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