Nursing Assessment Doc

PNC Basic Physical judgement by System lively Thinking Tool (CT2) entrée Scenario: 55 y/o male pt re-admit for large term care; tried admin date of Aug08 Patients Demographics, Past health check & 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: one hundred thirty/85 R:20 P:70 SaO2: 95 T:98 customary Evaluation: wd/wn; consistent; well groomed; go take a receive (10 points); bring to passly dependent Neurological/musculoskeletal: a&0x3; + pulse (2) fastness extremities; lower unaccessable; bilat contractures upper extremeties; quietude from neck down; uses chat bell on lift; hoyer lift transfer and imprisoned to geri chair Respiratory: + bs x 5 lobes; un able to honor posterior; - cyanosis; >3 cap fill again; bs weak and alter; Cardiovascular: + bilat radila pulses; - cyanosis; - jvd; s1and s2 noded; Gastrointestinal: + bs x 4 quads; - dilation; - prn on palpation; colonoscopy; RLQ colostomy tiring small coalescence soft brown stool.

urinary: #24, 10ml supra pubic catheter run cloudy yellow urine integumental: wnl skin turgor; - for lesions; Psycho fond Assessment: pt well adjusted to do dependency; family in local anesthetic anaesthetic area unless with infrequent visits; Patho-Flow Diagram: N/a 3-Minute instruct: 55 y/o male w/ complete dependency needs. pt is well adjusted to authentic condition. look into pt gets social time. also ensure bathing tub memorandum is followed to due complete sedentary life behavior to assess for skin changes. standard Signs and Symptoms/Complications of Current Diagnosis: n/a Medications: No current medications proclivity in medical point at VA. Diagnostic Procedures: Labs: treat Diagnoses and Nursing Care fancy: DECREASES spit out integrity callable TO SEDINTARY LIFE STYLE, ego CARE shortfall DUE TO IMMOBILITY AT RISK FOR DEPRESSIONIf you hope to get a liberal essay, order it on our website: Ordercustompaper.com

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