Report Venable Year Question & Answer Guide (With Explanation)

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Break the problem into smaller parts and analyze each logically.

Key Explanation

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Original Question

1-3. Report: Mr. Venable is a 72-year old male patient admitted on 5/21/22 with dehydration due to working in the heat on his farm. He is a full code and is allergic to codeine. He has a history of uncontrolled Type 2 diabetes current BS 356, HTN current BP is 106/68, and 5 vessel CABG. Mr. Venable is on a diabetic diet, but is noted to be noncompliant and snacks on candy bars and chips frequently. He has an IV of NS infusing at 75mL/hr. to the right forearm. He is on room air O2 Sat is 97%. Pt. ambulates independently and is up ad lib. 4. Medications: a. Metformin 1000 mg BID b. Lopressor 50 mg BID c. Hyzaar 100/25 mg daily d. Vitamin D 5000 IU daily e. ASA 81 mg every other day f. Lantus 40 units at HS 5. Chest X-Ray clear 6. Physical Assessment: a. Sitting in chair eating breakfast b. Alert oriented X4 c. V/S: HR68, RR14, POX97% RA, BP 106/68, Pain 0/10 d. PERRLA e. Mucous membranes dry double furrowed tongue, own teeth f. Skin warm, dry, intact, and tenting noted, capillary refill 5 seconds in all extremities g. Grips and muscle strength strong X4 extremities h. S1S2 apical 68 i. Lungs clear throughout all lobes j. Abdomen bowel sounds active X4 quadrants, soft and nontender, last BM soft this AM k. Bladder nonpalpable urine dark amber l. All pulses +2 m. Active ROM X4 extremities, ambulates independently gait steady n. Denies needs at this time 7. See #6 above 8. See report #1-3 above 9. Lab Values: a. BS 356 b. BUN 30 Creatine 1.6 10-11. List your goals. Be sure to prioritize based on your patient’s condition. Your goal must be specific, reasonable, measurable, and within timeframe. 12. List at least 3 implications/interventions to meet each goal. 13. Morse Fall Scale: Mr. Venable had a previous fall from a scaffold. Complete based on report information. 14. Braden Scale: Complete based on report information 15. Record NA for the mock chart

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