MIDLANDS TECHNICAL COLLEGE

ASSOCIATE DEGREE NURSING

NURSING 165
DATA COLLECTION TOOL

DATE: ___09/28/10_______________ STUDENT: ______Marilyn Stalnaker__________

PATIENT’S GENDER____F_____AGE: __71____ADMISSION DATE: _____09/19/10____________

CLINICAL AREA: __7 west Richland_______

Admitting Diagnosis___Acute Renal Failure_______________________________________________

_____________________________________________________________________________________

1. Medical Diagnosis/Pathophysiology. Include signs and symptoms. Give reference source.

Acute Renal Failure: A rapid decrease in kidney function, leading to the collection of metabolic
wastes in the body. ARF can result from conditions that reduce blood flow to the kidneys (pre
renal failure), damage to the glomeruli, interstitial tissue, or tubules (intrarenal/intrinsic renal
failure); or obstruction of urine flow (post renal failure). When ARF occurs in patients who
already have renal insufficiency, it may lead to end stage kidney disease or it may resolve to the
previous level of renal function. Many factors contribute to renal insults in acute renal failure,
but the acute syndrome may be reversible with prompt intervention.

The pathologic process of acute renal failure is related to the cause of the sudden decrease in kidney
function and to the affected kidney sites. Reduced blood flow, toxins, tubular ischemia, infections, and
obstruction have different effects on the renal system. Any of these can reduce glomerular filtration rate,
damage nephron cells, and obstruct urine flow in the renal tublules.

Symptoms include: Swelling, especially of the legs and feet, little or no urine output, thirst and a
dry mouth, rapid heart rate, feeling dizzy when you stand up. Loss of appetite, nausea, and
vomiting, feeling confused, anxious and restless, or sleepy, pain on one side of the back, just
below the rib cage and above the waist (flank pain).

Ignatavicius,Workman (2006). Medical-Surgical Nursing: Patient Centered Collaborative

Care. St. Louis, Missouri: Saunders.

2. Medical Diagnosis/Pathophysiology. Include signs and symptoms. Give reference source.

Ischemic colitis encompasses a number of clinical entities, all with an end result of insufficient
blood supply to a segment or the entire colon. This disease results in ischemic necrosis of
varying severities that can range from superficial mucosal involvement to full-thickness
transmural necrosis. Bowel ischemia is mainly a disease of old age caused by atheroma of
mesenteric vessels. Other causes include embolic disease, vasculitis, fibromuscular hyperplasia,
aortic aneurysm, blunt abdominal trauma, disseminated intravascular coagulation, irradiation,
and hypovolemic or endotoxic shock. Occlusive mesenteric infarction (embolus or thrombosis)
has a 90% mortality rate, whereas nonocclusive disease has a 10% mortality rate.
Venous infarction occurs in young patients, usually after abdominal surgery. Patients may
present with colicky abdominal pain, which becomes continuous. It may be associated with
vomiting, diarrhea, or rectal bleeding.
.

Symptoms include: abdominal pain, tenderness or cramping, localized to the lower left side of
the abdomen; the onset can be sudden or gradual, bright red or maroon-colored blood in stool or,
at times, passage of blood alone without stool, a feeling of urgency to move bowels, diarrhea,
nausea, vomiting. The risk of severe complications from ischemic colitis increases when signs
and symptoms affect the right side of the abdomen. The arteries that feed the right side of the
colon also feed part of the small intestine. When blood flow is blocked on the right side of the
colon, it's likely that part of the small intestine also is not receiving adequate blood supply and
pain will be more severe. Blocked blood flow to the small intestine may quickly lead to death of
intestinal tissue (infarction or necrosis). If this occurs, surgery to clear the blockage and to
remove the portion of the intestine that has been destroyed is necessary.

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR. (Sep 1, 2009). Colitis, Ischemic. In eMedicine
Specialties. Retrieved September 30, 2010, from
http://emedicine.medscape.com/article/366808-overview.

