NR 324 Week 5 Assignment_Clinical Care Plan for Patient with AML and CKD

Clinical Learning – Direct Patient Care Documentation Page 2 of 14 12-180405.4 0723pflcpe I-SBAR I – Introduce Yourself Your Name: Florence Senneh D#: D41237254 Your Title: Nursing Student Reason for being there: Adult Health I – NR324 Clinical Rotation Patient: W.S. Attending Physician: Thomas G Knight MD Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance: Acute Myeloid Leukemia (AML) in relapse, Chronic Kidney Failure Stage III, Type II Diabetes, Benign Prostatic Hyperplasia (BPH), Neutropenic Fever, Afib Pathophysiology of Primary Medical Diagnosis: AML is a blood cancer caused by genetic mutations that affect the DNA of bone marrow cells. Abnormal blasts multiply quickly, and reduce the production of normal red blood cells resulting in anemia and other conditions. Age: 75 Gender/Identity: Male Caucasian Height/Weight: 5’ 10” 197 lbs Allergies: Simvastatin S – Situation Code Status: Full Code Advance Directive (durable power of attorney, living will, other) and Clinical Significance: Spouse S.S. Privacy Code: NA Date of Care/Time: 11/27 07:00 am B – Background Include clinical significance with each: Past Medical History: HF, AFib, Cardiomyopathy, TACO Past Surgical History: NA (Transusfusion Associated Circulatory Overload) Immunizations Received: Influenza, Covid 19, TD (Teatnus), Zoster Social History/Socioeconomic Factors: WS lives in a ranch style home that is wheelchair accessible to include a ramp. He is supported and cared for by his spouse, and he shares that he has 20 barn cats that live around his home that he enjoys watching. A – Assessment Vital Signs: B/P HR RR TEMP SP02 PAIN 110/60 73 15 98.6° F Axillary 98% on RA 0/10 NA NA NA NA NA NA Fall Risk: High Fall Risk IV Site: PICC line left brachial vein Accu-check: 165 IV Fluids: NS & LR Lab/Test Results: Thorancentesis & bone marrow biopsy done on 11/25 I and O I: 237 & O: 237 as of current Isolation Isolation Precautions: Y ☒ N ☐ Contact Air ☐ Droplet ☐ RESPIRATORY R lung weak wet cough CARDIOVASCULAR Orthostatic hypotension, low BP, bilateral lower extremity edema NEUROLOGICAL Delayed speech, slurred, weak bilateral motor strength, drowsiness, fatigue GI/GU Bowel sounds active and audible in all 4 quadrents INTEGUMENTARY Bruising, redness, turgor, epidermis thin with loss of subcutaneous tissue PSYCHOLOGICAL FAMILY – SUPPORT Patient is cared for and supported by spouse who is in hospital with patient most days/nights SAFETY Teaching needed: Patient must ambulate to higher positions very slowly. Laying to sitting and sitting to standing. Quality in Safety Education Nurses (QSEN) Risk(s) Identified: NA R – REQUEST/ RECOMMENDATION Hand off report to: RN Andi From: RN Andi Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 Clinical Learning – Direct Patient Care Documentation Page 4 of 14 12-180405.4 0723pflcpe NURSING NOTES Date/Time Nursing Note 07:20am Patient sleep in bed, spouse sleep in side bed. We gently advised the patient that we were there as his student nurses to take his vitals. I advised WS that I would be taking his vitals. WS acknowledged, and remained laying down for vitals