L

Lincoln Memorial University

Comprehensive Project
NURS 125

Melissa Galentine
2-24-2016

LINCOLN MEMORIAL UNIVERSITY

Caylor School of Nursing
Laboratory Values: For Comprehensive Project ONLY
Student Name: MELISSA GALENTNE
Laboratory Test

CBC
White Blood Cells
(WBC)
Red Blood Cells (RBC)
Hemoglobin (Hgb)
Hematocrit (HCT)
Platelets (PLT)
Coagulation Studies
Prothrombin Time (PT)
International Normalized
Ratio (INR)
Activated Partial
Thromboplastin Time
(PTT)
Comprehensive
Metabolic Panel
Sodium (Na)
Potassium (K)
Chloride (Cl)
Calcium (Ca)
Magnesium (Mg)
Phosphorus
Glucose (FBS)

Hemoglobin A1C

Normal
Values

Admit
Values
Date
02/02

Preplan
Date
02/08

Clinic
Day 1
Date
02/09

Clinic
Day 2
Date
02/10

Rationale for Abnormal Values

Nursing
Implications

5,000-10,000

6.5

n/a

9.0

n/a

n/a

n/a

4.2-6.1
12-18
37-52%
150,000-400,000

4.12
12.9
40.1
150

n/a
n/a
n/a
n/a

4.27
13.6
41.1
237

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

11-12.5 sec
0.8-1.1

n/a
n/a

n/a
n/a

n/a
n/a

n/a
n/a

n/a
n/a

n/a
n/a

30-40 sec (APTT)

60-70 sec (PTT)

n/a

n/a

n/a

n/a

n/a

n/a

02/02

02/08

02/09

02/10

136-145
3.5-5
98-106
9-10.5
1.3-2.1
3-4.5
70-110

136
4.0
98
9.9
n/a
n/a
137

n/a
n/a
n/a
n/a
n/a
n/a
n/a

137
4.0
100
9.0
n/a
n/a
104

n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a

Most IV fluids contain dextrose; which is quickly

converted to glucose. Therefore, most patients receiving
IV fluids will have increased glucose levels. p. 475

Less than 7%

n/a

n/a

n/a

n/a

n/a

D5 NS at
125ml/hr was
changed to INT
on day 4 2/06
n/a

BUN
Creatinine
BUN/Creatinine Ratio
Laboratory Test
Lipid Panel
Cholesterol
HDL
LDL
Triglycerides
Liver Function Tests
Albumin
Bilirubin
ALT
AST
GGT
Ammonia
Amylase
Lipase

10-20
0.5-1.2
6-25

21
0.94
22.3

n/a
n/a
n/a

22
0.82
26.8

n/a
n/a
n/a

02/02
Admit
Day
Values

02/08
Preplan
Values

02/09
Clinic
Day 1
Values

02/10
Clinic
Day 2
Values

Less than 200

Greater than 45
Less than 130
35-160

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

3.5-5
0.3-1
4-36
0-35
5-38
10-80
60-120
0-160

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

Normal Values

Cardiac Enzymes
CK or CPK
CKMB
Troponin
B Natriuretic peptide(BNP)
Arterial Blood Gases (ABG)
pH
PCO2
PO2
HCO3
Urinalysis
Color
Appearance
Specific Gravity
pH
Glucose

n/a
n/a
Patient Dx with Stage 4 Renal Disease, BUN is a good
measurement of Renal Function. p. 947
Rationale for Abnormal Values

n/a
n/a
Strict I & O
Nursing
Implications

02/02
30-170
0%
Less than 0.1
Less than 100
7.35-7.45
35-45
80-100
21-28
Amber, Yellow
Clear
1.005-1.030
4.6-8
Negative

n/a
n/a
<0.03
n/a

n/a
n/a

n/a
n/a

n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a

n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

yellow
clear
1.012
5.5
negative

n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a

Ketones
Nitrates
Bacteria
RBC
WBC
Crystals
Urine C & S

Negative
Negative
Negative
Less than 2
0-4
Negative
2/2

negative
negative
negative
0
0
0
collected

n/a
n/a
n/a
n/a
n/a
n/a
No
growth

n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a

02/02

02/08

n/a

0700

02/1
0
0700

n/a

0700

02/0
9
0700

n/a

n/a

1200

1200

1200

1200

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Blood Culturs x2:

Results show no growth in 72hrs

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Diagnostics/
Blood Glucose levels
(Accucheck, Chemstrips, etc)
Therapeutic Drug Levels:
Peak & Trough
Culture Specimens:
Blood:
Sputum
Stool
Wound
MRSA
Biopsy

none

n/a
CT/MRI Scan

X-Ray

n/a
ABDOMEN flat & upright:
Nonspecific abdomen
CXR PA/LAT:
BIL BASILAR EFFUSION

EKG

n/a

Inflammation of the lung

(pneumonia). p. 240
n/a

n/a

n/a

n/a

n/a

n/a
Cough and deep breath and
use incentive spirometry
every hr, Administer ordered
IV antibiotics
n/a

