NR 226 week 8-2

NURSING ASSESSMENT & NOTES

10/24 1300

Nursing Note: Client ate 50% of a piece of toast, apple juice, and a bowl of chicken broth for lunch. Teeth brushed, and mouthwash used after lunch. Client vomited about one hour after lunch. Client was given half a cup of ice chips. Client states he is thirsty, and mouth feels dry. Urine in urinal appears dark amber, concentrated with no foul odor.

10/25 2010

Nursing Note: Placement confirmed. Tube feeding initiated.

10/27 0945

Nursing Note: The client states his mouth feels dry. There has been no nausea or vomiting since 10/24. Tolerating feedings well.

VITAL SIGN TREND

Date 

Temp

HR

RR

BP

SpO2

O2

10/24 1300

99.0° F (37.2° C)

106

18

108/68

99%

RA

10/27 0730

98.6° F (37° C)

82 

16

118/78

99% 

RA

intake and output

Date 

Intake Source & Amount

Output Source & Amount

Total

10/25 2030

Bowl of chicken broth, 250 mL

Water in cup, 12 oz

 Urine in bedside commode, 550 mL

 Urine in bedside urinal, 610 mL

 Emesis, 170 mL

Ice chips, 16 oz cup

PROVIDER PRESCRIPTIONS & NOTES

10/24 1300

Prescriptions:

· Insert nasogastric tube

· Clamp and measure strict I &O and monitor food intake for 24 hours

 10/25 1930

Prescriptions:

· Feeding tube: Lactose-reduced food supplement formula with fiber 1.2 cal - 1260 mL per 12 hours.

· Discontinue for 12 hours.

· Free water flush 200 mL q4h

· Begin nocturnal feedings at 2000

COLLABORATIVE CARE

10/27 0900

Wound Care Note: Skin breakdown on client’s nose and around tape. Tape changed to non-allergenic plastic tape with plastic skin adhesive. Taping moved off previous breakdown site. Will continue to monitor skin integrity. Supplies left at bedside.

NURSING ASSESSMENT & NOTES

2/19 1600

Nursing Note: Client reports urge to void but is unable. Reports history of stress incontinence, "I had five children." Client also reports, “I am not a big water drinker, just with my medicines. I do like coffee, but I only drink 2 cups per day. I don't drink otherwise. Maybe juice at lunch and a glass of wine at dinner.” Nurse Practitioner called and notified of assessments. Awaiting prescriptions.

2/19 1600

Neuro/Cognitive: Alert and oriented x 4. PERRLA.

Cardiovascular: Normal rhythm, S1, S2.

Respiratory: Lung sounds clear; lung expansion is equal bilaterally; some upper airway congestion which the client reports as baseline.

Gastrointestinal: Abdomen firm and distended, bowel sounds + in all quadrants

Genitourinary: Voiding small amounts every 6 hours. Denies urgency, frequency, hematuria, or leaking of urine. Does have hesitancy. No dysuria. Bladder scan at 1620 noted 465 mL urine in bladder after 1610 void in toilet of 45 mL.

Musculoskeletal: Moving arms and legs, grip strength strong in hands, left dorsiflexion strong, right leg slightly weaker.

Pain: 2/10 “ache in the hip”.

2/24 0850

Nursing Note: During ambulation from bathroom to bed, the client states, "I feel dizzy and lightheaded.” Escorted to and placed in bed. Client stated feeling better after 10 minutes in bed. Bladder scan 90 mL urine after client voided 250 mL. Nurse practitioner notified. Client rating pain as 2/10, stating, "ache in the hip".

VITAL SIGN TREND

Date

Temp

HR

RR

BP

SpO2

O2

2/19 1600

98.7 °F (37.1 °C) Temporal

86

18

132/76

98%

RA

2/24 0900

98.7 °F (37.1 °C) Temporal

96

20

92/52

98%

RA

intake and output

Date

Intake Source & Amount

Output Source & Amount

Total

2/23 - 2/24 1900 - 0700

Oral – 180 mL

Void – 220 mL Bladder scan – 65 mL Void – 120 mL>

2/24 0700 - 1900

Oral – 320 mL

Void – 200 mL Bladder scan – 65 mL Void – 180 mL Void – 120 mL Bladder scan – 90 mL Void – 220 mL Refused Void – 120 mL Bladder scan 90 mL

PROVIDER PRESCRIPTIONS & NOTES

2/19 1700

Prescriptions:

· Tamsulosin 0.8 mg daily by mouth

· Bladder scan q8h

· For urine volumes greater than 350 mL, insert intermittent catheter and measure urine volume

· Consult physical therapy for pelvic floor protocol

· Encourage fluids

2/24 0915

Prescriptions:

· Reduce daily tamsulosin to 0.4 mg/day by mouth

· Hold 2/24 dose of tamsulosin

· Encourage fluids

· Maintain bed rest today with one-person assist to bathroom as needed.

· Encourage voiding every four hours

· Monitor urine output

LAB RESULTS

Date

Lab

Normal

Result

2/19 1700

Urinalysis

Color

Yellow

Yellow

Clarity

Clear

Clear

pH

4.5-8

5.2

Specific Gravity

1.005 - 1.030

1.024

Glucose

Negative

Negative

Ketones

Negative

None

Nitrites

Negative

Negative

Leukocyte esterase

Negative

Negative

DIAGNOSTIC TEST RESULTS

Date

Diagnostic Test

Findings

2/19 1700

Urine Culture

No growth

COLLABORATIVE CARE

2/19 1500

Physical Therapy Note: Working with Mrs. Powell on ambulation, getting in and out of car, steps, and turns. Also consulted for pelvic floor exercises. Instructed on Kegel exercises and provided tracking grid and pamphlet with instructions. Will add to the Plan for Care and continue reinforcing frequent use of pelvic floor contractions. Maintaining one-person assist on all transfers and ambulation.

2/24 0930

Physical Therapy Teaching Plan:

· Instruct on effective voiding, which includes taking time on toilet, double voiding, leaning forward while on toilet, body positioning, gentle bladder pressure while voiding, warm cloths to the bladder.

· Consuming non-caffeinated fluids and increasing oral water intake.

· Encourage use of acetaminophen if pain while sitting on toilet or with pain assessment. Take 650 mg every 6 hours, not to exceed eight tablets (2600 mg) per day.

· Safety precautions with dizziness

Date

Temp

HR

RR

BP

SpO2

O2

3/31 0700

98.8 °F (37.1 °C)

98

24

124/78

98%

RA

3/31 0700

Religious Preferences: Practicing Muslim

PROVIDER PRESCRIPTIONS & NOTES

4/1 0715

Prescriptions:

· Continue home medications

· Normal saline IV continuous 125 mL/hr

· Acetaminophen 1000 mg q8h PRN for mild pain 3-5/10

· Tramadol 50 mg q4-6h PRN pain >5/10

· Activity: up ad lib

3/31 0700

Religious Preferences: Practicing Muslim

4/1 0800

Home Medications:

· Multivitamin daily

· Vitamin D3 supplement daily