University of Miami School of Nursing and Health Studies

Adult Health Nursing III

Nursing 411
Spring 2011

DAILY PATIENT ASSIGNMENT SHEET

Student: Thu Nguyen Date: 1/27/2010

Patient Initials: J.L. Room: 388D

Date of Admission: 12/26/2010 Age: 60 yo M

Admission Diagnosis: Upper GI bleeding

Additional Medical Diagnoses: Surgeries:

11/04 HIV E-lap and gastrostomy and dissection of duodenal
3/05 Chronic Cholecystitis

Nursing Diagnoses(List 3 in Priority):

1. Pain related to surgery as evidenced by patient’s complaint and increase anxiety
2. Impaired gas exchange related to tracheobronchial infection as evidenced by culture sputum.
3. Potential for injury related to restlessness as evidenced by patient excessively moving around and numerous attempts to ambulate out
of bed.

Vital Signs: 8am T: 98.6, Hr: 78, Bp: 110/60, R:20 Activity: Bedridden; immobile
12pm: T: 98.3, Hr: 98, Bp: 100/56, R: 21
Frequency: 8am/12pm Diet: TPN
Pt. Norms: T: 98.7, Hr: 69, Bp: 106/55, R: 20 I & O: actual I:643, O: 450

Venous Access Device: PICC peripheral L hand Tubes: Berne diverticulization (PEG), Foley
Type: Nutrition
Solution: Dextrose 150g with amino acid
Rate: 1000ml @ 42ml/hr

Medications: (name, dose, time, purpose) Treatments:

• Insulin Reg human recomb; (sliding scale) 8am Pt feeding tube clogged flush feeding tube to clean it and
• Heparin Sodium; 8am 5000u-1ml anticoagulant resume feeding
• Vivonex plus (nutrition) Preparation for catscan pt NPO administer mucosyst
• Sulfamethoxazole-trim 800mg/60 1tab (infection) medication as ordered pre and post catscan
• Esomeprazole 40mg=1each (blocks acid production)
• Glutamine 10g=1each 10am
• Efavirenz 600mg=1 tab (HIV infection)
• Truvada (emtricitabine) 200/200mg 1tab( HIV infection)
• Darunavir 10 (HIV infection)
• Ritonavir 1000mg=1cap (HIV infection)
• Meropen 1g/NS 1000ml  Bacterial meningitis, infectino
of skin and/or subcutaneous tissue, infection disease of
abdomen, nosocomia pneumonia

Scheduled Lab Tests/Diagnostic Studies: Daily scheduled lab tests Results of current lab tests/diagnostic studies:
Daily lab tests are done.
Pathophysiological Relationship of Diagnosis and
Co- Morbidities
 Ulcers occur when the normal defense mechanisms of the
intestinal mucosa, which include a mucous barrier, bicarbonate
secretion, and epithelial cell integrity, are disrupted.
Other pertinent information:
• Glucose 101
• Na 134
• K 4.6 (H) Due to trauma RBC loss and
release of potassium into bloodstream
• Cl 104
• BUN 22
• Albumin 2.5 (L)  pt on a low protein diet due to
conservation of kidneys
• AST 231 (H) **AST&ALT could be raised due to
numerous of medication being taken especially
from the cocktail of HIV medications
• ALT 200 (H)
• WBC (15) (H) Actual infection of pt
• Hemo 8.1 (L)  Patient was admitted with GI
bleed loss of blood; pt is recovering post
surgery loss of blood in surgery
• Hematocrit 25.3 (L)
Nursing Care Implications: S/S, monitoring, pt. and family
education
• Assess patient’s insertion sites of tubes and IV
lines monitor for placement and infection
• Auscultate patient’s lungs and monitor for signs of
respiratory distress
• Teach patient the potential and risk for injury of
ambulation on own
• Check patient’s tube and lines are patent and
working
• Check I & O frequently in regards to medication
administering and renal function
• Check WBC lab related to tracheobronchial
infection  check for current lab and compare to
baselines look out for increase/decrease
• Administer pain medication for pt comfortability,
recovery as well as decrease pt.’s anxiety