Student Name Date Assignment Help: How to Answer This Question

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Original Question

Student Name Date of Care 5/15/2025 Patient Initials TEG Date of Admission 5/10/2025 Patient Gender Male Patient Age 80 years old Room/Bed # Room 506 Code Status Full Code Height 185.4 cm Weight 95.4kg Race/Ethnicity White-Caucasian BMI 27.75kg/m2 Marital Status Widowed Religion Other Isolation Precautions Choose an item. none ALLERGIES TYPE NAME REACTION Medication Codeine rash Medication Darunavir rash Medication Sulfa rash Primary Admitting Diagnosis Dizziness, dehydration, hypotension, Diabetic foot infection, cellulitis; left foot 3rrd toe RELEVANT Past medical and Surgical History (Month/Year) BPH, Carotid artery Stenosis, CKD, COPD, CAD, HLD, PAD, Stroke, HTN, and sleep apnea VITAL SIGNS DATE Temp HR B/P RESP SpO2 Notes Time of Day 5/15/2025 98.1F 75 76/56 12 95% Time of Day 5/15/2025 98.0F 75 80/72 13 96% Time of Day 5/15/2025 98.1F 76 85/56 13 96% NEUROLOGICAL ASSESSMENT ☒Orientated ☐ Disoriented ☒ Person ☒ Time ☒ Place ☒ Situation ☐Calm ☐ Cooperative ☐Restless ☐ Combative ☐Confused ☐Agitated ☐ Withdrawn CARDIOVASCULAR Heart Tones ☒Regular ☐ Irregular ☒ S1 ☒ S2 ☐ S3 ☐S4 Gallop ☐ Distant ☐ Murmur ☐ Muffled Pulses All LUE RUE LLE RLE Absent ☐ ☐ ☐ ☐ ☐ Intermittent ☐ ☐ ☐ ☐ ☐ +1 ☐ ☐ ☐ ☐ ☐ +2 ☒ ☐ ☐ ☐ ☐ +3 ☐ ☐ ☐ ☐ ☐ Bounding ☐ ☐ ☐ ☐ ☐ Doppler ☐ ☐ ☐ ☐ ☐ Cap Refill Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. EDEMA ALL LUE RUE LLE RLE Absent ☒ ☐ ☐ ☐ ☐ Trace ☐ ☐ ☐ ☐ ☐ +1 ☐ ☐ ☐ ☐ ☐ +2 ☐ ☐ ☐ ☐ ☐ +3 ☐ ☐ ☐ ☐ ☐ +4 ☐ ☐ ☐ ☐ ☐ Non-Pitting ☐ ☐ ☐ ☐ ☐ Pitting ☐ ☐ ☐ ☐ ☐ Skin Color and Description (select all that apply) ☐ Appropriate for ethnicity ☐ Cyanotic ☐ Jaundiced ☐ Clammy ☒ Warm ☐ Diaphoretic ☐ Moist ☐ Fragile ☒ Dry ☐ Dusky ☐ Mottled Ashen ☐ Cool/Cold ☐ Flushed ☐ Pale ☐ Notes Respiratory Breath Sounds RUL LUL RML RLL LLL ☒ Anterior ☒ Anterior ☒ Anterior ☒ Anterior ☒ Anterior ☒ Posterior ☒ Posterior ☒ Posterior ☒ Posterior ☒ Posterior ☐ Clear ☐ Rales ☐ Crackles ☐ Rhonci ☐ Wheeze ☐ Coarse ☐ Inspiratory ☐ Expiratory ☐ Decreased ☐ Diminished ☐ Absent ☐ Stridor ☐ Clear ☐ Rales ☐ Crackles ☐ Rhonci ☐ Wheeze ☐ Coarse ☐ Inspiratory ☐ Expiratory ☐ Decreased ☐ Diminished ☐ Absent ☐ Stridor ☐ Clear ☐ Rales ☐ Crackles ☐ Rhonci ☐ Wheeze ☐ Coarse ☐ Inspiratory ☐ Expiratory ☐ Decreased ☐ Diminished ☐ Absent ☐ Stridor ☐ Clear ☐ Rales ☐ Crackles ☐ Rhonci ☐ Wheeze ☐ Coarse ☐ Inspiratory ☐ Expiratory ☐ Decreased ☐ Diminished ☐ Absent ☐ Stridor ☐ Clear ☐ Rales ☐ Crackles ☐ Rhonci ☐ Wheeze ☐ Coarse ☐ Inspiratory ☐ Expiratory ☐ Decreased ☐ Diminished ☐ Absent ☐ Stridor SPUTUM ☒ None ☐Clear/White ☐Blood streaked ☐Yellow ☐Rust colored ☐ Scant ☐Moderate ☐Copious OXYGEN ☐ Room Air ☒ % or LPM ____2______ Patient using oxygen at night ☒Nasal Cannula ☐T-Piece ☐Nasal Trumpet ☐Face Mask ☐ Non Re-breather ☐ Oral airway ☐ Trach Collar ☐ Other: ____________________ Notes: GASTROINTESTINAL DIET TYPE (Check all that apply) EMESIS ☐ Regular ☐ Bright Red Blood ☐ Clear Liquids ☐ Food ☐ NPO ☐ Bile/Green ☐ Tube Feed ☐ Coffee Ground Notes: carb diet GI Assessment: Appearance All Quadrant Bowel Sounds Soft ☒ Choose an item. ALL LUQ RUQ LLQ RLQ Flat ☐ Choose an item. Present ☒ ☐ ☐ ☐ ☐ Non Distended ☐ Choose an item. Hypoactive ☐ ☐ ☐ ☐ ☐ Non Tender ☐ Choose an item. Hyperactive ☐ ☐ ☐ ☐ ☐ Firm ☐ Choose an item. Absent ☐ ☐ ☐ ☐ ☐ Distended ☐ Choose an item. Notes: Round ☒ Choose an item. Rigid ☐ Choose an item. Tender ☐ Choose an item. Guarding ☐ Choose an item. Rebound ☐ Choose an item. PAIN ASSESSMENT Location Left foot Pain Type Acute Duration/Onset Before the amputation Pain Quality sharp Physical Signs of Pain none Alleviating Factors (nonpharmacological) none