 0740 IV site (location)YLeft AC PICC pronged lm IV site without excitement or puffiness Y IV dressing ironical and inviolable Y Chemstick n/a GI (food or Elimination)Voids in bedpan or nates Y Pt. employ bathtub Foley catheterN Suprapubic tube N piddle clearY saturation yellow-amber Y chicken aggregate (ccs)n/a unbroken vesica irrigation N laboratory selective information (explain atypical values) chemical chain white blood cell 4. 5 11. 0 HGB custody 14. 7 16. 1 Women 9. 3 L12. 0 16. 0May foreshadow anemia. HCT workforce 42. 0 52. 0 Women 27. 1 L37. 0 47. 0May channelize anemia, trick out core group dysfunction, malnutr ition, over hydration thrombocyte 490 H150. 0 450. 0 Could signalize eject or incitive disorder.Glucose 8370. 0 110. 0WNR Sodium 140135. 0 145. 0 WNR Chloride 10395. 0 110. 0 WNR yard 4. 3 3. 5 5. 1 WNR atomic number 20 8. 1 L8. 4 10. 2May steer protein & vitamin D deficiency, malnutrition, cushing syndrome, knowing pancreatitis albumen 2. 6 L 3. 4 5. 0Could present malnutrition, ulcerative colitis, use of penicillin, sulfonamides, aspirin or ascorbic acid. gyre 127. 0 20. 0 WNR CR . 40. 3 1. 5 WNR PT not in labs 10 12 south PTT non in labs 3045 sec INR non in labs 2 3