Course: NURS 101L
PATIENT PROFILE DATABASE
Date: __________5/6/2020________________________________________________
Student Name: Katie Lopez
Faculty Name: Sally Saites
1. ADMISSION INFORMATION
Date of Pt. Name: Admission A Gend Growth and Ethnicity: Occupa Spiritual
Care: T.M Date: g er: F Development (Erikson): Caucasian tion: Beliefs:
5/6/2020 5/5/2020 e Integrity vs despair Retired Catholic
:
9
0
Reason for Surgical Medical Diagnoses History: (Present and past diagnoses,
Hospitalization/Chief Procedures/Date: Physician’s History and Physical notes in the chart, nursing intake
Complaint (in pt’s own N/A assessment, with length of history if possible)
words):
“I had chest yesterday.” Hearing Impaired in the LT ear, CHF, GERD, A-Fib, Hypertension
Admitting Medical History of Present Illness: PT admitted w/ chest pain, 1 dose of nitro and chest pain was
Diagnosis: resolved, admitted for observation.
Chest Pain
ADVANCE DIRECTIVES (Nursing Admission Assessment):
Durable Power of Attorney: ☐ Yes Code status: ☐ Full Code ☐
Living Will: ☐ Yes ☐ No
(DAUGHTER) ☐ No DNR (Do Not Resuscitate)
2. MEDICATIONS ALLERGIES:
Drug Classification Dosage Route Frequency Purpose Nursing
(time due) Considerations
Digoxin Pharmacologic 10 to PO Every 6 to Increases the Arrhythmias,
class: Cardiac 15mcg/kg 8 hours force and nausea, vomiting,
glycoside divided velocity of a digitalis toxicity
Therapeutic into 3 myocardial and vison
Class: doses contraction. disturbances.
Antiarrhythmi
c
ASA Pharmacologic 50 to PO Once daily To reduce the Tinnitus upset GI if
class: 325mg severity of or not taken with
Salicylate to prevent food, bloody or
Therapeutic acute MI. tarry stools,
Class: NSAID vomiting.
Furosemide Pharmacologic 20 to PO Every 6 to To reduce Nephrocalcinosis,
class: Loop 80mg as a 8 hours. edema. nephrolithiasis,
Diuretic single fluid loss, BP, BUN,
Therapeutic dose, Blood glucose.
Class: increased
Antihypertensi by 20 to
ve 40mg
Famotidine Pharmacologic 10mg PO One hour To prevent Must be eaten one
class: before heartburn and hour before food
Histamine eating. indigestion. to avoid GI issues,
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, Course: NURS 101L
PATIENT PROFILE DATABASE
blocker Avoiding alcohol.
Therapeutic
Class:
Antiulcer
agent
Potassium Chloride Pharmacologic 25 to PO Once or To prevent or Hypokalemia,
class: 50mEq/g twice daily treat any fatigue,
Electrolyte insufficient arrhythmias.
cation dietary
Therapeutic potassium.
Class:
Electrolyte
replacement
Captopril Pharmacologic Initial: PO Initial: To control BP, Electrolytes,
class: 25mg twice to hypertension. renal function,
Angiotensin- Increased three WBC count.
converting to: 50mg times
enzyme daily.
inhibitor Increased:
Therapeutic twice to
Class: three
Vasodilator times
daily.
Wafarin Pharmacologic Initial: 2 PO Initial: For To prevent or Hepatic
class: to 5mg 2 to 4 treat impairment,
Coumarin daily days. pulmonary intracranial
derivative Usual: 2 Usual: embolism, A- hemorrhage,
Therapeutic to 20mg Daily fib, or MI. diarrhea.
Class: based on
Anticoagulant targeted
goal.