NSR
Electronic Arial Pacemaker

LINCOLN MEMORIAL UNIVERSITY

Caylor School of Nursing
Daily Sheet: For Project ONLY
Student name: MELISSA GALENTINE
Day 1
Date of Admission:
02/02/2016

HCP: DR. LONG

Consults: ORTHO

DATE: 2/9/2016

Code Status:
FULL CODE

Allergies: AMIODARONE,
DEMEROL, PCN,
PROPAFENONE

Marital Status:
WIDOWED

Religion:
BAPTIST

Occupation:
HOUSE WIFE

Admit
Diagnosis: PYLONEPHRITIS, PNEUMONIA

Psychosocial History
ETOH - OCCASIONAL
Tobacco- DENIES
Rec Drug use- DENIES

Medical/Surgical
History: AFIB, HTN, LUPUS, HYPOTHYROID,
COPD
Vital Signs
Time: 0930 T-98.3 ORAL P-75 R-18
148/92
O2 Sat 97% RA
Admission
Height: 5'5

BP

Admission
Weight: 67 KG

Physiologic/Physical Mode: Neurosensory

LOC: ALERT
Orientation:
Pupil
TIME, PLACE, Size: 3MM
PERSON
Visual Problems:
Yes No X
Corrective Lenses:
Yes X (READING) No
Oxygenation: Respiratory
Oxygen: AT HS
IS:
Delivery Device:
Goal :
BNC
2400 mL
LPM: 2L/MIN
Actual :
2200mL

Family Structure 4 CHILDREN LIVE LOCALLY,

LIVES ALONE
Time: 1130 T 98.7 ORAL P-72 R-20
152/90
O2 Sat 96% RA

BP

Daily Weight: Yes X No

Current Wt. 65 KG
PERRLA:
Yes X No

Hearing Problems: Yes

No X
Hearing Aids:
Yes No X
Continuous Pulse
Oximetry:
Yes No X

Follows Commands: Yes X

No
Swallowing problems:
Yes No X
Aspiration Precautions: Yes No
X

Cough:
Yes X No

Productive:
Yes No X
Sputum Color: N/A

Car5

CARDIAC
Heart Sounds:
S1, S2

Apical Rate: 75
Rhythm: NORMAL
SINUS
ICD

Cardiac Monitor:
Capillary
Yes X
No
Refill:
Telemetry Rhythm: NORMAL
< 3SEC
Abnormal Sounds: N/A
SINUS WITH PVC
Monitor #48
Edema: Yes X No
Pitting: Yes X No
Location: BILATERAL LOWER EXT
Degree: +2
Extremities
Pedal Pulses
SCD/PAS Hose: Yes
Color: PALE/DRY
Right: +2
Left: +2
No X
Temperature: WARM
TED Hose
Yes No X
Nutrition
Ordered
IBW
Oral Fluid
Percent Eaten:
Diet: REGULAR
59 KG
Intake:
Bkfst: 50%
860 ml
LUNCH: 50%
Mucous Membranes: Condition
Partials or
Abdomen: SOFT, NONDRY
of Teeth: GOOD
Dentures:
TENDER
NONE
Feeding Tube: Yes Placement
Formula:
Rate: N/A
Site &
NO X
Verified N/A
N/A
ml/hr
Appearance: N/A
Type: N/A
Elimination: Gastrointestinal
Emesis: Yes No X
Amount: N/A
Color: N/A
Nasogastric Tube: N/A Site: Right Left
N/A
Suction N/A
Verified: N/A Appearance: N/A Drainage Color: N/A NG Output N/A
Continent:
Yes X No
Amount:
SMALL
Ostomy:Ye Site:
s
NoX
Continent
Yes X
No
Ostomy:
Yes
No X

Bowel Elimination
Method: BSC
Usual Pattern: FORMED
N/A

Stool
Output:
N/A

Urinary Elimination
Method: BSC

Site:
N/A

Urine
Output:
N/A

Placement

Bristol Stool Type: 6

Color: BROWN
Bowel Sounds: NORMAL BOWEL SOUNDS
HEARED X 4 QUADS
Collection Device
Stoma Appearance:
N/A
Change Due: N/A