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 Midlands Technical College
Clinical Organizational Worksheet
Daily Plan Treatments
0700 Weight ______ Height ______ BMI ___VS Freq. standard___
preconference
Vital Signs:
Pt. norms _99.2T_91_P _24__R _142/92 P _98_pox
0800 Day 1:
get report Time_1200_T _98.2_P _86__R 148/88__BP __98__pox
meet patient
Time_0900_T _99.2_P _82__R _146/74_BP __98__pox
vital signs
Time_0800_T _98.4_P _91__R _98/141_BP __98__pox
Time_0342_T _99.2_P _82__R _146/74_BP __98__pox
0900
meds Day 2:
check on patient Time 2343T _98.4 P 97___R _20___BP _142/92pox
Time_2100T 98.1 P _102_R 20____BP _94/111pox
Time_16:35 T100.1 P _70_R 18__BP _96/144 pox
1000
breakfast/full liquid Time15:42T 99.4_P __81_R _18__BP _97/150_pox 98
assist to bedside commode
physical assessment Respiratory: Liters O2 _2_____ Method __NC________
1100 Treatments: O2 therapy 2L nasal cannula
check on patient
Invasive lines: (list IV type and site, fluids and rate)

Site:__IV Peripheral Fluids: __KPO___Rate 125cc/hr____

1200-vital signs Site:__________ Fluids: __________________Rate____
12:30 lunch me
return to patient room/lunch Site:__________ Fluids: ___________________Rate____
assist to bedside commode Bag Change Due: ______ Tubing Change Due: ________
bed bath Other tubes, drains, etc.
1300 none
change linens
Dressings: none

1400
check on patient Diet: (list any difficulties) Full liquid diet, not tolerating
post conference 1430

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 Day 1: Day 2:
Intake Output Input 820 Output 2

Physical Assessment Sheet

First Page

Code Status __Full________

Allergies: ____NKA_________

Spiritual ____not listed___

Communication/Neuro
Emotional/Mental
A&Ox3 able to follow
verbal commands. Glascow
score 15. 100%ROM all
extremities. Initiates
communication speech
clear.
Senses
Visual/Auditory
Can hear normal tones, Patient pleasant, in pain
passes finger rub test. but not depressed. States
Wears glasses for both “I am tired of being here
near and far vision. Able and I am ready to go
to read close and far away home”
with assistance of glassss.
PERRLA pupil size 2mm
dim room light.

Circulation Status Respiratory Status

Apical HR 86, S1S2 normal rate, All breath sounds clear. No cough present,
regular rhythm. PMI palpated between pulse ox 100% 2L O2 nasal cannula.
4th and 5th intercostals space. B/P
148/88 left arm lying. Bilateral
Peripheral pulses: carotid +3, Radial
+3 normal rate/rhythm, brachial +3
Femoral +2,popliteal +2, dorsalis pedis +1.
capillary refill fingernail1 sec, toenail 1 sec
Nailbeds pink. Skin tone appropriate
for race.
Skin Condition Wounds/Incisions/Decubitus

Temp 98.2 oral, Skin color pink, warm Broken skin under each breast, red, irritated.
to touch, dry. Skin turgor 1 sec, No incisions, no decubitus ulcers, patient has
redness/broken area beneath both hemorrhoids. Left lower Abdominal scars 2
breasts. Bilateral leg edema non pitting. previous cesarean sections.

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 Physical Assessment Sheet
Second Page

IV Site Mobility Status

Right peripheral IV #22. Patient ambulates with

no sign of redness or assistance. Can turn self in
swelling, no bleeding. bed. Unsteady gait due to
IV intact/patent. overall weakness. Stooping
due to abdominal pain.

Pain Assessment Nutritional Status

(Use pain scale)
Patient on full liquid diet. Unable
Patient states pain upper to keep down food. Suffering
abdominal area. Pain level of from nausea and diarrhea. Patient
8 on 1-10 scale. Patient states on IV electrolyte protocol.
that pain medicine does not Receiving KPO 125 cc/hr and
make it better. Patient states magnesium replacement.
that not moving and not
applying pressure to the site
helps. Turning/walking make
worse.

