Test/Result

Admit

8/23/20

Sun

8/29/20

Mon

8/30/20

Hemoglobin (g/dL)

13.8

7.4L

9.1L

Hematocrit (%)

42.2

21.1L

25.8L

RBC (M/uL)

4.35

2.28L

2.82L

WBC (K/Ul)

37.2H

11.4H

14.2H

MCV (FL)

97.1H

92.5

91.7

MCH (PG)

31.7

32.3

MCHC (g/dL)

32.7

35.2

RDW (%)

15

.1H

15.8H

1

5.5

H

PLT (K/uL)

461H

408

428H

MPV (FL)

7.5

6.6

6.3

PT (Sec.)

n/a

9.7

10.0

INR

0.93

0.96

PTT (Sec.)

29.4 @ 0600

30.3 @ 1400

24.6 @ 0600

48.1 @ 1400

guaiac

negative

BUN (mg/dL)

7L

6L

Creatinine–mg/dl

0.29L

0.36L

GFR AF

54

BNP

277H

AGAP

25.0H

8.0

9.0

Chlroide (mmol/L)

92L

102

98

CO2 (mmol/L)

13L

Potassium (mmol/L)

4.8

4.1

4.0

Sodium (mmol/L)

130L

134L

132L

Glucose (U/L)

397H

266H

368H

HgbA1C

10.3H

Urinalysis

Color

Yellow

yellow

Appearance

Clear

Hazy

Spec. Gravity

1.002-1.030

1.025

PH

4.5-8.0

Protein

Negative

200mg/dL

GLU

Normal

1000mg/dL

Ketones

Negative

>150

Blood

Negative

300

Urobilinogen

Normal

2mg/dL

Leuk Ester

Negative

500

Gram Stain

8/23/10 & 8/25/10 wound culture: gram positive cocci staph like

Cultures/

Sensitivities

8/23/10 blood culture: no growth after 5 days (8/28/10)

8/23/10 wound culture of groin abscess: staph aureus, sensitive to methicillin, clindamycin, erythromycin, oxacillin, naficillin, amoxicillin, clavulanic acid, ampicillin, sulbactam, SXT, most parenteral and oral cephalosporins

8/23/10 urine culture: >100,000 CFU/mL staph aureus sensitive methicillin, nitrofurantoin, oxacillin, SXT

8/25/10 culture abscess L bottom: staph aureus (see above wound culture for sensitivities)

Therapeutic

Drug Levels

PT (9-11.5 sec) and INR (2.0-3.0) evaluate therapeutic drug levels of coumadin, PTT (60-70 sec) evaluate therapeutic levels of heparin.

CXR

8/23/10 CXR: cardiac mediastinal silhouettes normal, lungs are clear. No pleural effusion or indication of CHF.

CT/US/

Nuc Med/ Spec Proc

8/26/10 CT abdomen & pelvis without contrast: inflammatory mass-like density with subcutaneous of R groin containing central air bubbles presumably secondary to recent drainage/intervention. No well-organized fluid collection in region. Body wall and intra-abdominal edema. Few non-specific bubbles of air within lower anterior abdominal wall. Abscess in proximal L thigh and L buttock not imaged.

8/26/10 CT pelvis with IV contrast: superficial L medial buttock abscess 5-6cm diameter extending inferiorly and connected to large deep muscle abscess, extends to femur measures 8x10cm

Cardiac monitoring

Measure and compare with report:

PR interval:

QRS:

QT interval:

P-P interval regular:

R-R interval regular:

Medications

Cefazolin (Ancef)

2g/D5W 110mL IVPB q 8hrs infuse over 30 min

Clindamycin (Cleocin)

900mg IVPB infuse over 30 min

Fluconazole (Diflucan)

100mg PO Q 24hrs

Heparin

100 units/mL standard infusion

Warfarin (Coumadin)

Nystatin

Topical

Insulin Aspart

0-14 units SQ 4 times daily ac/hs

Insulin Detemir (Levemir)

32 units SQ daily

Polyethylene glycol (Golytely)

400mL PO one time

Acetaminophen (Tylenol)

650mg PO q 4 hrs prn

Oxycodone (Oxycontin)

5 mg PO Q 4 hrs prn

Morphine (Duramorph)

4mg IV Q 3hrs prn

Hydromorphone (Dilaudid)

1mg IV Q 3hrs prn

Calcium Carbonate (Tums) chewable

500mg PO 3x daily prn

Promethazine (Phenergan)

6.25mg IV q 4hrs prn

Sennosides/ docusate sodium

8.6mg/50mg 1 tablet PO BID prn

Trazadone (Desyrel)

25mg PO hs prn

Content

Points

Analysis of data

All of these criteria apply:

·

Explanation unclear

· Interpretation inaccurate

· Some labs not addressed = 0 points

2 of these criteria apply:

· Explanation partially clear

· Interpretation partially inaccurate

· Some labs not addressed = 7.5 points

Explanation clear as to how altered lab values fit or don’t fit with patient’s current clinical status; all labs addressed; interpretation accurate =

15 points

Diagnostic Statement

· PCs/NANDAs are not based on lab results.

· Diagnostic statements are not in correct format = 0 point

1 of these criteria apply:

· PCs/NANDAs are not based on lab results.

· Diagnostic statements are not in correct format = 5 points

·

Identification of PCs/ NANDAs

based on lab results. Diagnostic statements are in correct format. = 10 points

Desired Outcome

· Desired outcomes are not measurable and achievable.

· Outcomes are not relevant to PCs/ NANDAs = 0 point

· Outcomes are not relevant to PCs/ NANDAs = 2.5 points

·

Desired outcomes are measurable and achievable and are relevant to the PCs/ NANDAs = 5 points

Interventions

· No specific intervention identified

· Interventions not relevant to NANDAs or PCs

· Rrationale do not support selected interventions. = 0 points

· Nursing/collaborative interventions are not consistent with NANDAs and PCs;

· Are not relevant to address/correct altered lab values

· Rationale do not support the selected interventions. = 7.5 points

·

Nursing/collaborative interventions are consistent with

NANDAs and PCs; relevant to address/

correct altered lab values. Rationale support selection of interventions. = 15 points

Evaluation

Inaccurate or no identification of effects of nursing interventions on patient’s status =

0 points

Partial identification of effects of nursing interventions on patient’s status = 2.5 points

Identification of effects of nursing interventions on patient’s status =

5 points

Format

Many spelling or grammar errors; or, no citing of references =
deduct

4 points

Some spelling or grammar errors; or, incorrect citing of references; or, references page not in APA format =
deduct 2 point

Free of spelling and grammar errors; correct citation of references; reference page contains references in APA format = 0 point

TOTAL POINTS