Foley
Catheter:
Yes No X

Last BM: 2/9/216

Secured:
Yes No
N/A

Collection Device
N/A
Change Due: N/A

Urine
Output
525 mL

CBI:
Yes
No
N/A

Urine
Color:
CLEAR
ORANGE

Stoma Appearance: N/A

Car6

Protection
Braden Scale:
16/AT RISK

Restraints:
Type: N/A

Seizure
Precautions:
Yes No X

Isolation: Yes No X
Type: N/A
Organism: N/A
Location:
N/A
Skin Color: PALE
Texture: DRY
Condition: SMOOTH
Turgor: ELASTIC
Surgical Drain: Yes No X
Site: N/A
Drainage Color: N/A
Type of Drain: N/A
Amount: N/A
Wound Vac N/A
Wound Care Orders:
Location :
N/A
N/A
Drainage:
N/A
Musculoskeletal
Ordered Activity:
Fall Risk
CSMs Intact
PT UP WALKING TID
Score: 18
Yes X
Johns Hopkins
No
Posture: SLIGHT KYPHOSIS
Heat or Cold therapy: N/A
Strength: WEAK
Gait: SLOW, STEADY
ROM: ACTIVE
Aids/Appliances: WALKER
Intravenous Therapy
Location
Size: 18
Type: INT
Location
Size: N/A
Type:
Site#1: LEFT
Site #2: N/A
PIV CVL
UPPER ARM
Insertion
Site Care
Insertion
Site Care
Date: 2/9 BY PICC TEAM
Due: 2/12
Date: N/A
Due: N/A
Primary IVF: N/A
IV
Other IVF: N/A
IV
Rate: N/A ml/hr
Intake: N/A Rate:
N/A
Intake: N/A
Site &
Tubing
Site &
Tubing
Appearance:
Labeled:
Appearance: N/A
Labeled:
NO EDEMA/REDNESS/PAIN
Yes No X
YES
Patient Controlled Anesthesia
Medication: N/A
Basal
Demand
Freq: N/A Lockout:
Attempts:
Rate: N/A
Dose: N/A
N/A
N/A
Injections:
N/A
Total given:
N/A
Pain Assessment
Pain:
Pain Scale: 6
Site:
Duration: Intermittent
Yes X No
Numeric 1-10
BACK
PRESSURE
Acute X
Chronic
Med given:
Dose:
Time:
Follow up
Non-Pharm
PERCOCET
5MG
0930
PRS: 4
Intervention: BACK RUB,
REPOSITIONED AND TURNED EVERY
Med given: N/A
Dose:
Time: N/A Follow up
2 HRS
N/A
PRS: N/A
Car7

Student:
DATE/
TIME
0930
2/9/16

MELISSA GALENTINE
CLINICAL DAY 1

1015
2/9/16

Attempted IV access to Right wrist area, #20ga x 1 stick with immediate blood return. When
flushed with 10ml saline swelling apparent to site. Patient c/o pain. Catheter removed.
Primary Nurse notified. PICC team notified to start peripheral access. M. Galentine LMUNS ---------------------------------------------------------------------------PICC team at bedside. #18ga cathlon inserted x1 stick with US guidance. Pt tol well. Sts
still nauseated. Anti-emetic given IV by Primary Nurse. M. Galentine LMU-NS
Removed food tray from room with 50% ate. Up to bedside commode voiding 200ml clear
yellow urine. Assisted back to bed. Call light within reach. Side rails up x 2. Voiced no
needs at present. I think Im going to take a nap. Family at bedside. M. Galentine LMUNS --------------------------------------------------------------------------------------------Resting with eyes closed. Breathing even and unlabored. No distress noted. Call light within
reach. Side rails up x 2. Bed in low position. Son at bedside. Report given to Primary Care
RN. M. Galentine LMU-NS --------------------------------------------------

1055
2/9/16
1310
2/9/16
1358
2/9/16

Date: 2/9/2016

Resting in bed. V/S: B/P 148/92 , Temperature 98.3/Orally. Alert and oriented x3. PERRLA
3mm with consensual reaction. Sts I wear glasses for reading. Speech clear, symmetrical
facial features. Mucous membranes pink, dry, and intact. Natural teeth in good condition.
Apical heart rate 74 beats per minute, regular rhythm, S1 and S2 audible. Telemetry monitor
#48 in place. Respiratory rate 18 breaths per minute, regular rhythm, normal depth and
unlabored. Crackles auscultated in bilateral lower lobes. O2 saturation at 97% on RA.
Capillary refill < 3 sec. Denies dyspnea. Even/shallow/unlabored breathing. Occasional
nonproductive cough. Abdomen slightly round, symmetrical, with normo-active bowel
sounds x4 quadrants on auscultation. Soft to palpate, denies tenderness. Sts I'm
nauseated but I am a lot, even at home. Ate 50% of Regular diet for breakfast. States, my
last bowel movement was this morning, small amount of brown liquid stool. Posture upright.
Ambulates with walker. Gait slow steady. Full active range of motion of upper and lower
extremities. Sts i just feel weak. Denies tenderness or pain in joints. 2+ pitting edema to
lower legs/ankles, erythema noted in joints of upper or lower extremities. Bilateral grips
strong and equal. Upper extremities strong and equal bilaterally, Left Lower Extremity
strong. Right lower extremity slightly weaker, ace bandage to right ankle/foot with bruising
to both foot/ankle. Elevated on pillows with heel off bed. Bilateral radial pulse 2+ and
dorsalis pedis pulses 2+ on palpation. Skin pale, warm, dry to touch and intact, turgor
elastic. Several small areas of purpura noted on both forearms and hands. Patient states I
am on a blood thinner. Transparent dressing over #22 ga. INT site present in forearm
clean, dry and intact with edema & erythema noted. INT d/c cathlon intact. Pt tol well.
225ML Clear orange urine in bedside commode. Denies pain/burning with urination. Lying
on left side watching TV, no request at this time. Side rails up x2. Call light in reach. Bed
locked in low position. M. Galentine LMU-NS ------------------------------------------------

