Admission Date: 4/15/2014

DOB: 10/14/1956

NURS 2645L Professional Nursing 1

WEEKLY WORKSHEET
STUDENT NAME: Natalee Bommer
INITIALS: J.C.

DATE OF CARE: 4/18/2014

PATIENT

DNR STATUS: Full Code SAFETY CONCERNS: Risk for Falls, Risk for DVT
ALLERGIES: NKDA
DIET (Type/Assistance needed) Regular
INTAKE 362 mL (fluid) OUTPUT ____ BKFT 100% LUNCH____% ACTIVITY ORDER Bedrest 1st day post-op
# OF ASSIST 1
ANY DEVICES Walker, Crutches
IVs LUE NaCl
7

VITAL SIGNS BP 126/71, HR 98, RR 18, O2 98%, 98.2F Pain Rating

TEACHING NEEDS Identify and State Reason (Cultural, Spiritual, Sexual, Psychosocial,
Knowledge Deficit) Teach patient to how to support R ankle and keep proper leg alignment.
PRIMARY MEDICAL DIAGNOSIS: LIST ETIOLOGY, PATHOPHYSIOLOGY, ALL
SIGNS/SYMPTOMS OF DIAGNOSIS, AND CAUSE OR EFFECT ON PATIENTS PRESENT
CONDITION. HIGHLIGHT ALL SIGNS/SYMPTOMS YOUR PATIENT EXHIBITS.
FRACTURES (RIGHT ANKLE)
Etiology: May result from a direct blow, a crushing force (compression), a sudden twisting motion
(torsion), a severe muscle contraction, or disease that has weakened the bone (stress/pathologic fracture).
Pathophysiology: A fracture occurs when the bone is subjected to more kinetic energy than it can absorb.
Direct force (kinetic energy applied at/near site of the fracture) and indirect force (kinetic energy
transmitted from the force of impact to a site where the bone is weaker) produce fractures. If the skin is
intact, the fracture is considered a closed/simple fracture. If skin integrity is compromised, the fracture is
considered an open/compound fracture. The fracture line may be oblique (at an angle to bone) or spiral.
An avulsed fracture pulls bone and other tissues away from the point of attachment. A fracture may also
be comminuted (broken in several places), compressed (crushed), impacted (broken bone ends forced into
each other), or depressed (broken bone forced inward). Complete fractures involve the entire width of
bone and incomplete fractures involve only part of the width. A stable/nondisplaced fracture is one in
which the bones maintain anatomic alignment. An unstable/displaced fracture moves bones out of correct
alignment and immediate interventions are required to prevent further damage.
Signs and Symptoms: soft tissue injuries that involve muscles, arteries, veins, nerves, or skin; deformity
of bones or abnormal position; swelling; pain/tenderness; numbness; guarding; crepitus; hypovolemic
shock; muscle spasms; ecchymosis
Cause or Effect on Patient: Patient on bed rest and unable to ambulate on 1st day post-surgery. Pain
rating of 7 in R ankle; patient refuses pain medication stating that it causes her nausea; I would rather be
in pain than feel sick.