Elimination:

Bowels: Continent of bowel. Bowl sounds present x 4. Abdomen soft, non-distended. Pain with
palpation upper right and left quadrants. Last BM 9/29/10 am loose, bloody stool.

Bladder: Patient semi continent of bladder, wears adult briefs. Urine clear yellow, no odor, no
blood.

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 Physical Assessment Sheet
Third Page

ERIKSON’S DEVELOPMENTAL STAGE:

Identify stage. Give rationale.

__ This patient has achieved the generativity stage of Eriksons Developmental stages.. She
appears to be coping with her illness. Patient does not display any signs of self-absorption. She
does not appear to be in denial or unhappy with advancing in age. She does not appear to be
preoccupied with herself. She displays physical, emotional and social stability as was displayed
with her relationship with visiting friends who state that she is generally happy and fun to be
around. She does not appear withdrawn. Patient is tolerant and although she complains of pain,
her mental status appears to be within reason for a person who has been hospitalized with an
acute illness.Patient is capable of love, she has two children and a grand child of which she
speaks highly of.

Critical Thinking Questions

1. In relation to the primary disease process/es that the patient has, compare and contrast the
actual signs and symptoms displayed by the patient to those listed in the textbook/reference
that you used.

The primary health care problem that this patient has is Ischemic Cholitis and the patient
displays textbook symptoms for the illness including, nausea, vomiting, bloody diarrhea, and
pain in the lower left abdominial region.

2. Discuss how your patient’s history relates to the present condition or illness. If there is no relation
please state so and explain.

The patients history does not relate to the present condition, as it is a condition that has an acute
onset and is common in the elderly population. Bowel ischemia is mainly a disease of old age
caused by atheroma of mesenteric vessels. Other causes include embolic disease, vasculitis,
fibromuscular hyperplasia, aortic aneurysm, blunt abdominal trauma, disseminated intravascular
coagulation, irradiation, and hypovolemic or endotoxic shock. This patient is neither symptomatic
of nor displaying any signs of the above listed conditions. She is 71 years of age and it is most likely that
her condition is related to age and atheroma of mesenteric vessels.

1. How did determine which health problem was priority? Discuss the rationale for your choice.

I chose Ischemic Cholitis as the primary problem because of the severity of her symptoms. The
patient was admitted severely dehydrated and required electrolyte replacement therapy.The
patient is not responding well to treatment even on a full liquid diet with bowel rest. She has

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 been hospitalized for more than a week and is showing no improvement. A bowel resection may
be necessary. Ischemic colitis is associated with chronic renal failure and atherosclerosis. If
Ischemic Cholitis is not promptly under control, additional problems can occur, including death.

CLINICAL LAB WORKSHEET

CHEMISTRY NORMALS PT. VALUES EXPLANATION OF ABNORMAL VALUES

Sodium 136-145 143
Potassium 3.4-5.1 3.5
Chloride 99-110 109
CO2 23-32 20 Decreased CO2 levels can be attributed to
increased ventilation. With increased
ventilation, CO2 levels decrease. This can be
because of pain or anxiety
Glucose 70-99 89
Bun 6-20 6
Creatinine 0.6-1.1 0.8
Uric Acid N/a
Calcium 8.5-10.5 7.9 Decreased calcium levels can mean
hypoparathyroidism or renal failure
Phosphorous N/a
Total Protein N/a
Albumin N/a
Total Bilirubin N/a
Bilirubin, Direct N/a
Alk. Phosphatase N/a
SGOT/AST N/a
SGPT/ALT N/a
GGTP N/a
LDH N/a
Cholesterol N/a
LDL N/a
HDL N/a
VLDL N/a
Triglycerides N/a
Bun/CR Ratio 7.5 In prerenal injury, urea increases disproportionately
to creatinine due to enhanced proximal tubular
reabsorption. BUN level increases in upper GI
bleeding because patients become prerenal,
secondary to blood loss which decreases blood flow
to the kidney
Bilirubin, Indirect N/a
Globulin N/a
A/G Ratio N/a

