Rasmussen College, NUR2115- Fundamentals of Professional Nursing, Course Project
Clinical Site/Unit: __Crestview Lutheran Home Clinical Site Instructor: Cheryle Gehrke
Patient Initials: H.H Gender: female Age: 93 Weight: 199.6 lbs. Height: 6’’
Baseline vitals (from patient chart)
BP: 149/76 Pulse: 70 RR: 21 T/mode: 97.8(Orally) Pulse ox: 93%
Your VS assessment: BP: 170/89 HR: 65 RR: 20
T: 97.0 SpO2: 92% 3L
Vital Sign analysis (potential cause of changes, intervention and recheck needed?): Increase in BP could be related to hypertension and decrease in O2 saturation could be related COPD. Hence patient should be monitored. All other vital signs are within normal ranges
Allergies: Eggs, Lisinopril and Nortriptyline
Social Health (family, significant other?): (Jacki and Judith are both daughters of the patient)
Marital Status: Widowed
Cultural Background: White- Patient stated both parents are Native American. She does not belong to any religion
Primary Language: English
Past Medical/Surgical History: Past Medical-, Pneumonia, Gout, Heart failure, Depression, Hypertension, diabetic, Gerd and Falls.
Surgical History- Cataract surgery of left eye (2002), Cancer of the lip (2009) surgery, Hysterectomy (May 3, 2010, Appendectomy (12/2001), Gerd, urinary incontinence.
Family Health History: Patient stated that her father died from lung cancer in 2005. Patients states mother died of COPD complications at the age 69
Diet: Ordered: Low fat milk, no fried foods, no added salt, vegetables and fruits, cereals.
Activity/Assistive Devices: One assist with transfer belt to the wheel chair
Treatment Orders (dressing changes, blood sugar monitoring, TEDS/ace wraps, nebulizer):
1. Glucose checks QID (before meals and bedtime)
2. Check feet on the 9th of each month
3. Lid scrub on both eyes’ lids BID
4. DuoNeb is one 3mL vial administered 4 times per day
5. Diabetic nails care every Wednesday
6. Chapstick due to dry lips BID
7. Daily weight monitoring
8. Incentive spirometer every hour while awake
9. Physical therapy 3 times a week for 30 days for therapeutic exercises, therapeutic activity.
10. Occupational therapy 2 times a week for 30 days to include self-care, therapeutic exercises, therapeutic activity and group activity
Interdisciplinary Cares (OT/PT/ST) and frequency: Physical therapy 3 times a week for 30 days for therapeutic exercises, therapeutic activity. Occupational therapy 2 times a week for 30 days to include self-care, therapeutic exercises, therapeutic activity and group activity
Dressings/Wounds: (type & location): None
ASSESSMENT SUMMARY: Documentation from your clinical day.
Subjective: Health History (from patient or chart)
Objective: Your assessment findings
Pain Level (pain scale 0-10/location):
Pain rating: 0-10: 6
Onset: Knee pain when...