Chamberlain College of Nursing| Care Plan NR 325. Ultimate study Guide

I Introduce Yourself S Situation B Background A Assessment Your Name: Your Title: Student Nurse Reason for Being Here: Clinical NR 325 Patient: S.R. Age: 70 y.o. Gender: ...

I Introduce Yourself S Situation B Background A Assessment Your Name: Your Title: Student Nurse Reason for Being Here: Clinical NR 325 Patient: S.R. Age: 70 y.o. Gender: Male Height/Weight: 180cm, 85kg Allergies: daptomycin, rocephin, inhalational anesthics, succinylcholine, invanz Code Status: Full resuscitation Privacy Code: Time: 07/19/18 Past Medical History: Chronic renal failure; Diabetes Mellitus type 2; GERD; hypercholesterolemia; Hypertension; Benign Prostatic Hypertrophy; Peripheral Vascular Disease Social History: Caucasian male, Married; former smoker, no alcohol use. Vital Signs: Falls Risk: Yes, Morse Fall- 50 IV Site: Right forearm, Left antecubital, Left upper arm CLINICAL i- SBAR Attending Physician: Dr. Milind Shirsat Patient Chief Complaint: Redness and numbness to left foot and calf, and weakness. Current Medications: amlodipine, aspirin, aztreonam, cholecalciferol, clodpidogrel, famotidine, gabapentin, glimepiride, insulin aspart, liraglutide, metformin, metoprolol, metronidazole, tamsulosin, vancomycin Accu Check: PRN order, 30min after each insulin dose IV Fluids: D10W, vancomycin, metronidazole, Isolation Respiratory Cardiovascular Neurological GI/GU I & O Integumentary Psychological Family- Safety Labs/Test Isolation Precautions: N Y Contact Air Droplet Respirations regular, even, and unlabored. Patient on room air. Lungs sounds clear both posterior and anterior. Apical heart rate 106 and regular. Capillary refill less than 3 seconds. No edema present. Radial pulse 2+ bilaterally. Pedal pulses not palpable bilaterally. Alert and oriented x3 to person, place, and situation. Bilateral lower extremity sensation intact. Denies numbness and tingling. No bladder distention. Patient is continent but has a condom catheter because of bedrest. Left foot ulcer, parameters 3x3.5. Ulcer clean and dry, no tunneling or undermining present. Skin intact around ulcer. Patient’s wife is involved in his care. Teaching Needed: Education regarding foot care and wound care. Teaching on diabetic diet. Teaching importance of good blood glucose and blood pressure control. Abnormal: RBC low; Hgb low; Hct low; Fibrinogen high; Glucose high; CO2 low; Calcium low. Pending: none