SECONDARY MEDICAL DIAGNOSIS: LIST ALL ON BACK OF PAGE. CHOOSE ONE

PRIORITY DIAGNOSIS. LIST ETIOLOGY, PATHOPHYSIOLOGY, ALL SIGNS/SYMPTOMS OF
DIAGNOSIS, AND CAUSE OR EFFECT ON PRIMARY DIAGNOSIS. HIGHLIGHT ALL
SIGNS/SYMPTOMS YOUR PATIENT EXHIBITS.
CEREBROVASCULAR ACCIDENT (W/ RIGHT-SIDED WEAKNESS)
Etiology: Nonmodifiable risk factors for CVA include: advancing age, being male, African American
race, and family history. Modifiable risk factors include: hypertension, heart disease, diabetes mellitus,
smoking, excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical
exercise, poor diet, and drug abuse. Motor deficits are caused by destruction of motor neurons in the
pyramidal pathway.
Pathophysiology: A stroke occurs when there is ischemia to a part of the brain (ischemic stroke) or
hemorrhage into the brain that results in death of brain cells (hemorrhagic stroke). The severity and type
of loss of brain function varies according to the location and extent of brain damage.
Signs and Symptoms: Right-brain damage: paralyzed left side, left-sided neglect, spatial-perceptual
deficits, tends to deny or minimize problems, rapid performance, short attention span, impulsive/safety
problems, impaired judgement, impaired time concepts; Left-brain damage: paralyzed right side, impaired
speech/language aphasias, slow performance/cautious, aware of deficits: depression/anxiety, impaired
comprehension related to language/math; motor deficits (loss of skilled voluntary movement/akinesia,
impairment of integration of movements); alterations in muscle tone, alterations in reflexes, and impaired
elimination (partial sensation for bladder filling, frequency, urgency, incontinence, constipation)
Cause or Effect on Primary Diagnosis: Right-sided weakness may contribute to unstable gait and
difficulty ambulating. Either CVA or medication may contribute to documented nighttime incontinence.

LABORATORY DATA
TEST
WBCS
RBCS
HEMOGLOBI
N
HEMATOCRIT
PLATELETS
PROTHROMB
IN TIME
INR
SODIUM (Na)
POTASSIUM
(K)
CHLORIDE
(Cl)
GLUCOSE
(FBS/BS)
BUN
Creatinine
DIAGNOSTIC

NORMAL
VALUES
(Female)
3.5-10.5
x103/mcL
3.9-5.03
x106/ L
12.0-15.5
g/dL
36-44%

DAT
E

WHY TEST
WAS ORDERED

RESULTS

Complete Blood
4/9
Count
2014
Complete
Blood
4/9
Count
2014
Complete
Blood
4/9
Count
2014
Complete Blood
4/9
Count
2014
Complete Blood
150-450
4/9
Count
x103/mcL
2014
General Blood
11-13 sec
4/9
Testing
2014
General Blood
0.8-1.1
4/9
Testing
2014
General Blood
136-145
4/9
Testing
mmol/L
2014
General Blood
3.5-5.1
4/9
Testing
mmol/L
2014
General Blood
98-107
4/9
Testing
mmol/L
2014
General Blood
70-110
4/9
Testing
mg/dL
2014
General Blood
7-19
4/9
Testing
mg/dL
2014
General Blood
0.4-1.3
4/9
Testing
mg/dL
2014
TESTS: Chest x-ray, EKG, sputum, blood
needed)

TEST

NORMAL
VALUES

DAT
E

X-ray R ankle

No fracture
or abnormal
findings

4/8
2014

WHY
TEST WAS
ORDERED
R ankle
pain,
swelling

REASON FOR
ABNORMAL
VALUES

4.9
3.81

Anemia

11.2

Anemia

32.8

Anemia

208.0
10.5

High intake of
Vitamin K

1
141
4.0
110
119

Medication, Fluid
Loss
Diabetes

15
0.9
culture (Use back of page if

RESULTS
R ankle oblique
fracture

REASON FOR
ABNORMAL
VALUES
Seizure caused fall
in bathroom at
home

TREATMENTS: (INCLUDE ELIMINATION, RESTRAINTS, DRESSINGS, O2 THERAPY)

Treatment
Vital signs

How
Often
q4h

Apply ice bag to R

ankle
Heel protector/pillow
under affected leg
Sponge bathe; shower
after 3 days post-op

q shift and
PRN
While in
bed
q daily

Cover R leg while

bathing
Gait training w/ walker
and crutches
Blood glucose
monitoring
Apply splint to affected
leg

While
bathing
q daily after 1st
post-op day

q.i.d.
q daily

Times

Rationale
To monitor for abnormal findings, development of
infection, blood clot formation, and pneumonia.
To reduce pain and inflammation in affected area.
To off-load weight from heel to protect against skin
breakdown.
To protect against skin breakdown, prevent infection,
and assess skin for abnormalities.

