NURSE 2645L Professional Nursing 1

WEEKLY WORKSHEET

STUDENT NAME: Harlie Silberman INTAKE: 1030 ml

DATE OF CARE: 3/15/18 OUTPUT: 900 ml & No seen BM
PATIENT INITALS: PP BKFT: 100%
DNR STATUS: DNR CC LUNCH: 100%
SAFETY CONCERNS: weakness/unsteady ACTIVITY ORDER: as tolerated
ALLERGIES: PCN, Bactrim, Keflex, & Septra # OF ASSIST: 1
Diet: NAS DEVICES: wheelchair/walker
IV: n/a

Vital Signs  BP: 118/56 TEMP: 98 PULSE: 69 RESP: 22 PAIN: 0

Primary Medical Diagnosis: CHF Congestive Heart Failure

Etiology: CAD, MI, HTN, Cardiomyopathy, Hyperthyroidism, Severe Anemia

Pathophysiology: a syndrome caused by a variety of abnormalities; the heart

muscle has reduced contractility leading to reduction in cardiac output (unable to
meet body’s peripheral demands)

All S&S’s of Diagnosis:

- Dyspnea
- Fatigue/Weakness
- Orthopnea
- Tachycardia
- Anorexia
- Weight loss
- Nocturia/oliguria
- S3 gallop
- Edema in lower extremities
- Congested cough
- Wheezing &/or Rales
Cause or Effect on Patient’s Present Condition:
- Pt is unable to walk long distances (dyspnea) & is on a No Added Salt
(NAS) diet

Secondary Medical Diagnoses: Pneumonia, BPH, Muscle Wasting & Atrophy,

Pleural effusion, Generalized muscle weakness, COPD, Macular Degeneration,
Anxiety disorder, HTN, GERD, Constipation, Hyperlipidemia, Diverticulosis of
intestine, Malignant Neoplasm of Prostate, Non-rheumatic Aortic Valve Stenosis
& Non-rheumatic Mitral Valve Insufficiency

Laboratory Data

Test Date Normal Value Results Reason for Abnormal

Values
WBC 9-18-17 4.5 – 10.8 k/cmm 5.7 WNL
HGB 11-7-17 14 – 18 g/dL 12.6 (LOW) Anemia, cancer, abnormal HGB,
bleeding, nutritional deficiency
HCT 11-7-17 42 – 54% 36.8% (LOW) Anemia, bleeding, nutritional
problems, destruction of RBC’s
GLUCOSE 12-7-17 70 – 100 92 WNL
Other:
BUN 12-7-17 7 – 25 mg/dL 18 WNL

GFR 12-7-17 >60 ml/min/1.732 69 WNL

Creatinine 12-7-17 0.6 – 1.3 mg/dL 1.0 WNL

Diagnostic Tests:

X-Ray 
- 2-18-18: evidence of joint effusion with anterior & posterior fat pads
positive in a recently nondisplaced fracture at radial head
- 2-19-18: no additional fracture
Chest X-Ray 
- 11-3-17: osseous structures appear intact, extensive pleural &
parenchymal scarring noted; no evidence of acute pulmonary-cardiac
disease, TB or a communicable disease
o Pt was complaining of SOB
- 11-14-17: minimal blunting of left sulcus & right sulcus (costophrenic)
suggesting atelectasis or minimal bilateral pleural effusions

TREATMENTS (INTERVENTIONS):

Treatment (Intervention) How Often Times Rationale

CMP
Gentle ROM for L Elbow
Crush meds & cocktails
unless contraindicated
Use generic equivalent’s
unless otherwise ordered
Go out on LOA with
medication unless
contraindicated
Bowel Routine as policy
Daily weight
Administer 4oz high fiber
juice if no BM in 48 hrs.
Pressure reducing mattress
to bed
Vital Signs
Q 3 mos 4x/year Monitor fluid balance, level of
electrolytes, kidney & liver function
Daily 7x/week Maintain flexibility & mobility at
joint; will help reduce stiffness of a
joint & keep it from contractures
- - Prevent choking or aspiration while
swallowing medication
- - Pharmacological effects of brand
name & generic often the same;
generic is cheaper
- - Allow the patient to have control &
ability to how to take medications
PRN PRN Prevent constipation, or Bowel
movements other than on the toilet
(prevent accidents)
Daily 7x/week Monitor for dietary insufficiencies,
malnutrition, &/or fluid water
retention
PRN PRN Decrease constipation, prevent a
fecal impaction and reduce
discomfort
Always Always Promote comfort for patient by
preventing skin breakdown, sores,
cuts, or wounds
Q month 12x/year Monitor heart functioning,
oxygenation, and respiratory rate
 HEAD to TOE Assessment
(highlight & explain abnormal assessment data)

