NURS 4045 Adult Health Competencies II

Texas Woman's University

Patient Data Sheet
Student's name: _Uyen Do____________Date of Care: _10/07/16_________ Pt. location/Unit: _7S4__________
Pt. initials: _SR_______
Age: _47______
Gender: _Male_________ Ethnicity: _White _
ALLERGIES:__NKA_______________________CODE STATUS:___Full code_________________
Medical Diagnosis: _Subdural hematoma _
Date of Admission & Course of present hospitalization:___ 47 yo male transfer for SDH secondary to Hemophilia
(Factor VIII, "mild") w Hx of HTN. Pt has weeks long history of headache that has become progressive and
included mild ptosis, noted by wife, and intermittent hearing loss (resolved). Pt developed 10/10 headache at
home and presented to SL Woodlands where he was transferred to St Luke Medical Center due to lack of factor
VIII availability. __________________________________________
________________________________________________________________________________________________
Past Medical/Surg.history:_
Bleeding disorder (Hemophilia)
Hypertension
Migraine
2005: left shoulder debridement _____
blood transfusion ___________________________________________________________________
________________________________________________________________________________________________
Social history: __using smokeless tobacco. Drink 12 oz alcohol/ week. Denied drug use
__________________________________________________________________________________
Family interaction/relationship: Wife at bedside, supportive
_____________________________________________________________________
Communication with patient: __Good. Patient is awake, alert, clear speech. Patient is open to conversation
_____________________________________________________________________
Isolation: Yes __ No_X_ Type: __N/A_____________Why: _N/A____________________________________
Oxygen Delivery: Room air:__X__ Nasal cannula: _N/A___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: regular______________ 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:_N/A___PA catheter _N/A_____ IABP:_N/A__
Page 1 of 11 Patient data sheet page

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Central line(s):_N/A_________ Peripheral IV(s):_left & right antecubital, intact, dry, 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: _194lb__________
Drug
infusion

Current
IV rate

Current
dose

IV site location
(where is it
running?)

Drug concentration (How is

bag mixed)

Why is THIS patient

getting this infusion?

N/A

Page 2 of 11 Patient data sheet page

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NURS 4045 Adult Health Competencies II

Patient Data Sheet- Assessment

Data

Neuro: ICP _N/A____ CPP_N/A____ GCS_N/A____Sedation Assessment (RASS score)__0- patient is awake,
alert, oriented _____________________________
_________________________________________________________________________________________________
Musculoskeletal: _5/5 muscle strength (all extremities), strong hand grips, sensation intact
_________________________________________________________________
Cardiovascular: HR_58___ BP_133/90____ABP_N/A____ CO/CI_N/A_______ PAP/PAWP _N/A_____
CVP_N/A____ SpO2__98%___________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Respiratory: Oxygen/Ventilator settings__Room air. No ventilator ______________________________________
RR_13 breaths/min_____
___________
_________________________________________________________________________________________________
GI: _hypoactive bowel sounds ____
no bowel movement since yesterday ____
tolerate PO well
_____________________________________________________________________________________
_________________________________________________________________________________________________
Renal: 24 hour I/O_Intake= 480_______
_______________Output=800__________________________________________________________
_________________________________________________________________________________________________
Integumentary: T:_97.6F_____ F or C
_____________________________________________________________________
_________________________________________________________________________________________________
Pain Assessment: _6/10 headache, dull, worse with sitting up/standing
________________________________________________________________________________
Delirium Assessment:_Oriented x 4. Memory intact
_____________________________________________________________________________
Psychosocial issues:_Not indicated
_____________________________________________________________________________
Other:___________________________________________________________________________________________
o

ECG strip:
Lead: ______ Atrial/ventricular rate: ______ Regular/irregular: _______ PR interval: _____ QRS interval: _______
Page 3 of 11 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 11 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

8.4

RBC

4.56

PLT

115

PT/I
NR
PTT

PT=13.1
INR=1.0
49.7

HgB

14.2

Hct

40.8

Na

139

3.7

Cl

105

Osmolality

N/A

BUN

13

Creatinine

0.76

Glucose

80

Albumin

3.9

Ca (Serum or Ionized?)

