Patient Assessment and Care Plan

STUDENT: _____Cynthia Robinson Date of Care: 03/15/13

STUDENT: _____Cynthia Robinson Date of Care: 03/15/13

Client Initials: LB__ Room # 320B DOB: 01/18/36 Age: 77 Gender: F
Admitted to facility Date: _01/23/13 Resuscitation Status ___CPR______ Allergies _NKDA__
Reason for Admission: Traumatic brain injury
Social: M W S D Significant other, Next of Kin or POA for Health Care: __Tawanna Williams
Occupation or former occupation: ______N/A_na___________________________________________________________________
Primary Health Care Provider(s): ________N/Ana______________________ Consultants/Specialists______N/A_____na_________________
Medical Diagnoses: ____S/P Assault, Traumatic Brain Injury, Dysphagia, and Altered Mental Status
Surgeries/Procedures and Dates: 2/11/13 Laparoscopic-assisted endoscopic percutaneous gastrostomy placement._______________________________________________________________________
Current Physician/Health Care Provider Orders (Prescriptions for Care) ITEM TYPE | THIS RESIDENT’S ORDERS | RATIONALE | Diet | NPO, ONLY LIQUIDS PO | DYSPHAGIA, PREVENT CHOKING | Activity | PHYSCIAL THERAPY | Promotes functional positioning of extremities and prevents contractures | I/O | N/A | N/A | VS | Q SHIFT | MONITOR BP, PT HAS H/O HTN | Accu-Cheks | ONCE A DAY @6:30AM | MONTIOR GLUCOSE LEVELS | Foley | N/A | N/A | NG | N/A | N/A | PEG/PEJ tube | FEEDINGS & MEDS VIA PEG TUBE | DYSHAGIA, PREVENT CHOKING | Wound Care / Dressing Change | Q SHIFT CLEAN AREA AROUND PEG TUBE | PREVENT INFECTION, AND CHECK SKIN INTERGITY | Respiratory Treatments | ALBUTEROL PRN | MAINTAIN EFFECITVE AIRWAY | Tracheostomy | N/A | N/A | Suctioning | N/A | N/A | Chest Tube | N/A | N/A | Special Equipment | N/A | N/A | Lab orders | N/A | N/A | Other | N/A | N/A | Rehab Services | Activity or Treatment Plan & Schedule | Rationale | Physical Therapy | YES- 5DAYS A WEEK | Promotes functional positioning of extremities and prevents contractures | Speech Therapy | YES-5DAYS A WEEK | IMPROVE QUALITY OF SPEECH | Occupational Ther | YES-5 DAYS A WEEK | REDEVELOP ADL SKILLS | IV Access: Type | N/A Site:N/A | Last Dressing Change | 03/15/13 Last Tubing Change:N/A | Reason for IV access | N/A | IV fluids and meds | NO IV FLUIDS, OXYCODONE 5MG Q4H PRN |

Most recent Imaging Findings: (CXR? CT? MRI?) Type of Imaging (X-Ray, CT, MRI, etc) | Body Area Imaged | Reason for testing and results of test | N/A | N/A | N/A | | | | | | | | | | | | |
Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?) Date | Lab Test | Results | Norms | Comments | 01/18/13 | INR | 1.02 | 0.8-1.02 | NORMAL | 01/18/13 | PTT | 30 | 25-30 seconds | Normal | 01/18/13 | WBC | 5.8 | 3.8-11.50 k/mm cubed | NORMAL | 01/18/13 | HEMOGLOBIN | 10.6 | 12.0-15.0 | LOW, PT TAKING FERROUS SULFATE BID | 01/18/13 | PLATELETS | 300,000 | 100,000-450,000 | NORMAL | 01/18/13 | SODIUM | 135 | 135-147 mEq/L | NORMAL | 01/18/13 | POTASSIUM | 3.5 | 3.5-5.2 mEq/L | NORMAL | 01/18/13 | BUN | 7 | 6-23mg/dl | NORMAL | 01/18/13 | CREATININE | 0.9 | 0.6-1.4mg/dl | NORMAL | | | | | | | | | | | | | | | | | | | | |
Other recent, significant procedures or tests (EKG, etc) Date | Test | Reason for testing and results of test | | | | | | |
Resident’s Developmental Stage according to Erikson: __Missing??________________Ego integrity vs. Despair_________________________
Your assessment of this resident’s response to the opportunities and potential conflicts of this stage: