NURS 4045 Adult Health Competencies II

Texas Woman's University

Patient Data Sheet
Student's name: __Uyen Do
Date of Care: 09/30/16__________
Pt. location/Unit: _7S5__________
Pt. initials: _MJ_______
Age: _63______
Gender: Female__________
Ethnicity:
_______________________
ALLERGIES:_Lisinopril___________________________________________________
CODE STATUS:__Full code__________________
Medical Diagnosis: _Sepsis, Hypokalemia, UTI, Metastatic colon cancer, acute renal failure, fibroid uterus
_______________________________________________________________________________
Date of Admission & Course of present hospitalization:_09/27/16 ____63 year old female with h/o widely
metastatic colon cancer (liver, lung), HTN, DM, hypothyroidism, who presented to ER with nausea, vomiting, and
abdominal pain. She was recently admitted to St.Luke with abdominal pain, leukocytosis and lactic acidosis. She
was discharged a few days ago but reports that she has been unable to tolerate PO. At home, constant vomiting
after oral intake, trouble taking meds. During last visit, she was diagnosed with UTI. Urine cultures show VRE,
discharged on levaquin. Patient reports taking oral meds but vomiting as above. Decided to come to St. Luke ER
this AM. No current dysuria, cough, SOB, chest pain, or headache. In ER, noted to have leukocytosis and
elevated lactic acid again. Given fluids and pain meds_________________________________________
________________________________________________________________________________________________
Past Medical/Surg.history:__
Hypertension
Diabetes mellitus
Thyroid disease (thyroid nodule)
Anemia
Chronic fatigue
Environmental allergies
Mass of colon
Renal disorder
Colon cancer
Sepsis
Surgical Hx: tubal ligation, colonoscopy- biopsy 04/28/14
_______________________________________________________________________
________________________________________________________________________________________________
Social history: _Former smoker (quit on 1993). Denied alcohol/drug use
___________________________________________________________________________________
Page 1 of 12 Patient data sheet page

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Family interaction/relationship: Husband, friends & relatives at bedside

_____________________________________________________________________
Communication with patient: __Moderate. Communication is limited because patient is tired & in pain.
_____________________________________________________________________
Isolation: Yes _X_ No__ Type: _Contact_____Why: _____UTI (Vancomycin-resistent enterococcus)
________________________________
Oxygen Delivery: Room air:__N/A______ Nasal cannula: _3L/min________Facemask: _N/A_____ Other:
___N/A_________________
Ventilator settings: TV: _N/A____ FIO2: N/A____ Mode:_N/A______ rate/total: _N/A__/___ PEEP: _N/A___ PS:
_N/A____CPAP: _N/A______
Nutrition: Diet: _Soft diet______Feeding tube(type and location): _N/A___________ TPN or PPN: _N/A____________
Chest tubes: ___N/A_____________________ Drains: _N/A_______________ NGT: ___N/A_______________
Foley: _N/A______
Invasive lines/monitoring: (include location) Arterial line:______________ PA catheter _____________ IABP:___
Central line(s):_Port-A-Cath right subclavian_(05/01/2014). Intact. Flushing_____Peripheral
IV(s):____N/A_____________________________ ICP monitor: _N/A_________
IV Infusions (dosage--include mcg/kg/min, mg/hr, units/min or other format as appropriate (look at the order)
PATIENT WT: _81.8kg (lose 5kg since 09/29/16)__________
Drug
infusion

Current IV
rate

Current
dose

Potassiu
m
chloride

100mL/hou
r

20mEq

Page 2 of 12 Patient data sheet page

IV site location
(where is it
running?)
Port-A-cath

Drug concentration (How is

bag mixed)

Why is THIS patient

getting this infusion?

20mEq/100mL

Hypokalemia

revised 9/30/16

NURS 4045 Adult Health Competencies II

Patient Data Sheet- Assessment

Data

Neuro: ICP _N/A____ CPP_N/A____ GCS__15___Sedation Assessment (RASS score)__0-alert, awake

_____________________________
_________________________________________________________________________________________________
Musculoskeletal: _Muscle strength (upper & lower extremities)= 4/5 . Moderate hand grip
_________________________________________________________________
Cardiovascular: HR_116___ BP106/68_____ABP_(see lab value)____ CO/CI__N/A______ PAP/PAWP _N/A_____
CVP_N/A____ SpO2__99%___________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Respiratory: Oxygen/Ventilator settings__Nasal cannula 3L/min______________________________________
RR__30 breaths/min. Occasional SOB. ____
___________
_________________________________________________________________________________________________
GI: _Stool occurrence today= 1. Soft. Bowel sounds present x 4. Reports pain in abdomen (pt has fibroids).
Renal: 24 hour I/O__Intake= 550 (IVPB + 20% meals) ______ ________________
Output= 1 urine occurrence, 1 stool occurrence
_________________________________________________________
_________________________________________________________________________________________________
Integumentary: T:_98.6F_____ F or C ______________
Dry, Warm, no edema, redness _______________________________________________________
______________Bilat_______________________________________________________________________________
____
Pain Assessment: ___ Pain= 6/10 in abdomen give Dilaudid. (0800) ___________________
Bilateral SCD ___________________________________________________________
Delirium Assessment:___Oriented x4
___________________________________________________________________________
Psychosocial issues:_Patient understands cancer diagnosis & prognosis ___________________
Family members express distress
__________________________________________________________
Other:___________________________________________________________________________________________
o

ECG strip:
Lead: ______ Atrial/ventricular rate: ______ Regular/irregular: _______ PR interval: _____ QRS interval: _______
Page 3 of 12 Patient data sheet page

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ECG interpretation: ___________________________ ECG Intervention:___________________________

(attach the ECG strip you analyzed above, here. Staple or tape it in place. NO NAMES or other identifying information left on strip.)