3. LABORATORY DATA
Test Norms On Current value Test Norms On Current
admission admission value
WBC 12 18 Sodium 135-145 156
Hemoglobin 11 Potassium 4.5
Hematocrit 36 Calcium
Platelets 150,000 BUN 24 25
PT 12 Creatinine 1.3
INR 2.5 Magnesium
aPTT Blood Glucose
HA1c Urinalysis
BNP 200 200 Cultures
blood/sputum
DIAGNOSTIC TESTS
Chest X-ray: Clear EKG: Normal Sinus Abnormal studies:
This study source
Pagewas downloaded
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https://www.coursehero.com/file/62024776/NURS-101L-Patient-Profile-Database-KTdocx/
PATIENT PROFILE DATABASE
Date: __________5/6/2020________________________________________________
Student Name: Katie Lopez
Faculty Name: Sally Saites
1. ADMISSION INFORMATION
Date of Pt. Name: Admission A Gend Growth and Ethnicity: Occupa Spiritual
Care: T.M Date: g er: F Development (Erikson): Caucasian tion: Beliefs:
5/6/2020 5/5/2020 e Integrity vs despair Retired Catholic
:
9
0
Reason for Surgical Medical Diagnoses History: (Present and past diagnoses,
Hospitalization/Chief Procedures/Date: Physician’s History and Physical notes in the chart, nursing intake
Complaint (in pt’s own N/A assessment, with length of history if possible)
words):
“I had chest yesterday.” Hearing Impaired in the LT ear, CHF, GERD, A-Fib, Hypertension
Admitting Medical History of Present Illness: PT admitted w/ chest pain, 1 dose of nitro and chest pain was
Diagnosis: resolved, admitted for observation.
Chest Pain
ADVANCE DIRECTIVES (Nursing Admission Assessment):
Durable Power of Attorney: ☐ Yes Code status: ☐ Full Code ☐
Living Will: ☐ Yes ☐ No
(DAUGHTER) ☐ No DNR (Do Not Resuscitate)
2. MEDICATIONS ALLERGIES:
Drug Classification Dosage Route Frequency Purpose Nursing
(time due) Considerations
Digoxin Pharmacologic 10 to PO Every 6 to Increases the Arrhythmias,
class: Cardiac 15mcg/kg 8 hours force and nausea, vomiting,
glycoside divided velocity of a digitalis toxicity
Therapeutic into 3 myocardial and vison
Class: doses contraction. disturbances.
Antiarrhythmi
c
ASA Pharmacologic 50 to PO Once daily To reduce the Tinnitus upset GI if
class: 325mg severity of or not taken with
Salicylate to prevent food, bloody or
Therapeutic acute MI. tarry stools,
Class: NSAID vomiting.
Furosemide Pharmacologic 20 to PO Every 6 to To reduce Nephrocalcinosis,
class: Loop 80mg as a 8 hours. edema. nephrolithiasis,
Diuretic single fluid loss, BP, BUN,
Therapeutic dose, Blood glucose.
Class: increased
Antihypertensi by 20 to
ve 40mg
Famotidine Pharmacologic 10mg PO One hour To prevent Must be eaten one
class: before heartburn and hour before food
Histamine eating. indigestion. to avoid GI issues,
This study source
Pagewas downloaded
1 of 7 by 100000848649392 from CourseHero.com on 07-17-2022 04:11:52 GMT -05:00
https://www.coursehero.com/file/62024776/NURS-101L-Patient-Profile-Database-KTdocx/
, Course: NURS 101L
PATIENT PROFILE DATABASE
blocker Avoiding alcohol.
Therapeutic
Class:
Antiulcer
agent
Potassium Chloride Pharmacologic 25 to PO Once or To prevent or Hypokalemia,
class: 50mEq/g twice daily treat any fatigue,
Electrolyte insufficient arrhythmias.
cation dietary
Therapeutic potassium.
Class:
Electrolyte
replacement
Captopril Pharmacologic Initial: PO Initial: To control BP, Electrolytes,
class: 25mg twice to hypertension. renal function,
Angiotensin- Increased three WBC count.
converting to: 50mg times
enzyme daily.
inhibitor Increased:
Therapeutic twice to
Class: three
Vasodilator times
daily.
Wafarin Pharmacologic Initial: 2 PO Initial: For To prevent or Hepatic
class: to 5mg 2 to 4 treat impairment,
Coumarin daily days. pulmonary intracranial
derivative Usual: 2 Usual: embolism, A- hemorrhage,
Therapeutic to 20mg Daily fib, or MI. diarrhea.
Class: based on
Anticoagulant targeted
goal.
3. LABORATORY DATA
Test Norms On Current value Test Norms On Current
admission admission value
WBC 12 18 Sodium 135-145 156
Hemoglobin 11 Potassium 4.5
Hematocrit 36 Calcium
Platelets 150,000 BUN 24 25
PT 12 Creatinine 1.3
INR 2.5 Magnesium
aPTT Blood Glucose
HA1c Urinalysis
BNP 200 200 Cultures
blood/sputum
DIAGNOSTIC TESTS
Chest X-ray: Clear EKG: Normal Sinus Abnormal studies:
This study source
Pagewas downloaded
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