Nursing Assessment Doc

PNC Basic Physical Assessment by System alert Thinking Tool (CT2) Admission Scenario: 55 y/o male pt re-admit for long term care; time-tested admin date of Aug08 Patients Demographics, Past Medical & 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: 130/85 R:20 P:70 SaO2: 95 T:98 popular Evaluation: wd/wn; lucid; easy groomed; falls take hold a chance (10 points); bring to passly dependent Neurological/musculoskeletal: a&0x3; + pulse (2) fastness extremities; lower unaccessable; bilat contractures upper extremeties; sluggishness from neck down; uses call bell on chin; hoyer lift transfer and enwrapped to geri chair Respiratory: + bs x 5 lobes; un able to prise posterior; - cyanosis; >3 detonator refill; bs weak and shallow; Cardiovascular: + bilat radila pulses; - cyanosis; - jvd ; s1and s2 noded; GI: + bs x 4 quads; - dilatation; - prn on palpation; colonoscopy; RLQ colostomy tiring small union soft brown stool.

Urinary: #24, 10ml supra pubic catheter draining cloudy color urine Integumentary: wnl skin turgor; - for lesions; Psychosocial Assessment: pt well adjusted to complete dependency; family in local anaesthetic area but with infrequent visits; Patho-Flow Diagram: N/a 3-Minute instruct: 55 y/o male w/ complete dependency needs. pt is well adjusted to true condition. look into pt gets social time. also ensure john memorandum is followed to due complete sedentary li fe movement to assess for skin changes. Te! xtbook Signs and Symptoms/Complications of Current Diagnosis: n/a Medications: No current medications list in medical exam file at VA. Diagnostic Procedures: Labs: Nursing Diagnoses and Nursing rush Plan: DECREASES spit out INTEGRITY DUE TO SEDINTARY feel STYLE, SELF CARE shortfall DUE TO IMMOBILITY AT RISK FOR DEPRESSIONIf you want to get a full essay, establish it on our website: OrderCustomPaper.com

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