Running Head: NURSING CASE STUDY.
AS, is a 74 year old male. He is married and has 3 children, and a few grand children. He lives in south bend with his wife and his youngest daughter. He seemed to be a family man. His family was in and out of the hospital while he was there. He is a very outspoken person; his family was very supportive.AS, formally worked for the city but is now retired. He is a full code with no known drug allergies. He presented to the emergency room with a fever of 100 degrees and complications from chemotherapy. Subjective symptoms upon admission were; nausea, vomiting and pain. Objective symptoms were a temperature of 100 degrees, and elevated blood pressure. He seemed calm, and was adjusting well with treatment and has accepted his medical condition. He has a past medical history of; Coronary artery disease (CAD), chronic renal insufficiency, myocardial infraction, and Gerd. His present medicals conditions are; uro sepsis, hypertension, urinary retention, general weakness, aplastic anemia, gastrointestinal prophylaxis, deep vein thrombosis, osteoarthritis, and was recently diagnosed with neck and head metastatic cancer of unknown cause. Surgical history include: Coronary artery bypass graft, cholecystectomy, gastric surgery, renal artery stenosis with stenting, port placement and right neck lymph node biopsy. Assessment Data Sheet
Patient Initials: AS Code Status full code Date of Care 9/4 and 5th.
| Medical Diagnosis CAD, chronic renal insufficiency, uro sepsis , hypertension,General weakness, neck and head metastatic ccancer. Osteoarthritis. Allergies NKDA
| Vital SignsB/P 177/101 on the 4th 130/72 on the 5th.Biox-98%Heart rate 74Respirations-20 (TPR, BP, & O, Sat) Pain (0-10 & describe) No pain on the first day of care. Pain of 8 on the second day, managed with medication.(Norco)
| Neuro/Sensory Integumentary
| 74 year oldMaleMarriedPatient has children and grand children.Supported by retirement income, and social security.Religion-Baptist.Ethnicity-African AmericanHobbies-fishing.Community involvement-churchDate of admission-9/2/12LOS- Discharged 0n 9/7/12.Interaction with staff and othersHx of alcohol –N/AQuit smoking 20 years ago.No change on the second day.
| Loc-alert, orientedx3PERRLA-yesSpeech-clearHearing-mild impairment noted. (AS was turning the TV volume up, and was using a loud tone of voice).No glassesResponded to touchTongue in midlineCalm at first, then became anxious and agitated later.Long/short term memory-intactFollows directions well but disagrees on a lot of things.Strong on the right upper and lower extremities but weak on the right side on the first day but were both strong on the second day.Needed one person assist on the first day but was steady the next day.No pain on the first day. Pain level of 5 on the second, managed with medication and dropped to 0
| Skin color- normal for ethnicity.Turgor-elasticNo bruises or rashesNo skin ulcerationMucous membrane-pinkFinger nails and toe nails-rigidFull head of hairNo abnormal opening.A peripheral port in place. No drainage, dressing intact and dry.2nd day.No changes on the above assessment.
Respirations- regular rate and rhythm.Biox-98% and 100%Lung sounds clear posterior and anterior bilaterally.Cough-present, productive with moderate secretions.Tracheal-midlineSmoking- hx of smoking but quit a few years ago. No change on the second day.
| B/p-177/101, then 130/72 on the 5th.Pulses-74, 72 on the 5th.Heart tones- S1no change on second dayNo pacemaker in placeEdema-no edemaHad his ted holes.Peripheral pulses-present 2+
| Abdomen- round, soft and non-tender.Bowel sounds-...
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