While PT
is present
AC and HS

To prevent damage to wound dressing and infection

development.
To prevent DVT, preserve ROM in non-affected
extremities, and regain ROM in affected ankle.
To detect trends in blood glucose level and indicate need to
adjust or maintain treatment for good diabetes control.

To maintain leg/ankle alignment during healing.

TARGET ASSESSMENT: IDENTIFY RESULTS AND EXPLAIN WHY

Pain and nausea assessment: q shift, before administration of meds, and before activity and
dressing changes patient states pain rating of 7; unable to give pain meds because of IV
infiltration and subsequent removal from L arm, CVA and weakness on R side, and nausea after
PO administration. Charge nurse notified and waiting on possible order for PO pain/nausea
medication.
Hand-washing and sterile procedure followed to prevent the spread of infection.
Blood glucose monitored and Novolog administered to control high blood glucose level.
Pillows strategically placed to support alignment of affected leg.

Katz Index of Independence in Activities of Daily Living

ACTIVITIES

INDEPENDENCE:

DEPENDENCE:

POINTS (1 OR 0)

(1 POINT)

(0 POINTS)

BATHING - 1

(1 POINT) Bathes self

(0 POINTS) Needs help

completely or needs help in with bathing more than one

bathing only a single part of part of the body, getting in
thePOINT)
body such
asclothes
the back, (0
or out
of the Needs
tub or shower.
(1
Gets
POINTS)
help

DRESSING - 0

TOILETING - 0

from closets and drawers

with dressing self or needs

and puts on clothes and

to be completely dressed.

outer
garments
(1
POINT)
Goescomplete
to toilet,

(0 POINTS) Needs help

gets on and off, arranges

transferring to the toilet,

clothes, cleans genital area cleaning self or uses bedpan

without
help.
or commode.
(1
POINT)
Moves in and out (0
POINTS) Needs help in

TRANSFERRING - 0

CONTINENCE - 0

FEEDING - 1

of bed or chair unassisted.

moving from bed to chair or

Mechanical transferring

requires a complete

aides
are acceptable.
(1
POINT)
Exercises

transfer.
(0
POINTS) Is partially or

complete self control over

totally incontinent of bowel

urination and defecation.

or bladder.

(1 POINT) Gets food from

(0 POINTS) Needs partial

plate into mouth without

or total help with feeding or

help. Preparation of food

requires parenteral feeding.

may be done by another

TOTAL POINTS =

6 = High (patient independent) 0 = Low (patient very

dependent)

Fulmer SPICES: An Overall Assessment Tool for Older Adults

Patient Name: L.Y.

Date: 2/28/2013

SPICES

EVIDENCE
Yes

No

Sleep Disorders

No sleep disorders observed

or documented in chart. Pain
sometimes interferes with
sleep, as stated by the patient.

Problems with Eating or

Patient ate majority of meals

despite transient nausea. PO
pain medication causes
intense nausea. Pain interferes
with appetite as well.

Feeding

Incontinence

Patient wears Depends at

night for nighttime
incontinence. Depends not
needed during the day
however.

Confusion

Evidence of Falls

Skin Breakdown

Alert and Oriented x 3.

Fracture caused by fall,

which occurred during a
seizure.

No evidence of skin
breakdown observed.

Completely Limited:
Unresponsive (does not
moan, flinch, or grasp) to
painful stimuli, due to
diminished level of
consciousness or sedation,
OR
limited ability to feel pain
over most of the body
surface.

Very Limited:
Responds only to painful
stimuli. Cannot
communicate discomfort
except by moaning or
restlessness,
OR
has a sensory impairment
which limits the ability to
feel pain or discomfort
over of the body.

