Patient: SS, 58 y/o female
Full code, Fall risk, no isolation, NKDA
Primary Dx: Bacteremia, Severe Back Pain
Hx: Patient reported to ED on 11/14 complaining of sudden, severe lumbar pain radiating to R. leg above the knee.
Comorbidities: HTN, CHF, COPD, Chronic Pain, Anxiety, Bipolar Depression
GU
PSYCHOSOCIAL
MS
GI
CARDIO
NEURO
RESP
SKIN
A/O x 4
Pupils 2mm, PERRLA
Speech clear, coherent
Normal s1 and s2, no extra heart sounds, no murmurs
cap refill < 2 seconds 10 fingers and 10 toes
Radial and DP pulse 80, 2+ bilat.
Deep, even, unlabored, no accessory muscle usage.
Clear on inhalation, Wheezes on exhalation in all lung fields
Room air
Rate 16
Normo-active bowel sounds in all 4 quadrants
AP diameter > transverse
Round contour
Last BM 11/20
output 800 mL since
Urine clear, yellow, no odor
Full ROM
5/5 strength
Hand grasp equal
warm and dry, turgor elastic
9/10 pain in neck
"stabbing feeling but changes."
only relief is narcotics, movement worsens and sharp pain radiates down spine/shoulders
RFA 20G removed at 0700 due to irritation/redness
Language: English
Support System: friends & family
Faith: Christian
Hx of drug abuse - oxycotin
Intimacy v. Isolation: patient is talkative and striving for connections with others, will to talk about all history
BP: 118/72
P: 89
O2: 94%
Heart Healthy Diet
Hx of C Spine Injury
EF < 55%
ND1: Decreased profusion r/t decreased output AEB EF < 55%
ND2: Risk of opiod abuse r/t prescription of hydrocodone AEB hx of oxycontin abuse
ND3: Readiness for enhanced learning r/t pain control AEB patient verbalizing desire to learn non-pharmacological interventions
Goal: patient will verbalize one non-pharm. way to cope with pain by the end of shift. - Goal Met
Teach patient about deep breathing exercises
Teach patient about mental imagery
Teach patient about different yoga classes or stretches
Goal: Patient shows no further worsening/repetition of deficits. - Goal Met
Apply support hose/SCDs as ordered.
Encourage patient to walk with support hose on and perform toe up and point flex exercises.
Teach patient to recognize the signs and symptoms that need to be reported to the nurse.
Goal: Patient will not ask for an opioid for pain more than once per day. - Goal Met
Talk with patient about non-pharmacological interventions
Assess if patient is aware of heightened risk for addiction due to history
Monitor patient's pain throughout day, being proactive about management
RBC: 3.6
WBC: 3.6
Hg: 10.5
Hct: 31.9
Platelets: 273
Na+: 140
K+: 3.9
Cl-: 102
Ca+: 9.2
CO2: 34
Docusate 100mg PO BID, given at 0900
Enoxaprin 40mg SubQ
Carvedilol 3.125mg PO
Lisinopril 2.5 PO
Furosemide 20 mg PO
given at 0900
Desvenlafaxine 50 mg PO
Divalproex 500 mg PO
Gabapentin 600 mg PO
given at 0900
Bacteremia: bacterial infection in the blood. (Harding et. al.)
Personal Goal: I will complete first head to toe assessment by 0800. - Goal Met
Patient Goal: Patient will teach back one non-pharmacological intervention for pain. - Goal not met
Katie Bott
BuID: 891857135
NUR3225
Week 6 Concept Map
Prof. Mussachio