Student name: Instructor: History of Present Illness: (A brief statement by the Doctor explaining what happened to the patient before they got to the hospital) Patient Education / Discharge Planning: (Barriers to education, learning goals, learning outcomes) (Home Vs Facility, services needed after discharge, adaptive equipment needed for home.) Erikson’s Developmental Stage Related to Pt & APA citations L.M is a 99-year-old female who presented to the emergency department on 6/29/2018 with increased shortness of breath and desaturation. L.M is a resident at Oak Park skilled nursing facility. Patient found to have pneumonia and admitted to the medical surgical floor. At that time, patient was on bed rest and speaking well. Patient does not appear toxic. However, L.M has shortness of breath with a productive cough. Pathophysiology of Admitting Dx with APA references: Cultural Considerations: Ethnicity, Occupation, Religion, Family Support, Financial Considerations. Diagnostic Tests / Lab Result w/ Dates and Normal Ranges (Prioritize tests that prove the admitting diagnosis exists/is correct) WBC: 11.3 Hemoglobin: 10.9 Hematocrit: 33.3% Platelets: 211 PT: 15.9 Sodium: 139 Potassium: 4.3 Calcium: 10.1 BUN: 27 Creatinine: 1 INR: 1.4 Blood glucose: 250 Diagnostic test> Chest x-ray: 7/10/18 0830 Clinical history> Shortness of breath Comparisons> No priors available for comparison Technique> A single portable AP view of the chest was obtained Findings> the cardio mediastinal silhouette and pulmonary vasculature are unchanged. Right greater-than-left pleural effusions and underlying opacity, slightly improved. No pneumothorax seen. Osseous structure remain grossly intact. Chief Complaint Patient Information Shortness of breath Name: L. M Age: 99 y/o Gender: female DPOA: Self Living Will: N/A Ht: 170 CM Wt: 90 kg Admitting/Current Diagnoses(es): Bilateral pleural effusion, elevated troponin, anemia Previous Medical History: (How does the current diagnosis affect the pre-existing medical conditions) L.M has a medical history of pleural effusion, hypothyroidism, diabetes mellitus, hypertension and atrial fibrillation. These problems remain active as of 7/15/2018. Plan of Care: Patient and caregiver will verbalize an understanding of appropriate arrangements prior to discharge. Patient will be free from falls and injuries related to falls throughout hospital stay. Previous Surgical History: N/A

(problem r/t cause a/e/b signs & symptoms) Objective Signs Priority Nursing Diagnosis #1 (problem r/t cause a/e/b signs & symptoms) Vital Signs Neurological Cardiovascular Respiratory Priority Nursing Diagnosis #2 T: 36.6 C axillary P: 80 RR: 18 BP: 106/44 O2: 99% mechanical ventilator Displays no signs and symptoms Mechanical ventilator: SpO2 99%, vent setting FiO2: 50% Aspiration risk: decreased ability to handle secretions Sedated Disoriented x4 to person, place, purpose & time Sensation: decreased Pain: non verbal pain tool (CPOT) relaxed, neutral PERRLA: 5mm Warm dry skin <3 capillary refill Edema present Bilateral upper/lower extremities pitting 2+ Irregularly irregular rhythm elevated HR lowered BP Pallor No pacemaker Impaired oxygenation related to respiratory failure secondary to pleural effusion as evidenced by O2 sat 88% on room air. Nutrition / Hydration GI GU Rest / Exercise Last bowel movement: 7/14/18 Passing flatus Emesis: none Enteral feedings Abdomen: rounded and symmetric Indwelling catheter Urine: clear, yellow, odorless Enteral feeding NG tube: Glucerna> 1.2 cal. Tube feeding 1,500mL 60mL/hr Bed rest ROM: moves without gravity No restraints extremity movement: equal Outcome Goal #1 (specific, measurable, achievable, realistic, time bound) Outcome / Goal #2 By the end of my shift patient will have a successful removal pleural effusion with thoracentesis procedure. Integumentary Endocrine Psychosocial Musculoskeletal Skin intact, warm and dry to touch No rash or lesions Excessive bruising No edema eyes and nose clear mouth sores present Braden scale score: 19 Left/right upper, left/right lower extremities: moves without gravity Type 2 DM Q6H accu check Pt is sedated and disoriented to person place purpose & time Interventions #1 Evaluation #1 (start with “goal met” or “goal not met”) Evaluation #2 Interventions #2 Prepared for thoracentesis. Order was declined per sons order. Goal was not met. . “Risk For” Interventions “Risk For” Evaluation “Risk For” goal “Risk for” Diagnosis (problem r/t cause)

Medication Name, Dose, Route, Freq & APA Citation Why Pt is Taking the Drug and Method of Action Side Effects Nursing Considerations Insulin detemir 10 units= 0.1 mL, subq, Q bedtime Sodium chloride 0.9% 1,000 mL IV Ascorbic acid 250 mg=0.5 tab PO BID Propofol Glucerna

References: At least 3 referneces & Standard APA Format