Med/Surg Assessment Tool

PATIENT PROFILE DATABASE

ADMISSION INFORMATION
Student Name: Pamela Bell
1. Date of Care:
3/22/12
3/23/12
2. Patient Initials
L.S.
3. Age
98
4. Growth and Development
Ego Integrity versus Despair
5. Sex:

Female
6. Admission Date:

3/17/12
7. Reason for Hospitalization (face sheet):
Rash and pruritus
8. Medical Diagnoses: (present diagnoses, past diagnoses; physician’s history and Physical notes in chart; nursing intake assessment and Kardex)

Cellulitis of the left shin
9. Surgical Procedures (consent forms, chart): Cataract removal, cholecystectomy, appendectomy, hysterectomy, skin cancer removal.

10. ADVANCE DIRECTIVES (Nurse’s Admission Assessment)
Living will: _____yes ___X___no
Power of attorney: ______yes ___X___no
Do not resuscitate (DNR) order: ______yes ___X___no
11. LABORATORY DATA
Test
Norms
On Admission
Current Value
Test
Norms
On Admission
Current Value

White Blood Cells

3.8 - 11.0 K / mm cubed

32.5

25.7

Potassium

3.5 - 5.5 mEq/L

5.1

4.5

Differential

Blood Glucose
40 - 85 mg/dL

99

98

Hemoglobin

11 - 16 g/dL

8.5

8.2

Cholesterol Less than 200 mg/dL desirable

212

212

Hematocrit

34 - 47%

27.0

25.2
Low-density lipoproteins
Less than 130 mg/dL desirable

141

141

Platelets
140,000 -450,000 / ml

146

112
Sodium
30 - 280 mEq

144

140

Prothrombin Time
12-14
seconds

12.4

12.4
Urinalysis

neg

negative

negative
International
Normalized ratio
2.0-3.0
seconds

1.2

1.2
Other

Activated partial
Thromboplastin time 21 - 35 seconds

151.5

23
Other

12. DIAGNOSTIC TESTS
Chest x-ray:
Normal for age
EKG:
Sinus rhythm with marked sinus arrhythmia. Right bundle branch block. Abnormal ECG
Other:
Other:
Other:
Other:
13. MEDICATIONS List medications and times of administration (medication administration record and check the drawer in the carts)
Medication/Time of Administration
Actions
Side effects
Acetaminophen (Tylenol) tablet 325-650mg prn
Inhibition of cyclooxygenase (COX). Peripheral anti-inflammatory activity is usually limited by several factors, one of which is high level of peroxides present in inflammatory lesions.
Liver toxicity, GI upset, lightheadedness
Ampicillin/sulbacatam (unasyn) intermittent infusion (minibag) 1.5g q12hr
Ampicillin exerts bactericidal action on both gram-positive and gram-negative organisms. Its spectrum includes gram-positive organisms’ e.g. S pneumoniae and other Streptococci, L monocytogenes and gram-negative bacteria e.g. M catarrhalis, N gonorrhoea, N meningitidis, E coli, P mirabilis, Salmonella, Shigella, and H influenzae. Ampicillin exerts its action by inhibiting the synthesis of bacterial cell wall. Sulbactam inhibits β-lactamases and extends the spectrum of ampicillin to include β-lactamase producing pathogens.
Pain at Inj site, thrombophlebitis, diarrhea, itching, nausea, vomiting, flatulence, candidiasis, fatigue, malaise, headache, chest pain, glossitis, abdominal distention, dysuria, urinary retention, oedema, erythema, epistaxis, mucosal bleeding.
Potentially Fatal: Fatal anaphylaxis.
Carbamide peroxide (Debrox) 6.5% 5drops bid in both ears carbamide peroxide is an oxidizer. This compound is a white crystalline solid which dissolves in water to give free hydrogen peroxide; the solubility of commercial samples varies from 0.05 g/mL[1] to more than 0.6 g/mL.[2] The solid state structure of this adduct at the right has been determined by neutron diffraction.[3
Stop using carbamide peroxide and call your doctor at once if you have a serious side effect such as: dizziness; ear pain, itching, or other irritation; discharge or bleeding from the ear; or decreased hearing for a prolonged period of time.
Fenofibrate micronized (Lofibra) capsule 67mg
Fenofibrate is a fibric acid