patient summation
Overview
Patient is a 83 year-old female, presented to the ED on 7/2/13 with complaints of chest pain caused by what family believed to be aspiration pneumonia, also with worsening stage 4 sacral wound. Patient has a past medical history of a subdural hematoma secondary to a fall from a ladder, IDDM, bleeding gastric ulcer, and aspiration pneumonia. EKG and cardiac enzymes were ordered in the ED, EKG was unremarkable with a normal sinus rate and rhythm, enzymes within acceptable range. Patient sacral wound assessed by ED as stage 4 ulcer, with tunneling, and draining sanguineous fluid. Patient to have consult with surgery for possible debridement and wound vac. Patient ordered chest x-ray in ED to confirm presence of pneumonia. Patient was admitted to unit from ED on 7/2/13.
Patient Assessment
83 year-old female with an admitting diagnosis of aspiration pneumonia, and sepsis. BP 120/62, HR 115, RR 22, temp 101.1, 96% sp02 on 2L nasal cannula. Patient is Awake and oriented to self but unable to identify year and location, PERRLA, speech is faint and unclear. Patient unable to ambulate and requires full assistance changing positions, minimal range of motion in arms and legs. Patient has a regular rate and rhythm with a clear distinction between S1 and S2, no extra heart sounds noted. No signs of edema, radial and pedal pulses + 2 equal bilaterally with a cap refill of less than 2 seconds on all extremities. Respirations shallow with diminished lung sounds bilaterally, rhonchi noted on right upper lobe, both posteriorly and anteriorly. Bowel sounds present in all four quadrants, patient has peg tube in place. Patient has a Foley catheter draining cloudy, yellow urine. Patient is NPO with 1L of NS infusing. Skin is warm, dry, with a stage 4 sacral ulcer with tunneling and draining sanguineous fluid, Oral mucosa is dry. Bed set in lowest position with 2 rails up and call bell in right hand.
NURSING DIAGNOSES
1. Risk
Patient is a 83 year-old female, presented to the ED on 7/2/13 with complaints of chest pain caused by what family believed to be aspiration pneumonia, also with worsening stage 4 sacral wound. Patient has a past medical history of a subdural hematoma secondary to a fall from a ladder, IDDM, bleeding gastric ulcer, and aspiration pneumonia. EKG and cardiac enzymes were ordered in the ED, EKG was unremarkable with a normal sinus rate and rhythm, enzymes within acceptable range. Patient sacral wound assessed by ED as stage 4 ulcer, with tunneling, and draining sanguineous fluid. Patient to have consult with surgery for possible debridement and wound vac. Patient ordered chest x-ray in ED to confirm presence of pneumonia. Patient was admitted to unit from ED on 7/2/13.
Patient Assessment
83 year-old female with an admitting diagnosis of aspiration pneumonia, and sepsis. BP 120/62, HR 115, RR 22, temp 101.1, 96% sp02 on 2L nasal cannula. Patient is Awake and oriented to self but unable to identify year and location, PERRLA, speech is faint and unclear. Patient unable to ambulate and requires full assistance changing positions, minimal range of motion in arms and legs. Patient has a regular rate and rhythm with a clear distinction between S1 and S2, no extra heart sounds noted. No signs of edema, radial and pedal pulses + 2 equal bilaterally with a cap refill of less than 2 seconds on all extremities. Respirations shallow with diminished lung sounds bilaterally, rhonchi noted on right upper lobe, both posteriorly and anteriorly. Bowel sounds present in all four quadrants, patient has peg tube in place. Patient has a Foley catheter draining cloudy, yellow urine. Patient is NPO with 1L of NS infusing. Skin is warm, dry, with a stage 4 sacral ulcer with tunneling and draining sanguineous fluid, Oral mucosa is dry. Bed set in lowest position with 2 rails up and call bell in right hand.
NURSING DIAGNOSES
1. Risk