Nursing Assessment Doc

PNC Basic Physical Assessment by System full of life 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 popular Evaluation: wd/wn; lucid; healthful groomed; falls contract a chance (10 points); bring to passly dependent Neurological/musculoskeletal: a&0x3; + pulse (2) fastness extremities; lower unaccessable; bilat contractures upper extremeties; composure from neck down; uses call bell on elevate; hoyer lift transfer and enwrapped to geri chair Respiratory: + bs x 5 lobes; un able to prise posterior; - cyanosis; >3 treetop refill; bs weak and shallow; Cardiovascular: + bilat radila pulses; - cyanosis; - jvd; s1and s2 noded; GI: + 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 lily-livered urine Integumentary: wnl skin turgor; - for lesions; Psychosocial Assessment: pt well adjusted to complete dependency; family in local anaesthetic 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 on-going condition. look into pt gets social time. also ensure bath memorandum is followed to due complete sedentary life dash to assess for skin changes. Text! book Signs and Symptoms/Complications of Current Diagnosis: n/a Medications: No current medications list in health check file at VA. Diagnostic Procedures: Labs: Nursing Diagnoses and Nursing caveat Plan: DECREASES spit out INTEGRITY DUE TO SEDINTARY lifespan STYLE, SELF CARE shortfall DUE TO IMMOBILITY AT RISK FOR DEPRESSIONIf you want to get a full essay, army it on our website: BestEssayCheap.com

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