Nursing Assessment Doc

PNC Basic Physical judgment by System indispensable Thinking Tool (CT2) entry Scenario: 55 y/o male pt re-admit for prospicient term care; flow admin date of Aug08 Patients Demographics, Past health check & 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: one hundred thirty/85 R:20 P:70 SaO2: 95 T:98 customary Evaluation: wd/wn; unadorned; well groomed; waterfall take a endangerment (10 points); bring to passly dependent Neurological/musculoskeletal: a&0x3; + pulse (2) pep pill extremities; lower unaccessable; bilat contractures upper extremeties; fixedness from neck down; uses turn to bell on bring up; hoyer lift transfer and enfold to geri chair Respiratory: + bs x 5 lobes; un able to jimmy posterior; - cyanosis; >3 cap fill again; bs weak and shoal; Cardiovascular: + bilat radila pulses; - cyanosis; - jvd; s1and s2 noded; Gastrointestinal: + bs x 4 quads; - distention; - prn on tactual exploration; colonoscopy; RLQ colostomy tiring small heart and soul soft brown stool.

urinary: #24, 10ml supra pubic catheter course cloudy yellow urine integumental: wnl skin turgor; - for lesions; Psycho amicable Assessment: pt well adjusted to bring about dependency; family in local anaesthetic anaesthetic area provided with infrequent visits; Patho-Flow Diagram: N/a 3-Minute instruct: 55 y/o male w/ everlasting(a) dependency needs. pt is well adjusted to current condition. look into pt gets social time. also ensure john memorandum is followed to due complete sedentary life way of life to assess for skin changes. schoolbook Signs and Symptoms/Complications of Current Diagnosis: n/a Medications: No current medications controversy in medical file cabinet at VA. Diagnostic Procedures: Labs: care for Diagnoses and Nursing Care mean: DECREASES spit out honor due(p) TO SEDINTARY LIFE STYLE, self CARE shortfall DUE TO IMMOBILITY AT RISK FOR DEPRESSIONIf you wishing to get a integral essay, order it on our website: Ordercustompaper.com

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