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HEENT: Head: symmetric, without lumps. Hair dark brown/gray, short, clean. Eyes: PERRLA. Corrective
glasses on pt. Ears: equal in size bilaterally with no swelling, thickening, or drainage. Nose: symmetric
and mid-line. Nostrils patent. No pain with pressure in sinuses. Mouth: No lesions, smooth, moist and no
difficulty swallowing or pain. Teeth clean w/ no halitosis. Neck: ROM smooth and controlled, no palpable
lymph nodes

Neuro: Alert and oriented to person, place, time and situation and appropriate for age. Moves upon
request x4. Pupils both 4+ round. Calm and cooperative. Hearing intact. Speech clear and
understandable.

Cardiac: Heart sounds regular rate and rhythm. Pulses bounding x4. Pitting edema present +2 on lower
extremities. Capillary refill less than 3 seconds. Skin appropriate for ethnicity, dry, warm, and intact

Respiratory: Room air, no sputum, cough, shortness of breath, clear breath sounds x5, regular
respiration. Incentive spirometer ordered 10x/hr

GI: Abdomen distended with hypoactive bowel sounds x4. No guarding when assessed. On fluid liquid
diet. No current nausea noted

GU: No difficulty with urination, yellow, clear, normal odor.

Musculo: Pt gait very unstable. Assistance always needed. Active assistive ROM x4. Physical therapy
ordered to assist w/ ambulation. Walker by side of bed

Mental: Pt pleasant, appropriate, and coping well. No current stressors. Pt verbal and insightful.

Notes: Nursing - Shift 10/25/2019 11:30

Discharge plan initiated after pt had bowel movement and passed gas.

Signed By: Kassandra Avila

Nursing - Shift 10/25/2019 11:00

Assessed vitals and assisted with food. Pt waiting for further instructions from Dr

Signed By: Kassandra Avila

Nursing - Shift 10/25/2019 10:00

Pt ambulated for 5 mins w/ physical therapist by side and w/ walker. Returned to bed after complaint of
headache.
Signed By: Kassandra Avila

Nursing - Shift 10/25/2019 09:30

Pt sitting up. Performed physical assessment. Assisted in hygiene and going to restroom.

Signed By: Kassandra Avila

Nursing - Shift 10/25/2019 08:00

Pt appears stated age. Pt sitting comfortably erect in low Fowler's on bed. A&O to person, place and
time. No signs of distress and no physical deformities. Maintained eye contact and expressions are
appropriate for situation. Comfortable and cooperative and interacted pleasantly. Speech clear and
understandable. Appears clean and groomed.

1) Generic name:

2) Trade name:

3) Dosage:

4) Frequency:

5) Route:

6) Safe Range:

7) Is dose safe? Yes

8) Classification:

9) Indication:

10) MOA:

11) Food/Drug Inter:

12) Side Effects (5):

13) Nursing Actions:

a. Assessment:

b. Medicate/Admin technique:

c. Interventions:

d. Evaluate:

e. Teach:
Test/Procedure: WBC

Normal Value: 4.5 to 10.5 × 103 cells/mm3 (SI, 4.5 to 10.5 × 109/L).

Clients Value: 11.2

Definition: An increased count (leukocytosis) commonly signals infection, such as an abscess, meningitis,
appendicitis, or tonsillitis, or may result from leukemia and tissue necrosis caused by burns, myocardial
infarction, or gangrene.

Interpretation: Patient is at risk of developing pneumonia.

Test/Procedure: RBC

Normal Value: In men, RBC count is 4.2 to 5.4 million/μL (SI, 4.2 to 5.4 × 1012/L) of venous blood.

Clients Value: 4.0

Definition: A low RBC count may indicate anemia, fluid overload, or hemorrhage beyond 24 hours.

Interpretation:

Test/Procedure: Hemoglobin

Normal Value: Results of this test are expressed as a percentage of total hemoglobin, with a normal
result being 5% to 7% (SI, 100 to 170 mg/dL or 5.5 to 9.3 mmol/L)

Clients Value: 11.6

Definition: In a patient with diabetes, an Hb A1c level of 7% or higher (SI, 170 mg/dL or 9.3 mmol/L or
higher) indicates that diabetes isn't well controlled. The test may be repeated to confirm results. Each
patient's target Hb A1c level should be determined by the patient and practitioner.

Interpretation:

Test/Procedure: Hematocrit

Normal Value: In adult men, the value is 42% to 52% (SI, 0.42 to 0.52).

Clients Value: 34%

Definition: Low HCT suggests anemia, hemodilution, destruction of RBCs, malnutrition, overhydration,
bone marrow dysfunction, or massive blood loss.

Interpretation:
Test/Procedure: Sodium

Normal Value: Adults: level is 135 to 145 mEq/L (SI, 135 to 145 mmol/L).

Clients Value: 133

Definition: Hyponatremia may be caused by inadequate sodium intake or excessive sodium loss because
of profuse sweating, GI suctioning, diuretic therapy, diarrhea, vomiting, adrenal insufficiency, burns, and
chronic renal insufficiency with acidosis.

Interpretation:

Test/Procedure: Potassium

Normal Value: For adults, a normal value is 3.5 to 5.2 mEq/L (SI, 3.5 to 5.2 mmol/L).

Clients Value: 3.2

Definition: Hypokalemia occurs in aldosteronism or Cushing syndrome, with loss of body fluids (such as
long-term diuretic therapy, vomiting, or diarrhea) or with excessive licorice ingestion.

Interpretation:

Test/Procedure: Cholesterol

Normal Value: In adults, cholesterol level is 140 to 199 mg/dL or 3.63 to 5.15 mmol/L.

Clients Value: 311

Definition: Increased serum cholesterol levels (hypercholesterolemia) may indicate a risk of CAD,
incipient hepatitis, lipid disorders, bile duct blockage, nephrotic syndrome, obstructive jaundice,
pancreatitis, and hypothyroidism.

Interpretation:

Test/Procedure: Triglyceride

Normal Value: Desirable levels are less than 150 mg/dL or less than 1.70 mmol/L.

Clients Value:422

Definition: An increase in serum triglyceride levels indicates diabetes mellitus, nephrotic syndrome,
alcoholism (levels can be extremely high), liver disease, hypothyroidism, pancreatitis, glycogen storage
disease, myocardial infarction, gout, Werner syndrome, Down syndrome, or anorexia nervosa.

Interpretation:
Test/Procedure: HDL/LDL

Normal Value: Desirable HDL levels are greater than 60 mg/dL (SI, > 1.55 mmol/L). Optimal LDL levels
are less than 100 mg/dL (SI, < 2.6 mmol/L); near optimal levels range from 100 to 129 mg/dL (SI, 2.6 to
3.3 mmol/L).

Clients Value: 33/142

Definition: HDL level inversely related to risk of coronary artery disease (CAD); the higher the HDL level,
the lower the incidence of CAD. LDL level directly related to risk of CAD; the higher the LDL level, the
higher the incidence of CAD

Interpretation:

Test/Procedure: Glucose

Normal Value: normal glucose levels should be in the range of 70 to 120 mg/dl.

Clients Value: 142

Definition: High blood sugar is a finding in a number of conditions, most notably diabetes mellitus.

Interpretation:

Test/Procedure:

Normal Value:

Clients Value:

Definition:

Interpretation: