Report for Clinic, Research Paper Example

CKS

        5222-01

Male

68

10/06/2010

Type of Reaction

if indicated

Yes, Morse =50

Bed rest

      Specify organism(s): MRSA

Route: Temporal

             172.5 cm.

                   65.2 kgs

Condition: intact, Wrapped with Kerlix

O RH+

 O2___L / ____

Flu                   YES

Pneumonia    YES

Other      

NPO

Yes, 5% Dextrose and 0.45% NaCl 1000mL IV, 100mL/hr

Patient denied

If Yes, Date______

09/10/2009

Adult: 40mg P.O daily at bedtime or 20mg P.O. b.i.d. for 8 weeks.

-650 mg, Tab PRN

Adult dose : of 325 – 650 mg Q4h, PRN

Adult dose varies on individual requirements based on diagnoses & severity

Adult dose: 1.7 mcg/kg P.O. /Daily , making adjustments in 12.5 to 25 mcg increments until patient is euthyroid and TSH level normalizes

Adult dose: Highly individualized. Initially 100mg P.O t.i.d,, usually 300mg-600mg daily

Adult dose: 4mg undiluted solution for injection I.M or I.V over 2 to 5 minutes

Adult dose:5-10mg/kg Daily.

Adult dose: initially 50mg P.O. b.i.d, 100 to 400mg P.O. daily

Solitary rectal ulcer syndrome is a condition that occurs when a sore (ulcer) develops in the rectum. The rectum is a muscular tube that’s connected to the end of your colon. Stool passes through the rectum on its way out of the body.

Solitary rectal ulcer syndrome can cause rectal bleeding with straining when you pass bowel movements.

 Clinical Signs & Symptoms

·   Constipation

·   A feeling of incomplete passing of stool

·   Pain or a feeling of fullness in your pelvis

·   Passing mucus from your rectum

·   Rectal pain or anal sphincter spasms

·   Rectal bleeding

·   Straining during bowel movements

Some people with solitary rectal ulcer syndrome may experience no symptoms.

Complications:

excessive rectal bleeding (hemorrhage)

extreme disturbance of bowel function

formation of an abscess

formation of a hole (perforation) through the rectal wall beneath the ulcer

surgical infection.

  Using a scope to examine rectum. During sigmoidoscopy, doctor inserts a flexible tube equipped with a lens into your rectum to examine rectum and part of colon. If a lesion is found, doctor may take a tissue sample for laboratory testing.

Using sound waves to create images of rectum. Ultrasound is an imaging technique that uses sound waves to create pictures. Doctor may recommend an ultrasound to help differentiate solitary rectal ulcer syndrome from other conditions.

An X-ray of rectum. During a procedure called defecation proctography, doctor inserts a soft paste made of barium into your rectum. Patient then pass the barium paste.The barium shows up on X-rays and may reveal a prolapse or problems with muscle function and muscle coordination.

 Collaborative Interventions(s)

– Treatment for solitary rectal ulcer syndrome depends on the severity of your condition. People with mild signs and symptoms may find relief by making lifestyle changes to control chronic constipation. People with more severe signs and symptoms may require treatments such as behavior therapy and surgery.

-Behavior therapy to stop straining during bowel movements.
-Surgery to remove the rectum,Rectal prolapse surgery

–Drink water throughout the day.

-Increase the amount of fiber in diet.

-Exercise most days of the week.

Patient stated that he can speak 8 different languages

No Exercise.

(finances, care after discharge, childcare)

Of feet: yellow, long(1 inch) and hypercurved,  thick, 3 sec)

Regular,                        strong,                        clear.

2 sec (finger) 3 sec (toe)

(Location & Degree)

grade force of

Right / Left

P. Tibialis__+1__/__+1__              D. Pedis __+1__/__+1__

Pt’s c/o L leg while moving         Pt denied numbness.

Temperature                                      Color of extremities

97.1 (Temporal)                             whitish legs

Teds Stockings? none                        Sequential Compression Devices? none

Accessory Muscle Use__No___ If yes, describe location:

Pink                                                Pink                             Pink

Sputum  (color, consistency, amount)    none

Nebulizer/Inhalers  none              CPAP   none             Incentive Spirometry none

Date of Last BM:

________________

Diarrhea/constipation?        Pain or difficulty with defecation?          Blood?

