NURS 4045 Adult Health Competencies II

Texas Woman's University

Patient Data Sheet
Student's name: __Uyen Do____________Date of Care: 10/14/16__________ Pt. location/Unit: _7S5__________
Pt. initials: _EP_______
Age: _67______
Gender: __F________
Ethnicity: __African American
ALLERGIES:__No medication allergy. Dust & pollen filter mask. Wheat containing product
CODE STATUS:__Full code__________________
Medical Diagnosis: _occlusion of right vertebral artery, dissection of vertebral artery, cervicalgia
_______________________________________________________________________________
Date of Admission & Course of present hospitalization:__10/13/16 _
Patient presented to outside St. Lukes facility for one week of left neck pain radiating to arm and shoulder. Was
previously admitted to methodist for 3 days earlier and did not find a cause for her main problem. MRI at St.
Lukes showed absence of right vertebral artery flow and this was also seen on MRA. Concern for vertebral artery
dissection so transferred to NICU. Denies neurological deficits. Denies dizziness or symptoms other than her
pain. Pain is described as moderate and radiated down from her left neck into her left arm. 8/10. Constant,
stabbing pain partially relieved with morphine. ___________________________________________
________________________________________________________________________________________________
Past Medical/Surg.history:_________________________________________________________________________
_Medical Hx: HTN, hypopituitarism, CAD, hypothyroidism, chronic kidney disease_
Surgical Hx: 2005 cardiac catheterization, pituitary gland removal
______________________________________________________________________________________________
Social history: __Denied smoking, alcohol, drug use
__________________________________________________________________________________
Family interaction/relationship: _Daughter called today. Daughter does not live in Houston, expect to be here
tomorrow ____________________________________________________________________
Communication with patient: _WDL. Patient has clear speech, normal affect, open to conversation
______________________________________________________________________
Isolation: Yes __ No_X_ Type: ____________ Why: _____________________________________
Oxygen Delivery: Room air:__X______ Nasal cannula: __N/A_______Facemask: _N/A_____ Other:
Ventilator settings: TV: _____ FIO2: ____ Mode:_N/A______ rate/total: _N/A__/___ PEEP: N/A____ PS:
_N/A____CPAP: _N/A______
Nutrition: Diet: restricted sodium. Low fat. Low cholesterol ____ Feeding tube( type and location):
____N/A________________ TPN or PPN: __N/A___________
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Chest tubes: ___N/A_____________________ Drains: ____N/A____________ NGT: _____N/A_____________

Foley: _N/A______
Invasive lines/monitoring: (include location) Arterial line:_N/A____PA catheter __N/A___________ IABP:_N/A__
Central line(s):_______________ Peripheral IV(s):__R antecubital- phlebitis grade 0, intact, flushed _____
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: ___________
Drug
infusion

Current
IV rate

Current
dose

Magnesiu
m sulfate

25 mL/
hour

2g

Page 2 of 12 Patient data sheet page

IV site location
(where is it
running?)
R antecubital

Drug concentration (How is

bag mixed)

Why is THIS patient

getting this infusion?

2g/50 mL

revised 10/14/16

NURS 4045 Adult Health Competencies II

Patient Data Sheet- Assessment

Data

Neuro: ICP _N/A____ CPP__N/A___ GCS_____Sedation Assessment (RASS score)___-1 (drowsy) 0800
__________________________________________________________________________0- awake, alert at 1400
Musculoskeletal: __muscle strength 5/5 bilaterally. Full sensation. Strong hand grips _________________
Activity: progressive ambulation _______________________________________________________________
Cardiovascular: HR_85___ BP_96/62____ABP__N/A___ CO/CI__N/A______ PAP/PAWP _N/A_____ CVP__N/A___
SpO2___96%__________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Respiratory: Oxygen/Ventilator settings___Room air. 20 breaths/min, regular
_________________________________________________________________________________________________
GI: ___Hypoactive bowel sounds ______
No stool occurrence for 1 day ______
Loss of appetite. Drink little water
_______________________________________________________________________________
_________________________________________________________________________________________________
Renal: 24 hour I/O___Intake= 250 _____ _________________
Output= 300 _____Net= +50 mL ___________________________________________________
_________________________________________________________________________________________________
Integumentary: T:__98.7____ F or C
_____________________________________________________________________
_________________________________________________________________________________________________
Pain Assessment: _0800 pain= 7/10 at neck, radiates to left arm, stabbing _________________
1000 pain= 5/10 at neck, radiates to left arm, stabbing _________________
1400 pain= 5/10 at neck, shoulder, stabbing _Patient refused pain medication due to tolerable
pain, doesnt want too much morphine. Heating pad is ordered for pain
___________________________________________
Delirium Assessment:__Alert, oriented x 4. Intact memory.
____________________________________________________________________________
Psychosocial issues:_N/A
_____________________________________________________________________________
Other:___________________________________________________________________________________________
o

Page 3 of 12 Patient data sheet page

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ECG strip:
Lead: ______ Atrial/ventricular rate: ______ Regular/irregular: _______ PR interval: _____ QRS interval: _______