Neuro/Mental: alert & oriented to person, place, & time; hand grasp equal
bilaterally; PERRLA - both pupils 3 mm with light & without 4 mm

Cardiovascular: S1/S2 heard & S3 present; 78 bpm Apical rate  irregular rhythm
- Irregular rhythm & S3  CHF
Peripheral/Vascular: carotid, radial & pedal pulses 2+ bilaterally. All pulses rate
on 0-3+ scale, Cap refill < 3 secs; Edema 2+ on left ankle foot; Pulse OX 97%
- Edema 2+ on left ankle foot  fluid retention r/t CHF

Respiratory: RR uneven & labored; lungs with wheezing on posterior bilateral

lungs; clear auscultation to anterior & lateral lungs; congested lungs
- Wheezing on posterior bilateral lungs  r/t COPD & CHF
- Congested cough  r/t COPD & CHF (HX of pneumonia)

Gastrointestinal: nasal & oral mucosa intact (pink & moist); bowel sounds present
in all 4 quadrants. No pain or masses noted upon light palpation. Abdomen soft &
non-distended, Pt denies N/V/D, continent of bowel – Last BM unknown

Genitourinary: yellow urine without sediment; continent

Skin: warm, dry, & intact; color flesh tone; tenting - skin turgor. Both ears without
drainage
- Tenting - skin turgor  r/t aging (loss of Sub Q fat), muscle wasting, and
atrophy

Musculoskeletal: Full ROM in all extremities; full sensation – able to resist equally
in all extremities & neck. Ambulates with walker; unsteady gait
- Unsteady Gait  r/t generalized weakness

Psychosocial: Pt seems content, pleasant, and enjoyed his company. No confusion

or signs of dementia/memory loss during conversations

Pain/Discomfort: Pt denies pain when asked. Pt complained of nasal congestion,

“I am stuffy.”
 - Nasal Congestion  r/t possible cold/allergy symptoms
Patient Name:______________________ Date:_____________
PP
Patient ID #________________________ 3/15/18
Katz Index of Independencein Activities of Daily Living
Activities Independence Dependence
Points (1 or 0) (1 Point) (0 Points)

NO supervision, direction or personal WITH supervision, direction,

assistance. personal assistance or total care.

BATHING (1 POINT) Bathes self completely or (0 POINTS) Need help with

needs help in bathing only a single part bathing more than one part of the
Points: __________ of the body such as the back, genital body, getting in or out of the tub or
area or disabled extremity. shower. Requires total bathing

DRESSING (1 POINT) Get clothes from closets
and drawers and puts on clothes and
1
Points: __________ outer garments complete with fasteners.
May have help tying shoes.
(0 POINTS) Needs help with
dressing self or needs to be
completely dressed.

TOILETING (1 POINT) Goes to toilet, gets on and (0 POINTS) Needs help

off, arranges clothes, cleans genital area transferring to the toilet, cleaning
Points: __________ without help. self or uses bedpan or commode.
1
TRANSFERRING (1 POINT) Moves in and out of bed or (0 POINTS) Needs help in moving
chair unassisted. Mechanical transfer from bed to chair or requires a
Points: __________ aids are acceptable complete transfer.

CONTINENCE (1 POINT) Exercises complete self (0 POINTS) Is partially or totally

1 control over urination and defecation. incontinent of bowel or bladder
Points: __________
FEEDING (1 POINT) Gets food from plate into (0 POINTS) Needs partial or total
mouth without help. Preparation of food help with feeding or requires
Points: __________ may be done by another person. parenteral feeding.
1
TOTAL POINTS: ________ SCORING: 6 = High (patient independent) 0 = Low (patient very dependent

1
Source:
try this: Best Practices in Nursing Care to Older Adults, The Hartford Institute for Geriatric Nursing, New York University, College of
1
Nursing, www.hartfordign.org.

6
PP 3/15/18

NO
NO
NO
NO
Unsteady gait with generalized
weakness  YES

NO
PP Harlie Silberman

Total Points: 18

Clinical Judgment:
No risk for
Pressure Sore
0

3
 3/15/18
PP

Harlie Silberman

0-10 Pain Scale  Patient rates pain a “0”.

N/A

N/A

N/A

N/A

N/A

N/A