21.08.2019-185 views -Nursing Care Program & Standard
COMMUNITY COLLEGE OR UNIVERSITY
DEPARTMENT OF NURSING
SCIENTIFIC ASSESSMENT DEVICE
Subjective Info (Basic Fitness Factors)
College student: Date of Care: 10/03/09
Patient's Initials: P. V. Era: 37
Place #: 3114 Bed 1Allergies:
Sexuality: FMedications: NKA
Admitting Medical diagnosis: Pancreatitis
Developing Stage (Erickson and Havinghurst): (List Developing stage and tasks, evaluate each task) 1 . Choosing a mate: Although patient is definitely single, she has many good friends. Patient was happy to expose her friends that came to go to. Introductions had been all made as friends, no man or hubby mentioned. installment payments on your Starting a family group and elevating children: Individual is certainly not interested in these kinds of aspects of existence. Patient is far more concerned more than her close friends and their actions that they carry out together. a few. Managing home: While the sufferer lives exclusively, she would opt to have a roommate to talk about housekeeping responsibilities and hire. 4. Choosing civic responsibility: Patient is usually not interest in helping out community. 5. Beginning occupation: Sufferer has been a Title Researcher for two years, the lady claims that it is just a job to pay the bills. 6. Getting congenial sociable group: Sufferer claims that she has a tight group of friends that the girl enjoys seeing. While the patient was acceptable, she wished to be kept alone.
The Erickson stage which the patient is at is adult life; Intimacy versus Isolation. I actually find that Miss F. Sixth is v. to be in isolation, developmentally. She desired no socialization from me, lives alone, and performs alone. She's not positively looking for a lover and was demanding to acquire her door shut my personal entire shift, which was standard since the girl was publicly stated 20 days and nights ago.
History of present illness: In 9/13/09 affected person presented with extreme ABD pain in ED. A computed tomography Check out (CT-Scan) in the abdomen and pelvis with contrast was performed; showing severe pancreatitis with dominant pancreas showing significant edema. Moderate to large amounts of ABD ascites demonstrating basic fluid damping was mentioned. Peritoneal improvement was mainly noted within the left ABD, reflecting significant peritonitis. No bowel obstruction was known and pancreatic necrosis was not excluded. Moderate bilateral pleural effusions were also noted.
Earlier medical history:
Irritable Bowel Syndrome
Cocaine employ (1998)
Past medical history:
none of them
Drug NameDoseRoute FrequencyClassification
Metoprolol Tartrate50mgPO q12hAntihypertensive
Enoxaparin Sodium40mgSQ dailyAnticoagulant
Esomeprazole Mag Trihy40gmPO dailyAnti-ulcer
Hydromorphone hydr2mgPO PRN Opioid Junk Ergocalciferol800int unitsPO daily Vitamin
Complementary/Alternative Medical Practices
Herbal Remedies: None
Vitamins/Minerals: Daily multivitamins
Meditation/Yoga: Not one
Various other: None
Health Care Systems (Current orders and role of health care members): Low fat diet plan
IV [email protected]/hr q24h
Twice Lumen PICC line Remaining AC
Sociocultural / religious orientation: none
Family program: Patient offers family support, however lives alone in a walk up apartment.
Patterns of Living:
A. Employment: Subject Researcher
W. Education: A lot of college
C. Hobbies / interest: Probably none
D. ETOH / medication use: Interpersonal only
Environment (Conditions of living and working): Client lives alone, even though the answer changed from 9/13/09 to 9/14/09 to lives with a good friend. Family is encouraging. Friends will be supportive.
Available Methods (Economic, personal, agencies): Primary Insurance: Major Insurance is a HMO with BlueCross BlueShield.
Target Assessment of the USCR's
Rehabilitation: F. Sixth is v. Room 13314 Bed one particular Jennifer Barnes...