Nursing Assessment Doc

PNC Basic Physical Assessment by System decisive Thinking Tool (CT2) Admission Scenario: 55 y/o male pt re-admit for long term care; accepted admin date of Aug08 Patients Demographics, Past Medical & Surgical History: 55 y/o, MALE, Room 305B, Init: R.G. NKA PMH: ms; depression; hx mrsa 2007; contracted f number extremities; htn; PSH: bilat aka; suprapubic cath 2007; colostmomy Patients Vital Signs: BP: 130/85 R:20 P:70 SaO2: 95 T:98 familiar Evaluation: wd/wn; lucid; thoroughly groomed; falls set about a chance (10 points); bring to passly dependent Neurological/musculoskeletal: a&0x3; + pulse (2) fastness extremities; lower unaccessable; bilat contractures upper extremeties; quietude from neck down; uses call bell on bring up; hoyer lift transfer and enwrapped to geri chair Respiratory: + bs x 5 lobes; un able to prise posterior; - cyanosis; >3 detonating device refill; bs weak and shallow; Cardiovascular: + bilat radila pulses; - cy anosis; - jvd; s1and s2 noded; gastrointestinal: + bs x 4 quads; - dilatation; - prn on palpation; colonoscopy; RLQ colostomy tiring small union soft cook stool.

Urinary: #24, 10ml supra pubic catheter draining cloudy yellow-bellied urine Integumentary: wnl skin turgor; - for lesions; Psychosocial Assessment: pt well adjusted to complete dependency; family in local anaesthetic(a) area but with infrequent visits; Patho-Flow Diagram: N/a 3-Minute instruct: 55 y/o male w/ complete dependency needs. pt is well adjusted to period condition. look into pt gets social time. also ensure lav me morandum is followed to due complete sedenta! ry life style to assess for skin changes. Textbook Signs and Symptoms/Complications of Current Diagnosis: n/a Medications: No current medications list in medical file at VA. Diagnostic Procedures: Labs: Nursing Diagnoses and Nursing charge Plan: DECREASES spit out INTEGRITY DUE TO SEDINTARY liveliness STYLE, SELF CARE shortfall DUE TO IMMOBILITY AT RISK FOR DEPRESSIONIf you want to get a full essay, vow it on our website: BestEssayCheap.com

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