Car8

LINCOLN MEMORIAL UNIVERSITY

Caylor School of Nursing
Daily Sheet: For Project ONLY
Student name: MELISSA GALENTINE
Day 2
Date of Admission:
02/02/2016

HCP: DR. LONG

Consults: ORTHO,
GI

DATE: 2/10/2016

Code Status:
FULL CODE

Allergies: AMIODARONE,
DEMEROL, PCN,
PROPAFENONE

Marital Status:
WIDOWED

Religion:
BAPTIST

Occupation:
HOUSE WIFE

Admit
Diagnosis: PYLONEPHRITIS, PNEUMONIA

Psychosocial History:
ETOH - OCCASIONAL
Tobacco- DENIES
Rec Drug use- DENIES
Family Structure:
4 CHILDREN LIVE LOCALLY
LIVES ALONE

Medical/Surgical
History: AFIB, HTN, LUPUS, HYPOTHYROID,
COPD
Vital Signs
Time: 0810 T-97.6 ORAL P-74 R-18
162/88
O2 Sat 94% RA
Admission
Height: 5'5

Admission
Weight: 67 KG

BP

Time: 1145 T 98.3 ORAL P-78 R-20

158/92
O2 Sat 95% RA
Daily Weight: Yes X No
Current Wt. 64 KG

Physiologic/Physical Mode: Neurosensory

LOC: ALERT
Orientation:
Pupil
PERRLA:
TIME, PLACE, Size: 3MM Yes X No
PERSON
Visual Problems:
Hearing Problems: Yes
Yes No X
No X
Corrective Lenses:
Hearing Aids:
Yes X (READING) No
Yes No X
Oxygenation: Respiratory
Oxygen: AT HS
IS:
Delivery Device:
Goal:
BNC
2400 mL
LPM: 2L/MIN
Actual:
2250mL

BP

Continuous Pulse
Oximetry:
Yes No X

Follows Commands: Yes X

No
Swallowing problems:
Yes No X
Aspiration Precautions: Yes No
X

Cough:
Yes X No

Productive:
Yes X No
Sputum Color:
THICK, YELLOW

Car9

CARDIAC
Heart Sounds:
S1, S2
Abnormal Sounds:
MURMUR
Edema: Yes No X
Location: N/A
Extremities
Color: PALE/DRY
Temperature: WARM
Nutrition
Ordered
Diet: REGULAR

Apical Rate: 72
Rhythm: NORMAL
SINUS WITH PVC
ICD

Pedal Pulses
Right: +2

Mucous Membranes: Condition

MOIST
of Teeth: GOOD
Feeding Tube: Yes Placement
Formula:
NO X
Verified N/A
N/A
Type: N/A
Elimination: Gastrointestinal
Emesis: Yes No X
Amount: N/A
Nasogastric Tube: N/A Site: Right
Verified: N/A Appearance: N/A
Drainage Color: N/A NG Output N/A

Left

Continent:
Yes X No

Bowel Elimination
Method: BSC

Amount:
SMALL
Ostomy:
Yes No
X

Usual Pattern: FORMED

ContinentYe
sX
No
Ostomy:
Yes
No X

Stool
Output:
N/A

Urinary Elimination
Method: BSC
Site:
N/A

Capillary
Refill:
< 3SEC

Pitting: Yes No X
Degree: N/A

IBW
59 KG

Site: N/A

Cardiac Monitor: Yes X

No
Telemetry Rhythm: NORMAL
SINUS with pvcs
Monitor #48

Urine
Output:
N/A

SCD/PAS Hose:
No X
TED Hose
Yes No X

Left: +2

Yes

Oral Fluid
Percent Eaten:
Intake:
Bkfst: 50%
860 ml
LUNCH: 50%
Partials or
Abdomen: SOFT, NONDentures:
TENDER
NONE
Rate: N/A
Site &
Appearance: N/A
Color: N/A
N/A