Usual habits?              Recent Changes?          Aids (stool softener/laxatives/fiber/etc)

Tenderness                                Inflammation

Odor            Pus/mucous              Sediment            Blood/clots           Other?

Change in urine stream                           Usual pattern

Urostomy?

Tenderness                                 Inflammation

Breast Self Exam (BSE)                               Pregnancy History

Note symmetry, shape, contour,  pain, inflammation, temperature, sensation, paralysis/paresis

Limitations

Weight bearing ability

Mobility Devices? _____                  Prosthetics?

Fall Prevention Implemented?_____

1 or 2

Supporting achievement in each category.

A.     Competencies

·        Performs techniques according to stated criteria and institutional policy.

·        Complies with OSHA guidelines.

·        Performs skills correctly.

·        Applies principles of safety.

·        Explains the therapeutic aspects of medication administration.

·        Demonstrates understanding of client’s nutritional needs.

-I have followed appropriate OHSA guidelines for hygiene and client  care to be provided for clients

–I was able to provide him with appropriate AM care and turning in bed to maximize his level of comfort and prevent pressure ulcers.

-I have assisted him to eat breakfast for his well-balanced nutrition.

-I have performed correct therapeutic communication, AM care, occupied bed, assessment and care support for client.

A.     Communication

·        Demonstrates the ability to speak, comprehend, read and write English at a level that is accurate, clear and effective.

·        Demonstrates therapeutic communication techniques.

·        Applies principles of documentation and communication methods among health care team.

B.   Cultural Competence

·        Assesses cultural beliefs of clients and describes the effects on nurse-client interaction.

-I have reported my findings at the end of my shift for the shift Nurse.

-Client is originally from Korea and knowing that I am also from Korea seems to have helped him to be more cooperative and improve the overall ease of communication

A.   Ethical Care

·        Describes ethical framework for client care; assumes responsibility for own behavior and identifies ethical behavior. Demonstrates non-judgmental approach to client care.

B.   Legal Responsibilities

·        Identifies legal dimensions of nursing practice for a student nurse.

·        Complies with MC and clinical facility policies, Maryland Nurse Practice Act and ANA Code for Nurses.

C.  Professionalism

·        Demonstrates appropriate professional behavior.

·        Accesses appropriate resources when providing care.

-I understand the legal responsibility and accountability I have as a nursing student both in terms of care and confidentiality an haven’t overstepped my boundaries

-I understand the rules set by Montgomery College governing clinical care by students and have complied with them

-I have demonstrated appropriate professional behavior expected of a Nursing Student

·        Makes appropriate observations.

·        Identifies client’s problems / needs.

·        Assesses the “5 Dimensions of Person” (physical, intellectual, emotional, spiritual & social-cultural)

·        Recognizes developmental stage and life span status.

Developmental Stage: Old stage

Patient is in a weakened state and confused. His is a foreign born individual with a high degree of education, being college educated and having the ability to speak multiple languages. His vulnerable state, due to illness and age, has made him uneasy and untrustworthy of strangers.

·        Prioritizes nursing diagnoses using Maslow’s hierarchy of needs.

·        Completes one nursing diagnosis statement for the diagnosis with highest priority.

The primary diagnosis is twofold. His physiological state is comprised, which is measurable from his multiple diagnosis. His lack of movement has caused a weakening of his muscles and led to other complications. His physical conditions have led to a feeling of vulnerability and fear. He is confused and scared, as was observed when he pulled out his IV forcefully. His physical condition can be treated with medication and hospital care but until he is mentally more secure he will continue deny help and this will impede recovery.

·        Determines broad goal for above nursing diagnosis.

·        Identifies an outcome that is specific, measurable & attainable within a reasonable time frame.

·        Lists and implements appropriate nursing interventions specific to client’s needs as identified in the nursing diagnosis statement.

·        Identifies client’s need for health teaching.

I 2) Client needs to understand that in order to heal he needs to cooperate with the doctors orders. Proper nutrition will give his body the energy it needs to heal.

·        Assesses client’s response to interventions.

·        Assesses if interventions were effective.

·        Revises interventions / outcomes as indicated.

Evaluate the Outcome:   (Circle one)

Outcome Met          Partially Met                Not Met

E 2) Partially Met