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

Rationale and/or importance for this patient

WBC

4.0-10.0
K/L
4.00-5.00
M/L
150-430
K/CU MM
N/A

7.2

Normal

4.77 M/L

Normal

280

Normal

N/A

N/A

N/A

N/A

N/A

12.0-15.0
GM/DL
36.0-45.0
%
136-145
meq/L
3.5-5.1
meq/L
98-107
meq/L
N/A

13.8

Normal

37.9

Normal

131

Low (chronic kidney disease, hypopituitarism)

5.4

High (chronic kidney disease, hypopituitarism)

102

Normal

N/A

N/A

7-21
mg/dL
0.57-1.25
mg/dL
70-105
mg/dL
N/A

17

Normal

1.91

High (chronic kidney disease)

75

Normal

N/A

N/A

9.6

Normal

Mg

8.5-10.5
mg/dL
1.6-2.6

1.2

Low (hypopituitarism)

CK

N/A

N/A

N/A

CK-MB

N/A

N/A

N/A

Troponin

0-0.03

0.03

Normal

Arterial : pH

N/A

N/A

N/A

PaCO2

N/A

N/A

N/A

PaO2

N/A

N/A

N/A

HCO3

N/A

N/A

N/A

BE

N/A

N/A

N/A

RBC
PLT
PT/I
NR
PTT
HgB
Hct
Na
K
Cl
Osmolality
BUN
Creatinine
Glucose
Albumin
Ca (Serum or Ionized?)

Ventilator settings
for the blood gas
Urinary: pH

This is required for blood gases.

5-8

6.0

Normal

Specific gravity

1.001-1.035

1.015

Normal

sodium

N/A

N/A

N/A

osmolality

N/A

N/A

N/A

Creat. clearance

N/A

N/A

N/A

Page 5 of 12 Patient data sheet page

N/A

revised 10/14/16

GFR

32

Amylase and
Lipase
Liver
transaminases
Protein, urine

N/A

N/A

N/A

N/A

N/A

N/A

0-14

12

Normal

Uric acid

2.5-8

6.8

Normal

Lipid profile
Cholesterol
Triglyceride
HDL
LDL
Hemoglobin A1C

<200
<150
>=60
<100
4.3-6.1

210
183
33
140
5.3

Normal

Vitamin B12

213-816

580

Normal

Folate

>=7

13.2

Normal

TSH

0.35-4.94

0.01

Low (Hypothyroidism)

Free T4

0.7-1.48

1.08

Normal

PTH

15-90

74.4

Normal

ANA

Negative

Negative

Normal

Ds DNA Ab

Negative

Negative

Normal

C3 complement

82-193

144

Normal

C4 complement

15-57

41

Normal

Hepatitis B surface
Ag
Hepatitis C Ab

Nonreactiv
e
Nonreactiv
e

Nonreactive

Normal

Nonreactive

Normal

High (Hx of CAD, Dx of vertebral artery occlusion)

Positive Culture Reports?

Date
Site

Result

Additional Notes/ Comments:

_10/13/16 MR orbit face neck without IV contrast: Long segment right cervical
level vertebral artery vasculopathy and flow compromise
10/13/16 MR neck without IV contrast: No visible flow right vertebral artery,
chronicity and specific etiology unknown.
10/13/16 MR head without IV contrast: No visible right vertebral artery flow.
Otherwise negative MRA head
08/05/15 Protein electrophoresis: Gamma globulins increased in a diffuse fashion.
This indicates a chronic immune or inflammatory
response._____________________________________________________________
_08/05/15 Urine electrophoresis: Urine electrophoresis shows no evidence of
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monclonal proteins or free light

chains________________________________________________________________
_04/15/15 DEXA Bone Density
These findings are consistent with a normal BMD of the lumbar spine
and bilateral femoral necks. There is no increased risk of an
osteoporotic fracture as compared to the young adult population__]
_05/01/15 _Ultrasound right breast_____
There is no sonographic evidence of malignancy.
The 5 mm oval cyst in the right breast is benign. A 1 year screening mammogram
is recommended
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________________________

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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
81
Daily
PO
0700 1300
Aspirin
mg
0800 1400

Atorvastatin
(Lipitor)
Clopidogrel
(Plavix)
Enoxaparin
(Lovenox)
Famotidine
(PF)
Famotidine
(Pepcid)
Gabapentin
(Neurontin)
Hydrocortis
one (Cortef)
Magnesium
sulfate IVPB

Spironolact
one
(Aldactone)

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

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

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

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

80
mg

Q night

PO

75
mg

Daily

PO

30m
g

Q 24 h

Sub
Q

20m
g/2m
L

2 times
daily

IV

20m
g

2 times
daily

PO

300
mg

3 times
daily

PO

20m
g

Daily

PO

2g in Once
50m
L
steril
e
wate
r
25m Daily
g

Page 8 of 12 Patient data sheet page

IV

PO

revised 10/14/16

PRN Medications
Medication
Dosag
e
Morphine
1mg
injection
10 mg

Frequenc
y
Q4 hour

Rout
e
IV

Why patient is
getting.
Severe pain 7-10

Q 6 hour

IV

N/V

Major Side Effects

Prochlorperazine
(Compazine)

Page 9 of 12 Patient data sheet page

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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 10/14/16

Diagnosi
s#

Interventions (What did you do?)

Page 12 of 12 Patient data sheet page

Evaluation (How did it work)

revised 10/14/16