HEALTH ASSESSMENT
Ceyong
VINCENTCAREPLAN.docxName: Vincent Sunderman
Age: 83 years
Provider: S. Gupta MD
Allergies: NKDA
Code Status: DNR
Admit Wt: 135.4 lbs (61.4 kg)
BMI: 21.1
· Nursing
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NURSING ASSESSMENT & NOTES |
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5/23 1030 |
Nursing Note: Vince is experiencing dysuria with pain rated 6/10. Administered acetaminophen 650 mg by mouth per standing order. He was encouraged to increase fluid intake. He is anxious and fidgety, wanting to get up from his recliner and “move around” but also needing to stay near his bathroom, at times seeming confused. Grimaces with voiding dark, cloudy, foul-smelling urine. UA sent to the lab. |
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VITAL SIGN TREND |
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Date |
Temp |
HR |
RR |
BP |
SpO2 |
O2 |
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5/23 1800 |
98.2 °F (36.5 °C) |
79 |
20 |
142/85 |
96% |
RA |
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5/23 1800 |
Medical History: Hypertension, hyperlipidemia, gastroesophageal reflux disease, mild dementia Surgical History: Closed reduction of distal radius fracture |
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NURSING ASSESSMENT & NOTES |
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|
5/23 1030 |
Nursing Note: Vince is experiencing dysuria with pain rated 6/10. Administered acetaminophen 650 mg by mouth per standing order. He was encouraged to increase fluid intake. He is anxious and fidgety, wanting to get up from his recliner and “move around” but also needing to stay near his bathroom, at times seeming confused. Grimaces with voiding dark, cloudy, foul-smelling urine. UA sent to the lab. |
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5/23 2100 |
Nursing Note: Discussed ways to prevent future UTIs. Informed the client not to hold urine when the urge is felt. Be sure to notify the nurse if help is needed to clean the foreskin. Drink fluids regularly, especially water. Report any symptoms to the nurse as soon as possible, as prolonged delay can lead to future complications. |
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5/23 2300 |
Pain: 3/10 with urination |
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VITAL SIGN TREND |
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|
Date |
Temp |
HR |
RR |
BP |
SpO2 |
O2 |
|
5/23 1800 |
98.2 °F (36.5 °C) |
79 |
20 |
142/85 |
96% |
RA |
|
5/23 2030 |
98.2 °F (36.5 °C) |
80 |
16 |
142/85 |
96% |
RA |
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5/23 2300 |
98.4 °F (36.9 °C) |
80 |
22 |
150/82 |
97% |
RA |
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PRESCRIPTIONS & NOTES |
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5/23 1700 |
Provider Prescriptions: · Cefaclor 250 mg elixir by mouth q8h x 7 days |
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MEDICATION ADMINISTRATION RECORD |
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Medication |
5/23 0900 |
5/23 1800 |
5/23 2100 |
5/23 2300 |
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Pantoprazole 20 mg by mouth daily at 0900 |
Given MEB |
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Atenolol 25 mg by mouth twice daily at 0900/2100 |
Given MEB |
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Given SSJ |
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Acetaminophen 650 mg by mouth q6h PRN for pain or fever |
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Given SSJ |
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Atorvastatin 40 mg by mouth daily at bedtime |
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Given SSJ |
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Cefaclor 250 mg liquid by mouth q8h x 7 days |
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Given SSJ |
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5/23 1800 |
Medical History: Hypertension, hyperlipidemia, gastroesophageal reflux disease, mild dementia Surgical History: Closed reduction of distal radius fracture |