Suction N/A

Last BM: 2/10/216

Placement

Bristol Stool Type: 6

Color: BROWN

Bowel Sounds: NORMAL BOWEL SOUNDS

HEARED X 4 QUADS
Collection Device
Stoma Appearance:
N/A
Change Due: N/A

Foley
Catheter:
YesNo X

Secured:
Yes No
N/A

Collection Device
N/A
Change Due: N/A

Urine
Output
525 mL

CBI:
Urine
Yes
Color:
No
CLEAR
N/A
ORANGE
Stoma Appearance: N/A

Car10

Protection
Braden Scale:
16/AT RISK

Restraints:
Type: N/A

Seizure
Precautions:
Yes No X

Isolation: Yes No X
Type: N/A
Organism: N/A
Location:
N/A
Skin Color:
Texture: SMOOTH
Condition:
Turgor:
PALE
THIN
ELASTIC
Surgical Drain: Yes No X
Site: N/A
Drainage Color: N/A
Type of Drain: N/A
Amount: N/A
Wound Vac: N/A
Wound Care Orders: N/A
Location : N/A Drainage: N/A
Musculoskeletal
Ordered Activity:
Fall Risk Score: 18
Johns CSMs Intact:
OOB TID
Hopkins
Yes X No
Posture: SLIGHT KYPHOSIS
Heat or Cold therapy: N/A
Strength: WEAK
Gait: SLOW, STEADY
ROM: ACTIVE
Aids/Appliances: WALKER
Intravenous Therapy
Location Site#1:
Size: 18 Type: INT
Location
Size: N/A
Type:
LEFT UPPER ARM
Site #2: N/A
PIV
Insertion
Site Care
Insertion
Site Care Due:
Date: 2/9 BY PICC TEAM
Due: 2/12
Date: N/A
N/A
Primary IVF: N/A
IV Intake:
Other IVF: N/A
IV Intake:
N/A
N/A
Site & Appearance: BRUISING Tubing
Site &
Tubing
AROUND SITE, FLUSHES
Labeled:
Appearance: N/A
Labeled:
WELL, NO EDEMA//PAIN
Yes No X
Yes X No
Patient Controlled Anesthesia
Medication: N/A
Basal
Rate: N/A

Demand
Dose: N/A

Pain Assessment
Pain:
Pain Scale: 6
Yes X No
Numeric 1-10
Acute Chronic X
Med given:
PERCOCET
Med given:
PERCOCET

Dose:
5MG
Dose:
5MG

Time:
0725
Time:
1130

Follow up
PRS: 4
Follow up
PRS: 3

Freq: N/A Lockout:

N/A

Attempts: N/A
Injections: N/A
Total given:
N/A

Site:
Duration: Intermittent,
BACK &
BURNING/CRAMPING
RIGHT 1ST
TOE
Non-Pharm
Intervention: BACK RUB,
REPOSITIONED AND TURNED EVERY
2 HRS

Car11

STUDENT: MELISSA GALENTINE

DATE: 2/10/2016
Date/Time
Narrative Day 2
00810
Resting in bed. V/S: B/P 162/88 , Temperature 97.6/Orally. Alert and oriented x3.
2/10/16
PERRLA 3mm with consensual reaction, wears glasses for reading. Speech clear,
symmetrical facial features. Mucous membranes pink, dry, and intact. Natural teeth in
good condition. Apical heart rate 74 beats per minute, regular rhythm with occasional
PVC's, S1 and S2 audible with audible murmur. Telemetry monitor #48 in place.
Respiratory rate 18 breaths per minute, regular rhythm, normal depth and unlabored.
Lung sounds clearer bilaterally with rhonchi heard in upper bronchial branches on
inspiration. O2 saturation at 94% on RA. Capillary refill < 3 sec. Denies dyspnea.
Even/shallow/unlabored breathing. Occasional productive cough with thick yellow
sputum. Abdomen slightly round, symmetrical, with normo-active bowel sounds x4
quadrants on auscultation. Soft to palpate, denies tenderness. Sts Im not nauseated
today Ate 50% of Regular diet for breakfast. BM this AM small amount of mucous,
fluffy, brown liquid stool. Posture upright. Ambulates with walker. Gait slow steady. Full
active range of motion of upper and lower extremities. Sts I feel better today. Denies
tenderness or pain in joints. No edema to lower legs/ankles, erythema noted in joints of
upper or lower extremities. Bilateral grips strong and equal. Upper extremities strong
and equal bilaterally, Left Lower Extremity strong. Right lower extremity slightly
weaker, ace bandage to right ankle/foot with bruising to both foot/ankle. Elevated on
pillows with heel off bed. Bilateral radial pulse 2+ and dorsalis pedis pulses 2+ on
palpation. Skin pale, warm, dry to touch and intact, turgor elastic. Several small areas
of purpura noted on both forearms and hands. Patient states I am on a blood thinner.
Transparent dressing over #18 ga. INT site present in Left upper arm clean, dry and
intact, cathlon flushes well with blood return. Bruising noted around injection site, no
swelling/redness noted denies pain. 350ML Clear yellow urine in bedside commode.
Denies pain/burning with urination. Lying supine with head of bed at 45 degreess, no
request at this time. Side rails up x2. Call light in reach. Bed locked in low position.
M. Galentine LMU-NS ------------0950

1150
1310

Completed self-bath while sitting in chair, assisted with washing and lotion to back, tol
well. Bed lines changed. Will ice water. i think I will sit up a while Family at bedside.
Call light within reach. No requests at this time. ---------M. Galentine LMU-NS---------------------------------------------------------------------Up to BSC voiding 225 clear yellow urine. Assisted back to bed, tol well. Positioned for
comfort. Side rails up x2. Call light in reach. Bed locked in low position. M. Galentine
LMU-NS -------------------------------------------------Sitting up on side of bed. Removed lunch with 50% ate. Im going to take a nap now.
No requests at this time. Side rails up x2. Call light in reach. Bed locked in low
position. M. Galentine LMU-N ------------------------------------------

