Assessment Enter Problem Explained for Students (Easy Guide)

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Original Question

o For Assessment, enter 1 problem you see from patient chart (example: Low Calcium level) o For Diagnosis, enter 1 NANDA nursing diagnosis connecting to the assessment (example: Nutrition Imbalanced: Less Than Body Requirements relating to ?? as evidence by ??) o For Outcomes/Planning, enter 1 outcomes/planning connecting to the assessment. Must be realistic, measurable, with a time frame. (example: pt’s calcium level will be ??? by the end of the shift or in 2hrs or etc) o For Interventions, enter 3 non-pharmacological interventions, 3 pharmacological intervention, and 1 consult referral connecting to the assessment Example: Non-pharm = teach about diet, provide calcium rich food, educate about ??? Pharm = Calcium supplements, Vit D, and ??? Consult = dietician o For Evaluation, describe the outcomes Primary Concern: Sepsis The Patient Summary is read only! To add or edit data you must open another page by clicking the appropriate tab to the left. Vital Signs 02/01/2022 1256 02/01/2022 1311 Heart Rate 72 100 Blood Pressure 96/48 94/44 Respirations 20 26 Temperature 99.4°F (Axillary) 100°F (Axillary) SpO2 (%) 97% 97% Pain Allergies Allergy Date Noted Reaction Meperidine 43 years ago Confusion Orders Type of order to view: All DietImagingLabMedicationNursing/Other OrdersRespiratory Search: Show 102550100 entries Previous 1 2 3 Next Start Date Order Details Status All ActiveCompleted 02/01/2022 1256 (LEVAQUIN) LEVOFLOXACIN IN DEXTROSE 5% IVPB/DRIP Written order Dose/Frequency: 500 mg Every 24 Hours Route: IVPB Start Date: 02/01/2022 1256 End Date: Give first dose after cultures and then q 24 hours. Infuse over 90 minutes. Active 02/01/2022 1256 0.9% SODIUM CHLORIDE (NACL) Written order Dose/Frequency: Continuous Rate: 125 mL/hour Route: IV Start Date: 02/01/2022 1256 End Date: Start maintenance fluids after fluid bolus is complete. Active 02/01/2022 1256 0.9% SODIUM CHLORIDE (NACL) Written order Dose/Frequency: 30 mg/kg Once Route: IV Start Date: 02/01/2022 1256 End Date: Give 0.9% NS IV fluid bolus of 30 ml/kg STAT Active 02/01/2022 1256 ACETAMINOPHEN Written order Dose/Frequency: 650 mg Every 6 Hours PRN Route: Rectal Start Date: 02/01/2022 1256 End Date: As needed every 6 hours for temperature greater than 100.4 degrees Fahrenheit Active 02/01/2022 1256 Activity-Bedrest Written order Frequency: Continuous Start Date: 02/01/2022 1256 Active 02/01/2022 1256 Admit to Telemetry Written order Frequency: Once Start Date: 02/01/2022 1256 Active 02/01/2022 1256 Arterial Blood Gases (ABG) Written order Frequency: Once Start Date: 02/01/2022 1256 Call respiratory to draw ABGs Active 02/01/2022 1256 Blood Cultures X2 Written order Frequency: Once Start Date: 02/01/2022 1256 Active 02/01/2022 1256 Cardiac monitor Written order Frequency: Continuous Start Date: 02/01/2022 1256 Active 02/01/2022 1256 Complete Blood Count (CBC) with differential Written order Frequency: Once Start Date: 02/01/2022 1256 Active 02/01/2022 1256 Prothrombin Time and International Normalized Ratio (PT/INR) Written order Frequency: Once Start Date: 02/01/2022 1256 Active 02/01/2022 1256 Pulse Oximetry-Continuous Written order Frequency: Continuous Start Date: 02/01/2022 1256 Active 02/01/2022 1256 Sequential Compression Device Written order Frequency: Continuous Start Date: 02/01/2022 1256 Active 02/01/2022 1256 Urinalysis (UA) Written order Frequency: Once Start Date: 02/01/2022 1256 Active 02/01/2022 1256 Urine culture and sensitivity Written order Frequency: Once Start Date: 02/01/2022 1256 Active 02/01/2022 1256 Vital signs Written order Frequency: Other-See Comments Start Date: 02/01/2022 1256 Every 15 minutes Active 02/01/2022 1256 X-Ray: Chest Anterior and Posterior Written order Frequency: Once Start Date: 02/01/2022 1256 Completed Chest X-ray No indication of masses or pleural spacing in all fields. No cardiomegaly noted. POSITIVE: Patches of infiltrates bilaterally. 02/01/2022 1311 Nursing Note Nurse Amalia Bayt, RN Transferred to Telemetry unit. Continues to deteriorate in mental status. Confused to situation, year, and place. Assessment otherwise unchanged from initial presentation. SBARR given to floor RN. 02/01/2022 1301 Nursing Note Nurse Amalia Bayt, RN Presented to the emergency department via ambulance. Nurse from LTC reported new onset of confusion on prior shift. Pt is confused to person place and timer. Patient denies pain. Allergic to Demerol. ID band has been applied. Patient has a DNR in place. Notarized documentation of DNR has been provided to hospital by LTC facility. 