Page 4 of 12 Patient data sheet page

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LIST ALL VALUES that are pertinent to this patients situation. Provided all values highlighted please.

Lab

Normals

Results/Date

WBC

23.5

RBC

2.59

PLT

265

PT/I
NR
PTT

PT=18.6
INR=1.6
33.7

HgB

7.9

Hct

25.2

Na

132

3.6

Cl

105

Rationale and/or importance for this patient

Osmolality
BUN

10

Creatinine

0.68

Glucose

64

Albumin

2.1

Ca (Serum or Ionized?)

8.5

Mg

1.7

CK

29-200

196

CK-MB

0.0-6.6

0.4

Troponin

0-0.03

<0.01

Arterial : pH

7.32-7.42

7.4

PaCO2

41-51

38

PaO2

25-40

42

HCO3

21-29

23

BE

-2.0-3.0

-1.9

Ventilator settings
for the blood gas
Urinary: pH

This is required for blood gases.

5.0-8.0

6.0 (09/27)

Specific gravity

1.001-1.035

1.018 (09/27)

sodium
osmolality

N/A
40-1400

187

Creat. clearance

N/A

GFR

106

Amylase and
Lipase
Liver
transaminases

N/A

Normal
Kidney damage

AST=128
Alt=26

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Alkaline
phosphatase
Total bilirubin

40-150

656

0.2-1.2

1.9

Direct Bilirubin

0.1-0.5

1.4

Lactate,venous

0.5-2.2

5.8

Positive Culture Reports?

Date
Site
09/19/16
Urine, clean catch
09/27/16
09/28/16

Venous line
Urine, Foley
C.Diff

Result
20-29000 col/mL vancomycin resistant
enterococcus
No growth in 48 hours
No growth
Not detected

Additional Notes/ Comments:

_09/27/16 CT abdomen/ pelvis: inumerable bibasilar pulmonary nodules. Stable
soft tissue mass in cecum/ileocolic junction. Colic diverticulosis. Stable
indeterminate left adrenal nodule. Uterine fibroids. Small amount of nonspecific
pelvic free fluid 09/27/16 2D Echo Doppler: sinus tachycardia
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________

Page 6 of 12 Patient data sheet page

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Scheduled Medications-Include all IV Medications. Infusions are listed on first page.

Medication
Time
Dose Frequency Route Why Patient is
Major Side Effects
Name
getting
(must have)
0600 1200
400
Q 24 h
IV
0700 1300
Fluconazole 0800 1400 mg
0900 1500
(Diflucan)
1000 1600
Heparin
Lactulose
(Chronulac)

Linezoid
(Zyvox)
Magnesium
oxide (Magox)
Metoprolol
(Lopressor)
Metronidaz
ole (Flagyl)
Pantoprazol
e (Protonix)
Sennadocusate
(Senokot-S)
Linezolid

Dextrose
50% (D50W)

1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100

1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700

5000 Q8h
units

Sub
Q

20g

2 times
daily

PO

600
mg

Q12h

IV

400
mg

Daily

PO

50m
g

2 times
daily

PO

500
mg

Q8h

IV

40m
g

Daily

IV

8.650m
g

2 times
daily

PO

600
mg

Q12h

IV

50m
L
(25g)

Page 7 of 12 Patient data sheet page

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Medication
Name

Time
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100

Dose Frequency Route Why Patient is

getting

Major Side Effects

(must have)

1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700

Page 8 of 12 Patient data sheet page

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PRN Medications
Medication
Dosag
e

Frequenc
y

Page 9 of 12 Patient data sheet page

Rout
e

Why patient is
getting.

Major Side Effects

revised 9/30/16

Problem list
List 5-10 problems, ranking them in order of importance. The most important items become
your care plan focus.
1.
2.
3.
4.
5.
6.
7.
8.
9.

10.

Page 10 of 12 Patient data sheet page

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10

NURS 4045 Adult Health Competencies II

Patient Data Sheet Patient Care Plan
Primary Nursing Diagnosis (1) with related information and evidence:

Secondary Nursing Diagnosis (2) with related information and evidence:

Intervention(s) and Evaluation(s):

Diagnosi
s#

Interventions (What did you do?)

Page 11 of 12 Patient data sheet page

Evaluation (How did it work)

revised 9/30/16

Diagnosi
s#

Interventions (What did you do?)

Page 12 of 12 Patient data sheet page

Evaluation (How did it work)

revised 9/30/16