8.8

Mg

2.1

CK

N/A

CK-MB

N/A

Troponin

N/A

Arterial : pH

N/A

PaCO2

N/A

PaO2

N/A

HCO3

N/A

BE

N/A

Ventilator settings
for the blood gas
Urinary: pH

Rationale and/or importance for this patient

This is required for blood gases.

5.5

Specific gravity

1.021

sodium

N/A

osmolality

N/A

Creat. clearance

N/A

GFR

96

Amylase and
Lipase
Liver
transaminases

N/A
AST=67
ALT=146

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Triglyceride

0-149

201

High

Cholesterol

167

100-199

High

LDL

0-99

82

Normal

HDL

>39

45

Normal

Total bilirubin

0.5

Alkaline
phosphatase
Hb A1C

61
4.8-5.6

5.8

High

TSH

0.450-4.50

2.640

Normal

Vitamin D

30-100

27.3

Low

Vitamin B12

211-946

359

Normal

Factor VIII activity

45-150

96

Normal patient was given factor VIII yesterday

Hep A IgM

nonreactiv
e
nonreactiv
e
<8.0

nonreactive

Nonreactiv
e
nonreactiv
e

Nonreactive

Hep A IgG
Hep B Surface Ab
Hep B Core total
AB
Hep B surface
Blood
compatibility
Urinalysis
Blood
Ketones
Nitrite
Leukocytes
Squamous epithel

nonreactive
18.8

High

Nonreactive
A positive

Negative
Negative
Negative
Negative
<1

Negative
Negative
Negative
Negative
<1

Positive Culture Reports?

Date
Site
N/A

Result

Additional Notes/ Comments:

10/06/16 MRA head w/o contrast: negative intra- & extra cranial MRA
10/06/16 MRA neck w/o contrast: negative intra- & extra cranial MRA 10/06/16 MR
brain: small volume bilateral hemispheric subdural hematoma w/o remarkable
mass effect
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Page 6 of 11 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
5mg Daily
PO
Treat HTN
0700 1300
Amlodipine 0800 1400
0900 1500
(Norvasc)
1000 1600
Lisinopril

Famotidine
(PF)

Famotidine
(Pepcid)
Sennadocusate
(Sennokot)
Gabapentin
(Neurotin)
Antihemophilic
factor VIII

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

20
mg

Daily

PO

Treat HTN

20m
g/
2mL

2 times
daily

IV

Prevent GERD

20
mg

2 times
daily

PO

Prevent GERD

1 tab
(8.650
mg)
100
mg

2 times
daily

PO

Treat /prevent
constipation

3 times
daily

PO

Treat

IV

Hemophilia

3400 Once
inter
natio
nal
units

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PRN Medications
Medication
Dosag
e
Potassium
20-60
chloride
mEq
(Kayciel)

Frequenc
y
PRN

Rout
e
PO

Why patient is
getting.
Low potassium
3.5-3.9: give 20
mEq

1g

PRN

IV

Serum Mg= 2-2.2

30 mL

Q4h PRN

PO

Indigestion

2mg
10-325
mg

Q4h PRN
Q6h PRN

IV
PO

Pain severe
Moderate pain (46)

Hydralazine

10mg

IV

HTN

Bisacodyl
(Ducolax)

10mg

Q15 min
PRN
PRN

PO

Constipation

Insulin Lispro
(Humalog)

0-4

Every
night PRN

Sub
Q

High blood sugar

1mg

PRN

IM

12.5g
(25mL)

PRN

IV

Blood sugar <70

Patient is unable
to take PO &
unable to give
D50W
Blood sugar <70
& patient cant
take PO
juice/soda

Magnesium
sulfate
Aluminum &
magnesium
hydroxidesimethicone
(Maalox plus)
Morphine
Hydrocodoneacetaminophen
(Norco)

Glucagon
(human
recombinant)
Dextrose 50%
(D50W)

Page 8 of 11 Patient data sheet page

Major Side Effects

revised 10/7/16

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 9 of 11 Patient data sheet page

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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 10 of 11 Patient data sheet page

Evaluation (How did it work)

revised 10/7/16

Diagnosi
s#

Interventions (What did you do?)

Page 11 of 11 Patient data sheet page

Evaluation (How did it work)

revised 10/7/16