02/01/2022 1256 Progress Note Physician Ahn Phung, DO Ms. Jackson presents to the emergency room for altered mental status. Primary care nurse at long-term care facility reported the altered mental status overnight. Transferred to this facility via ambulance. Oriented to self, confused to situation, year, and place. Pupils 5mm and reactive. Breath sounds clear bilaterally. S1S2 noted with controlled atrial fibrillation noted on telemetry. Moves all four extremities. Pulses palpable all 4 extremities. Decreased urinary output reported by LTC facility nurse. No urine noted since arrival. Last bowel movement unknown. Bowel sounds all four quads active. Orders placed. Hypertension Date of diagnosis: 40 years ago Details and treatments: SNF reports pt has hx of HTN but takes no Rx for HTN or Afib Dementia Date of diagnosis: 10 years ago Details and treatments: Atrial Fibrillation Date of diagnosis: 20 years ago Details and treatments: SNF reports pt has hx of A-fib but takes no Rx for HTN or Afib Vision Impairment Wears glassesHearing Impairment Has hearing aids, but refuses to wear them MA 02/01/2022 1316 Hypertension Family members affected: Pt’s Mother Vascular Disorders Family members affected: Pt’s Father Informant(s) Informant-If not patient (Name and relationship) Admission Problems Chief Complaint Fever and Altered Mental Status Primary Concern – Admission Diagnosis Sepsis Other Problems/Diagnosis History of Present Illness/Injury Location (Where are the symptoms located? Are they local or do they radiate?) Symptoms are systemic Duration (When did it start? How long has this problem existed? Is it getting worse? Changing?) Primary care nurse at long-term care facility reported the altered mental status overnight. Timing (When does it occur? Night or day? At work? etc.) Constant Quality (Characteristics such as constant, sharp, dull, sore) Constant Severity (How bothersome is the problem? Can you sleep, work, etc?) Symptoms are severe Describe this illness/injury related to how and where this problem began. Patient with underlying dementia, noted to have increased altered mental status with fever starting last night at the long term care facility. What makes this problem worse or better? Tylenol helped with the fever. Last dose given at midnight. Signs and Symptoms Fever, altered mental status Comments Allergies Meperidine Date allergy noted: 43 years ago Confusion Admission Data Does patient require interpretive services? If so, make appropriate selections. No Interpretive Services Comments Admitted Via Ambulance Admitted From Long-term care facility Contact Person Daughter- Jessica Cohen (Medical Power of Attorney) Orientation to Environment No smoking policy, Intercom/bed controls, Call light/bedside and bathroom, Phone/TV, Visiting hours Belongings Accompanying Patient Glasses Valuables – Disposition None Valuables – Comments Advanced Directives – Which do you have? Do not resuscitate (DNR) Advanced Directives – Comments Additional Demographic Info Marital Status Widow Is English the Primary Language? Yes Preferred Language if Not English Educational Level Bachelor Degree Religion/Spirituality Baptist Occupation Retired School Teacher Race/Ethnicity Hispanic or Latino Comments Home Medication List Past Medical History Hypertension Date of diagnosis: 40 years ago Details and treatments: SNF reports pt has hx of HTN but takes no Rx for HTN or Afib Dementia Date of diagnosis: 10 years ago Details and treatments: Atrial Fibrillation Date of diagnosis: 20 years ago Details and treatments: SNF reports pt has hx of A-fib but takes no Rx for HTN or Afib Past Surgical History Family History Vascular Disorders Family members affected: Pt’s Father Hypertension Family members affected: Pt’s Mother Immunization Screen-Add details to Immunization Record tab if available. (example dates) Immunization Schedules from CDC – Click Here Tetanus Influenza Pneumococcal Hepatitis B DPT Polio (IPV) Chicken Pox (Varicella) Measles, Mumps, Rubella (MMR) Additional immunization, Comments

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