Slightly Limited:
Responsive to verbal
commands but cannot
always communicate
discomfort or need to be
turned,
OR
has a sensory impairment
which limits ability to feel
pain or discomfort in 1 or
2 extremities.

No Impairment:
Responds to verbal
commands. Has no
sensory deficit which
would limit ability to
feel or voice pain or
discomfort.

MOISTURE
Degree to which
skin is exposed to
moisture

Constantly Moist:
Skin is kept moist almost
constantly by perspiration,
urine, etc. Dampness is
detected every time patient is
moved or turned.

Moist:
Skin is often but not
always moist. Linen must
be changed at least once
a shift.

Occasionally Moist:
Skin is occasionally moist,
requiring an extra linen
change approximately
once a day.

Rarely Moist:
Skin is usually dry;
linen requires
changing only at
routine intervals.

ACTIVITY
Degree of physical
activity

Bedfast:
Confined to bed.

Chairfast:
Ability to walk severely
limited to nonexistent.
Cannot bear own weight
and/or must be assisted
into chair or wheelchair.

Walks Occasionally:
Walks occasionally during
day but for very short
distances, with or
assistance. Spends
majority of each shift in
bed or chair.

Walks Frequently:
Walks outside the
room at least twice a
day and inside room
at least once every 2
hours during walking
hours.

MOBILITY
Ability to change
and control body
position

Completely Immobile:
Does not make even slight
changes in body or extremity
position without assistance.

Very Limited:
Makes occasional slight
change in body or
extremity position but
unable to make frequent or
significant changes
independently.

Slightly Limited:
Makes frequent though
slight changes in body or
extremity position
independently.

No Limitations:
Makes major and
frequent changes in
position without
assistance.

NUTRITION
Usual food intake
pattern

Very Poor:
Never eats a complete meal.
Rarely eats more than 1/3 of
any food offered. Eats 2
servings or less of protein
(meat or dairy products) per
day. Takes fluids poorly.
Does not take a liquid dietary
supplement,
OR
Is NPO and/or maintained on
clear liquids or IVs for more
than 5 days.

Probably Inadequate:
Rarely eats a complete
meal and generally eats
only about of any food
offered. Protein intake
includes 3 servings of
meat or dairy products per
day. Occasionally will take
a dietary supplement,
OR
Receives less than
optimum amount of liquid
diet or tube feeding.

Adequate:
Eats over half of meals.
Eats a total of 4 servings
of protein (meat, dairy
products) each day.
Occasionally will refuse a
meal, but will usually take
a supplement if offered,
OR
Is on a tube feeding or
TPN regimen, which
probably meets most of
nutritional needs.

Excellent:
Eats most of every
meal. Usually eats a
total of 4 or more
servings of meat
and dairy products.
Occasionally eats
between meals.
Does not require
supplementation.

FRICTION AND
SHEAR

Problem:
Requires moderate to
maximum assistance in
moving. Complete lifting
without sliding against sheets
is impossible. Frequently
slides down in bed or chair,
requiring frequent
repositioning with maximum
assistance. Spasticity,
contractures, or agitation
leads to almost constant
friction.

Potential Problem:
Moves feebly or requires
minimum assistance.
During a move skin
probably slides to some
extent against the sheets,
chair, restraints, or other
devices. Maintains
relatively good position in
chair or bed most of the
time but occasionally
slides down.

No Apparent Problem:
Moves in bed and in chair
independently and has
sufficient muscle strength
to lift up completely during
move. Maintains good
position in bed or chair at
all times.

SENSORY
PERCEPTION
Ability to respond
meaningfully to
pressure-related
discomfort

Total Points:

16
Clinical
Judgment:
Mild Risk for
Pressure Ulcers

BRADEN SCALE - PRESSURE ULCER RISK- Assess Prior to and during clinical.
N2645 Assessment: Directions: Add up the total points, a perfect score is 23. A high score means lower risk for
developing a pressure ulcer. A low score means higher risk.