Car12

LINCOLN MEMORIAL UNIVERSITY

Caylor School of Nursing
Comprehensive Medication List for the Project ONLY
Student Name: MELISSA GALENTINE
Name of Medication
Generic & Trade
AZITHROMYCIN/
ZITHROMAX
RIVAROBABAN/
XARELTO
GABAPENTIN/
NEURONTIN
GUAIFENSON/MUCINEX

Classification
Functional &
Chemical
ANTI-BACTERIAL

DATE: 2/9/2016

Dose

Route

Time

Home
Med

500mg

IV

2100

NO

ANTI-COAGULANT

75mg

PO

0900

YES

ANTICONVULSANT
EXPECTORANT

100mg

PO

2100

YES

600mg

PO

NO

LEVOTHYROXINE/
SYNTHROID
SIMVASTATIN/ZOCOR

THYROID
HORMONE
ANTI-LIPIDEMIC

150mcg

PO

0900
2100
0900

YES

20mg

PO

2100

YES

METOPROLOL/TOPROL

BETA BLOCKER
ANTI-HTN
DIURETIC

50mg

PO

YES

25mg

PO

0900
2100
0900

OPIATE

5mg

PO

YES

ANTI-EMETIC

4mg

IV

PROMETHAZINE/
PHENERGAN

ANTI-EMETIC/
ANTI-HISTAMINE

6.25mg

IV

IPRATROPIUM/ATROVENT

BRONCHODILATOR

3ML

INHALATION

PIPERACILLIN-TAZOBACTAM
ZOSYN

ANTI-INFECTIVE/
PENICILLIN

3.375M
G

IV

EVERY
6HRS
PRN
EVERY
12HRS
PRN
EVERY
6HRS
PRN
EVERY
4HRS
PRN
06:00
12:00
18:00
00:00

HYDROCHLOROTHIAZIDE/
DIAZIDE
OXYCODONEACETAMINPHEN;
PERCOCET
ONDANSETRON/ ZOFRAN

YES

NO
NO
YES
NO

Car13

LINCOLN MEMORIAL UNIVERSITY

Caylor School of Nursing
Comprehensive Project: Nursing Health History
STUDENT NAME: MELISSA GALENTINE

Date of Care: 02/09-10/2016

Clinical Supervisor: KIN SINGLETON, RN

Facility: BLOUNT MEMORIAL

BIOGRAPHICAL DATA
Gender: F
Marital Status:
WIDOWED
Fixed Income: Yes X No
PRESENT ILLNESS DATA
Date of Admission: 02/02/2016

Medical Diagnosis on Admit #1

PYELONEPHRITIS
Pathophysiology of Diagnosis #1:
Kidney infection (pyelonephritis)
is a specific type of urinary tract
infection (UTI). Typically occurs
when bacteria enter your urinary
tract through the tube that carries
urine from your body (urethra)
and begin to multiply. Typical
symptoms include:

Fever

Back, side (flank) or groin

pain

Abdominal pain

Frequent urination

Strong, persistent urge to

urinate

Ethnicity:
Religion:
CAUCASION
BAPTIST
Access to Healthcare:
Yes X No

Occupation:
HOUSEWIFE
Insurance/Supplements:
MEDICARE

Health Care Provider:

DR LONG
Consults: GI/ ORTHO

Reason for Admission:

WEAKNESS, CONFUSION,
FALLS

Medical Diagnosis on Admit # 2

PNEUMONIA
Pathophysiology of Diagnosis #2:
Pneumonia is an infection that
inflames the air sacs in one or both
lungs. The air sacs may fill with fluid
or pus (purulent material), causing
cough with phlegm or pus.
Fever
Chills
Difficulty breathing.
A variety of organisms, including
bacteria, viruses and fungi, can cause
pneumonia. (Mayo Clinic Staff,
2015)

Medical Diagnosis on Admit # 3

N/A
Pathophysiology of Diagnosis #3:
N/A

Car14

Burning sensation or pain

when urinating

Pus or blood in your urine

(hematuria)

Urine that smells bad or is

cloudy

A variety of organisms, including

bacteria, viruses and fungi, can
cause pneumonia. (Mayo Clinic
Staff, 2014)

HEALTH HISTORY DATA

Advance Directive:
Yes
Medication Allergies:
AMIODARONE
DEMEROL
PCN
PROPAFENONE

Healthcare POA:
Code Status:
Yes
Full Code
Reaction specific to each medication:
AMIODARONE - SVT
DEMEROL NAUSEA/VOMITING
PCN - RASH
PROPAFENONE - ANAPHYLAXIS

Tobacco Use: No
ETOH Use: No

# PPD N/A
# Years N/A
Type/Amount: N/A

#Years Quit N/A

Frequency N/A

Recreational Drug Use: No

Type/Amount: N/A

Frequency N/A

Childhood Illnesses:
PNUEMONIA
FX T-SPINE
CHICKEN POX
MEASLES

Recent (past year)

