NURSING ASSESSMENT & NOTES.
1012 Neuro/Cognitive: Alert, oriented x 4. Speech clear
0730
Respiratory: Breathing nonlabored
Psychosocial: Reports suicidal ideation. States, “f | had a gun Id blow my
brains out " Reports there are no guns in the house, “but | can get some
States homicidal ideation towards “anyone who gets in my way.” The client
frequently uses expletives in language. States dificulty with keeping a job
because "I dont see eye to eye with many people.” The client has good
hygiene. His mood is indifferent to the client's situation
LABRESULTS
Date Lab Normal Result
101 RBC 4259 cellslL
1810
Hgb 1247 gL
Het 3651% 4
wec 4,000-10,000 mm? 4,200
Platelets 150,000-350,000 210,000
BUN 820 mg/dL 18
cr 07-1.3 mg/dL 08
K 355.0 mEgL 41
Na 136-145 mEQIL 1
, Ca 9105 mg/dL
Glucose 70-100 mg/dL
TSH 0550 07
ETOH via 00.08 1810: 0.202
breathalyzer 0300 0.76
Urine toxicology « Amphetamines
negative
+ Barbiurates: negative
» Benzodiazepines:
negative
« Buprenorphine: negative
« Cocaine: negative
« Cannabinoids: positive
« Fentanyl: negative
« Methadone: negative
« Opiates: positive
« Oxycodone: negative
Nursing | Lab & Diagnostics Other
10/1 1800 Psychosocial History:
« Childhood sexual and physical abuse
« Antisocial personality disorder
« IV drug use x 10 years
+ Smoking cigarettes 1.5 pack/day x 12 years
1012 Neuro/Cognitive: Alert, oriented x 4. Speech clear
0730
Respiratory: Breathing nonlabored
Psychosocial: Reports suicidal ideation. States, “f | had a gun Id blow my
brains out " Reports there are no guns in the house, “but | can get some
States homicidal ideation towards “anyone who gets in my way.” The client
frequently uses expletives in language. States dificulty with keeping a job
because "I dont see eye to eye with many people.” The client has good
hygiene. His mood is indifferent to the client's situation
LABRESULTS
Date Lab Normal Result
101 RBC 4259 cellslL
1810
Hgb 1247 gL
Het 3651% 4
wec 4,000-10,000 mm? 4,200
Platelets 150,000-350,000 210,000
BUN 820 mg/dL 18
cr 07-1.3 mg/dL 08
K 355.0 mEgL 41
Na 136-145 mEQIL 1
, Ca 9105 mg/dL
Glucose 70-100 mg/dL
TSH 0550 07
ETOH via 00.08 1810: 0.202
breathalyzer 0300 0.76
Urine toxicology « Amphetamines
negative
+ Barbiurates: negative
» Benzodiazepines:
negative
« Buprenorphine: negative
« Cocaine: negative
« Cannabinoids: positive
« Fentanyl: negative
« Methadone: negative
« Opiates: positive
« Oxycodone: negative
Nursing | Lab & Diagnostics Other
10/1 1800 Psychosocial History:
« Childhood sexual and physical abuse
« Antisocial personality disorder
« IV drug use x 10 years
+ Smoking cigarettes 1.5 pack/day x 12 years
