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Saturday, October 5, 2013

Guide To Clinical Paperwork

Clinical




Here's An Example Of A Patho That Passed
copyright Janice Silbermann :)

Diabetes Mellitus
Disease of deficiency or resistance to the effects of insulin. Cells use insulin for energy needs. Insulin also promotes fatty acid storage in the adipose tissues. Type 1 diabetes is an absolute deficiency in insulin and type 2, which has a later onset and is related to diet and life-style choices, is insulin resistance.
Diabetes has a hereditary component in both types and along with obesity is a risk factor. High cholesterol, triglycerides and high BP also constitute risk factors
Diabetes puts a patient at risk of multisystem complications including peripheral vascular disease, heart disease and renal disease
Hyperglycemic symptoms include polyuria, polydipsia, weight loss, fatigue, weakness and frequent skin complications such as infections
Tests include fasting plasma glucose levels. A reading of > 126 mg/dL is considered high. Random blood glucose testing may reveal a level of >200 mg/dl. Oral dextrose (75g) is given in the third test and a BG level is obtained 2 hours later. A reading of >200mg/dL is indicative of DM.
Treatment includes changes in diet and exercise. Type 1 requires insulin replacement as the body is not manufacturing insulin. Type 2 may be treated with oral anti-diabetic drugs which will stimulate the body to produce insulin or increase sensitivity at the cellular level. Injected insulin may also be used in Type 2. Dietary measures include a consistent carbohydrate diet, which is calorie controlled to maintain optimal weight. The diet is carefully calculated to keep BG levels in optimal range.
Insulin can be characterized by its rate of onset, peak and duration. Rapid (lispro), for example has an onset of fewer than 15 minutes, while Lente has an onset of 1-3 hours, but lasts 18-24 hours in contrast with Lispo’s 3-4 hours duration.


LeMone, P., K. Burke, and G. Bauldoff. Medical-surgical nursing: Critical thinking in patient care. Fifth. Upper Saddle River, NJ: Pearson Education,Inc., 2011. Print.





Here's An Example Of A Physical Assessment That Passed


Neurological: Not oriented to person, place and time. Unresponsive to verbal commands. Withdraws from stimuli. Pupils equal, round, reactive to light. Sluggish pupil response, 6cm bilaterally, accommodation present. Unable to assess hand grips. Bilateral ankle dorsificaton and plantar flexion, equal, weak.

Pulmonary: Trach present. control assist ventilator, Vent Settings:  Mode: assist control     FiO2:40%  Rate:14    TV:420mL   Vmax:50L/min  Respiratory rate between 17-26 during 8 hour shift. Tachypnea. Breathing labored and shallow, bilateral, equal use of accessory muscles, no retractions. Chest rise equal bilaterally. Rhonchi present upper left, upper right, lower left and lower right lobes. No cough.
Moderate secretions, thick, blood-tinged.

Cardiac: Apical pulse 0800 -108bpm, 1000-119bpm, 1200-107bpm,1400-96, strong, regular. S1 and S2 present. No murmurs heard. Sinus tachycardia. HR between 97-140 during 8 hour shift.
BP: 0800-141/74 1000-134/61 1200-101/42 1400-11/48-automatic cuff, left arm, taken supine.
Radial pulses, equal 3+ bilaterally. Doralis pedis pulses equal, 3+ bilaterally, tibial pulses equal 3+ bilaterally. Cap refill right hand <3sec, left hand <3 sec, right foot <3 sec, left foot < 3sec.
Pitting edema 4+- bilateral hands, feet, thighs, ankles. Pitting edema 1+ above knee. Pitting edema 1+ above elbow. Facial edema present.
No JVD present.

GI/GU: Abdomen soft, round. Bowel sounds heard immediately in all four quadrants. No rebound tenderness or masses. Bowel movement 0930 1-28-13, soft, formed, brown, no foul odor. zero residual in g-tube. Auscultation shows correct placement.
Urine clear, dark yellow. Foley catheter. Tube feeding with Nova Source Renal 30 mL/hour. NPO.

Musculoskeletal: Passive ROM in all extremities, unable to move spontaneously. Unable to assess neck range of motion due to edema and presence of trach collar. Gait and posture unable to assessed-non-ambulatory.

Integumentary: skin color normal for ethnicity. Skin warm  and clammy on palpation. MM moist, pink. Not tenting in upper extremities. Lower extremities edematous, skin tight and shiny. Nail color pink. No clubbing observed. PICC line present right antecubital. Dressing dry and intact, no drainage, no bleeding.
Large area of reddened, denuded, sloughing skin both buttocks, both things, sacral area, moist.

















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