Hospitalizations:
PNEUMONIA
ORIF RIGHT HUMERUS

Last Tetanus vaccine: 2012

Last Flu vaccine: 10/2015

Surgical History:
LAMINECTOMY
HYSTERECTOMY
C-SECTION
APPENDECTOMY
BOWEL RESCECTION
EGD
COLONOSCOPY

Last Pneumonia vaccine:2012

Car15

Personal/Family History (Include Type of Disease in Each Column):

D
e
c
e
a
s
e
d

N
e
u
r
o

Car
diac

Endo

A-FIB

HypoThyroid

GI

G
U

MS

Resp

Chroni
c Pain

S
k
i
n

Mental
Illness

GERD

N/A

MuliOrthoFx

COPD

BACK
PAIN

N/
A

Depression

N/A

N/A

Hip
Fractur
e

N/A

N/A

N/
A

Depression

Self

N/A N/A

Mother

yes

CV
A

N/A

HypoThyroid

Father

yes

N/A

A-FIB

N/A

NIDD

BPH

N/A

COPD

N/A

N/
A

N/A

Siblings

yes

CV
A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/
A

N/A

SELF-CONCEPT MODE
Describe Spiritual Beliefs:
Baptist

Satisfied with Spiritual Self:

Sts I am ready to go home to
my fathers

Eriksons Developmental Stage:

Recent Major Life Changes:

Education/Discharge Needs:

Deficit: Yes X No

Husband died in 2015, Son

moved in with Her.

Being discharged to
Rehabilitation Center for
Physical Therapy of Right foot
and to regain strength.

ROLE FUNCTION MODE

Primary Role: Mother, Friend

Secondary Role: Caregiver

Discharge Planning Needs: Daily ADLs, increased nutritional

needs, Ambulating with assistance

Integrity vs. Despair

Anticipate Change in Role: Need of

support from family, reversal in role
of caregiver to patient
Deficit: Yes No X

INTERDEPENDENCE MODE
Significant Other:

Support System at home:

Community Support Systems:

Car16

Cultural Beliefs (affecting care):

HUSBAND DEASED

Discharge Placement: 2
Sons, 2 Daughters. A son will
move in with patient

Deficit: Yes No X

PHYSIOLOGIC/PHYSICAL MODE: NEUROSENSORY

History of Neurosensory Problems:

Neurosensory Lab/Diagnostics:

Acute Pain: Yes X No

Current pain or neurosensory

medications:

Relief Measures: PERCOCET

Location & Characteristics: RIGHT FLANK

Chronic Pain: Yes X No

Relief Measures: REPOSITIONING, OPIATES

Location & Characteristics: LOWER BACK PAIN

Exacerbation(s): LAYING OR SITTING IN ONE POSITION TO LONG
Educational/Discharge Needs:
USE OF WALKER,
TRANSFERING, NON OPIATE
PAIN CONTROL

Assistive devices: WALKER

Deficit: Yes No X

BEDSIDE COMMODE

OXYGENATION: RESPIRATORY
History of Respiratory Problems:
COPD USES OXYGEN AT
NIGHT WHILE ASLEEP

Respiratory Lab/Diagnostics:
CXR CHRONIC
OBSTRUCTIVE PULMONARY
CHANGES

Education/Discharge Needs: USE OF INCENTIVE SPIROMETER

Current Respiratory Medications:

ALBUTERAL NEB TX EVERY 6
HOURS FOR PAIN
Deficit: Yes X No

OXYGENATION: CARDIAC
History of Cardiac Problems: AFIB, BRADY CARDIA

Cardiac Lab/Diagnostics: EKG,

Education/Discharge Needs: LOW SODIUM, LOW FAT DIET

Current Cardiac Medications:

METOPROLOL
Deficit: Yes No X

NUTRITION: GASTROINTESTINAL
Recent Gains & Amount: 0lbs
Recent Losses & Amount: 3bls

Gastrointestinal Lab/Diagnostics
(Include Date & Result): N/A

Current Type of Gastrointestinal

Medications: OMEPRAZOLE

Diet: REGULAR

Food Allergies: NONE

Restrictions: (Fluid and/or Calorie)

N/A

Supplements: NONE

Car17

Chewing/Swallowing Difficulty:
NONE

Education/Discharge Needs:

Deficit: Yes No X

NONE

Pain or Discomfort r/t Oral Intake:

NONE

ELIMINATION: GASTROINTESTINAL
History of Gastrointestinal
Problems: BOWEL
OBSTRUCTION

Gastrointestinal Lab/Diagnostics:
FLAT/UPRIGHT ABD: NON
SPECIFIC ABDOMEN

Current GI Medications:
OMEPRAZOLE

Last BM: 2/10/2016

Normal pattern of elimination:

SOFT, FORMED

Screening procedures: NONE

Education/Discharge Needs: FLUID INCREASE, HIGH FIBRE

Deficit: Yes No X

ELIMINATION: GENITOURINARY
History of Urinary Problems:

Genitourinary Lab/Diagnostics:
URINE CULTURE GRAM
POSITIVE COCCI

Education/Discharge Needs: PERI HYGIENE

Current Genitourinary Medications:

LEVAQUIN
Deficit: Yes No

PROTECTION
History of Skin Problems:
(i.e. Burns, Lacerations, Lesions, Incisions, Scars, & Ulcerations Location, Appearance, & Treatment)
Current Medications:

Education/Discharge Needs:

Deficit: Yes No

History of Mobility Problems:

Current Exercise Regimen:

Leisure Activities:

Current Medications:

Education/Discharge Needs:

Deficit: Yes No

Hours of Nighttime Sleep:

Quality:

ACTIVITY AND REST: MOBILITY

SLEEP
History of Sleep Problems:

Naps: Frequency and Length

Current Sleep Medications:
Education/Discharge Needs:

Environmental Disturbances:

Sleep Rituals:
Deficit: Yes No

Car18

References
Ackley, B. J. (2014). Nursing Diagnosis Handbook. Maryland Heights: Mosby El Sevier.
Mayo Clinic Staff. (2014, August 16). Diseases and Conditions Kidney Infection. Retrieved from Mayo
Clinic: http://www.mayoclinic.org/diseases-conditions/kidney-infection/basics/causes/con20032448
Mayo Clinic Staff. (2016, March 14). Mayo Clinic Diseases - Conditions, Pneumonia. Retrieved from
Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/pneumonia/basics/definition/con20020032
Pagana, Pagana, & Pagana. (2015). Mosby's Diagnostic & Laboratory Test Reference. St. Louis: El
Sevier.
Solway, S. M. (2002, July 1). American College of Chest Physicians. Retrieved from
www.journal.publications.chestjournal.org:
http://journal.publications.chestnet.org/data/Journals/CHEST/21980/56.pdf?resultClick=3

19

LINCOLN MEMORIAL UNIVERSITY

Caylor School of Nursing
Grading Rubric - NURS 124/125 Comprehensive Nursing Project
Student:_______________________________________Clinical Supervisor:___________________________
4 points
3 points
2 points
1 point
0 point
Clearly and accurately
Clearly stated;
Ambiguously stated;
Poorly stated;
Information
stated; well-organized;
organized; incomplete slightly organized;
Unorganized; incomplete
not included in
complete; appropriate use with 1-5 omissions or
incomplete with 6-8
with greater than 9
project.
of terminology; shows
inappropriate uses of
omissions or inappropriate
omissions or inappropriate
excellent understanding of terminology
use of terminology; logical
use of terminology; does not
the project
but lacks depth.
answer specific questions
Nursing information required on assigned patient/resident is specified below. 100 points total per Rubric above. Minimum of 80
points required to be satisfactory. To be graded by Clinical Supervisor. Please include this rubric in your envelope when turning
in.
1.
Nursing History
a.
Educational/Discharge Teaching Needs ... __________ points
b.
Incorporation of Lab/Diagnostics . . __________ points
c.
Incorporation of Current Meds . __________ points
2.
Nursing Assessment
a.
Physical Assessment Day 1 with narrative.. __________ points
b.
Physical Assessment Day 2 with narrative
__________ points
3.
Medication Sheets
a.
Comprehensive Medication List (including routine and PRN medications) __________ points
b.
Medication Worksheets (Personalized to patient/resident) with Citations.. __________ points
4.
Concept Maps
a.
Nursing Diagnosis #1 Physical (Physiological Mode) numbered by priority.. __________ points
b.
Assessment information pertinent ton Nursing Diagnosis ....__________ points
c.
Outcomes and Evaluation (Short Term & Long Term) .... .. __________ points
d.
Nursing Interventions.......
__________ points
e.
Rationale (for each Nursing Intervention) with Citations...
__________ points
f.
Nursing Diagnosis #2 Physical (Physiological Mode)numbered by priority.__________ points
g.
Assessment information pertinent to Nursing Diagnosis ...__________ points
h.
Outcomes and Evaluation (Short Term & Long Term) ..
__________ points
i.
Nursing Interventions ...
__________ points
j.
Rationale (for each Nursing Intervention) with Citations __________ points
k.
Journal article (appropriate article, cited correctly with at least one intervention
of priority diagnosis) __________ points
l.
Oral Presentation: 20 minutes (professional appearance, eye contact, communication skills) __________ points
m.
Visual aid: poster and/or handouts to use with presentation (creativity, visual appeal) __________ points
5.
Lab/ Diagnostic Sheet (Rationale/Nursing Implications for Abnormal Labs)
a.
All columns completed or marked N/A . __________ points
b.
Rationale & Nursing Implications for All Abnormal Labs
__________ points
6.
Professional Submission
a.
Title Page and Reference Page.
__________ points
b.
APA format, correct grammar, spelling, punctuation, spacing, and neatness.
__________ points
c.
All areas addressed in each section (history, concept map, lab/diagnostic, medication sheets) __________ points
Points Earned: (First Attempt)
Points Earned: (Second Attempt)

Days Late (1 point per day deducted)

Later than 1 week = zero for entire care plan

Grade
Rework Grade

20