In week 1 of clinical, I was assigned to an 82-year-old female who was admitted on February 15th for RFV Acute purpulent bronchitis Leukocytosis. She has multiple secondary diagnoses as well, such as, dementia, pneumonia, throat cancer, stricture of the epiglottis, and more. During my shift she had four types of medications, Cefepime, Heparin, Levothyroxine, and Pantoprazole. She is also a NPO patient and continuously asked for food and water. The nurse pointed out edema on her arm and elbows because the IV fluids were not going to her hands. Also some bruising and erythema on her left shoulder and her coccyx area.
Next, her lab tests showed a high WBC count at 23.1 thousand/mCL and a high neutrophil count at 22.0 thousand/mCL. Because of …show more content…
I noticed my patient had a cough and had the suctioning machine at her bed side. Overall though, her lung sounds were clear and had an unlabored respiratory effect. Personally, I did not think her cough was severe. She has a minimal cough, without reading her record I would have never guessed she had two respiratory infections. Lastly, one out of her two nursing diagnosis is risk for falls. My patient has a Morse Fall Score of 85. That is at high risk and requires high risk fall prevention interventions. My patient has a restrict order from the doctor stating her all four of her bed rails to be up at all times. In front of her bed is a camera, monitoring her movements at all times. She also should not be leaving her bed unless a health care provider is there to assist her. Another nursing diagnosis is risk for impaired skin integrity. Her Braden Scale score was 13. She is at moderate risk and should use interventions such as, turning patient on a regular schedule, monitor site of skin impairments, skin products, and continence status, protecting any bony prominences, use pressure-redistribution surfaces, and manage moisture, nutrition, friction, and shear. We provided my patient with an adhesive pad for her coccyx to prevent further
Next, her lab tests showed a high WBC count at 23.1 thousand/mCL and a high neutrophil count at 22.0 thousand/mCL. Because of …show more content…
I noticed my patient had a cough and had the suctioning machine at her bed side. Overall though, her lung sounds were clear and had an unlabored respiratory effect. Personally, I did not think her cough was severe. She has a minimal cough, without reading her record I would have never guessed she had two respiratory infections. Lastly, one out of her two nursing diagnosis is risk for falls. My patient has a Morse Fall Score of 85. That is at high risk and requires high risk fall prevention interventions. My patient has a restrict order from the doctor stating her all four of her bed rails to be up at all times. In front of her bed is a camera, monitoring her movements at all times. She also should not be leaving her bed unless a health care provider is there to assist her. Another nursing diagnosis is risk for impaired skin integrity. Her Braden Scale score was 13. She is at moderate risk and should use interventions such as, turning patient on a regular schedule, monitor site of skin impairments, skin products, and continence status, protecting any bony prominences, use pressure-redistribution surfaces, and manage moisture, nutrition, friction, and shear. We provided my patient with an adhesive pad for her coccyx to prevent further