Interventions (Medication Name, dose, route) Tylenol 650mg oral Pain score ☐ ☐ ☐ ☐ ☐ ☒ ☐ ☐ ☐ ☐ ☐ 0 1 2 3 4 5 6 7 8 9 10 Pain Reevaluation ☐ ☐ ☒ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 0 1 2 3 4 5 6 7 8 9 10 Notes TUBING – Drains Drain/Tube/Line Location Drainage Type Site Assessment Choose an item. none Choose an item. none Choose an item. none VASCULAR ACCESS Type Size Location Date Inserted Site Assessment Peripheral 18G Left posterior forearm 5/10/2025 The site is clean and dry Choose an item. Click here to enter a date. Choose an item. Choose an item. Click here to enter a date. FALLS RISK Low Fall Risk ☐Yes ☐No Fall Prevention Measures Implemented ☐Yes ☐No Notes Moderate Fall Risk ☐Yes ☐No High Fall Risk ☒Yes ☐No **Fall risk based on facility/unit’s risk assessment tool** #1 Concept: perfusion Nursing Diagnosis (include r/t statement): #2 Concept: infection Nursing Diagnosis (include r/t statement): Assessments & Supporting Data for Nursing Diagnosis: (include normal & abnormal findings) Assessments & Supporting Data for Nursing Diagnosis: (include normal & abnormal findings) Male condom-external urinary Left foot third -amputate cellulitis Lab/Diagnostics: Lab/Diagnostics: x-ray Desired Outcome: Desired Outcome: Interventions Response to Interventions Interventions Response to Interventions Evaluation: Evaluation: #3 Concept: Metabolism Nursing Diagnosis (include r/t statement): #4 Concept: mobility Nursing Diagnosis (include r/t statement): Assessments & Supporting Data for Nursing Diagnosis: (include normal & abnormal findings) Assessments & Supporting Data for Nursing Diagnosis: (include normal & abnormal findings) Lab/Diagnostics: Lab/Diagnostics: Desired Outcome: Desired Outcome: Interventions Response to Interventions Interventions Response to Interventions Evaluation: Evaluation: # Concept: Nursing Diagnosis (include r/t statement): # Concept: Nursing Diagnosis (include r/t statement): Assessments & Supporting Data for Nursing Diagnosis: (include normal & abnormal findings) Assessments & Supporting Data for Nursing Diagnosis: (include normal & abnormal findings) Lab/Diagnostics: Lab/Diagnostics: Desired Outcome: Desired Outcome: Interventions Response to Interventions Interventions Response to Interventions Evaluation: Evaluation: # Concept: Nursing Diagnosis (include r/t statement): # Concept: Nursing Diagnosis (include r/t statement): Assessments & Supporting Data for Nursing Diagnosis: (include normal & abnormal findings) Assessments & Supporting Data for Nursing Diagnosis: (include normal & abnormal findings) Lab/Diagnostics: Lab/Diagnostics: Desired Outcome: Desired Outcome: Interventions Response to Interventions Interventions Response to Interventions Evaluation: Evaluation: Discharge Planning: Outcomes to meet @ d/c: Disposition/location/level of care: Anticipated Date Range: Learning Needs: Caregiver: Reflection on Learning: MEDICATION DATA SHEET Patient initials: Date: Medication name (trade & generic) Drug/Dose/Route/Frequency Include all current IV fluids and IV medications Therapeutic & Pharmacologic Classification Is this dose safe (Y/N) & Reason med ordered Drug/Food Interactions for this Patient What needs to be assessed before, during, and after giving this medication? List the THREE most common effects/adverse reactions to watch Tylenol 650mg oral PRN every 6 hours Atorvastatin 80mg nightly Ceftriaxone 2g IV nightly Metoprolol 25mg oral every evening 4 concepts Assessments & Supporting Data for Nursing Diagnosis on each concept 4 interventions and rationale on each concept Smart outcome goal for each concept Evaluation of each concept Fill out the medication sheet

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