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8
 HEMATOLOGY NORMALS PT. VALUES EXPLANATION OF ABNORMAL VALUES
WBC Count 3.7-9.1 7.6
RBC Count 3.8-5.3 3.62
Hemoglobin 11.1-15.8 9.7 Decreased levels of hemoglobin can indicate anemia,
cirrhosis, hemolytic anemia, hemorrhage, dietary
deficiency, renal disease
Hematocrit 32.5-48 29.2 Decreased hematocrit can indicate anemia,
hemorrhage, dietary deficiency, bone marrow
failure and renal disease.
MCV 80-101 80.6
MCH 27-32 26.7 Decreased MCV values mean the RBC is
abnormally small or microcytic. This is
associated with iron deficiency anemia or
thalassemia.
MCHC 32-36.5 33.1 MCHC is a measure of the average
concentration or percentage of hemoglobin
within a single RBC. Decreased values mean
that the cell has a deficiency of hemoglobin and
is said to be hypochromic.
Red Cell Distr Width 11.5-14.5 14.3
Platelet Count 150-450 310
DIFF NORMALS PT. VALUES EXPLANATION OF ABNORMAL VALUES
Polynuc Neutrophil 40-70 56
Band Neutrophil N/a
Lymphocyte 15-45 11 Decreased Lymphocytes can be indicative of
leukemia, sepsis immunodeficiency diseases,
lupus, erythematousus, later stages of HIV,
aplastic anemia drug therapy and Lupus.
Monocyte 0-10 10
Eosinophils 0-6 5
Basophils 0-2 1
RBC Morphology N/a
WBC Morphology N/a
Platelet Comments N/a
URINALYSIS NORMALS PT. VALUES EXPLANATION OF ABNORMAL VALUES
Urine Specific Gravity N/a
Urine PH N/a
Urine Glucose N/a
Urine Bilirubin N/a
Urine Occult Blood N/a
Urine Urobilinogen N/a
Urine Nitrate N/a
Protein (Urine) N/a
Ketones N/a
Leukocyte. Ester. N/a

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 URINE MICRO EXAM NORMALS PT. VALUES EXPLANATION OF ABNORMAL VALUES
Urine WBC N/a
Urine RBC N/a
Urine Epithelial N/a
Urine Bacteria N/a
Urine Cast N/a
Urine Crystals N/a
Urine Misc. N/a

The following lab tests were not orderd

COAGULATION

PT __________________________ 11.0-13.0 SEC ________________________

PTT __________________________ 22.0-32.0 SEC ________________________

ABG’s
PH __________________________
pCO2 __________________________
po2 __________________________
BASE _________________________
HCO3 __________________________
O2 SAT.__________________________
7.35-7.45 ________________________
35-45 ________________________
80-100 mmHg ________________________
+ OR – 3 mEq/L________________________
22-26 mEq/L ________________________
95-100% ________________________

OTHER

DIGOXIN _________________________ 1.0-2.0 ________________________

DILANTIN _________________________ 10-20 ________________________
THEOPHYLLIN _________________________ 10-20 ________________________

Other Diagnostic Test:

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 MEDICATION PATIENT ROUTE TIMES CLASSIFICATION MECHANISM PATIENT NURSING
DOSE OF ACTION SPECIFIC IMPLICATIONS
RSD RATIONALE
Adjusted IV PRN .
according to
electrolyte need.
replacement
therapy

5 mg daily po 0900 Vasodilators, dihydropyridine hypertension Check B/P and apical

hypotensive calcium ion heart rate before
amlodipine medicines channel blocke administering

2 drops each Opthalmolic 0900 Ophthalmic solution is Treat

dorzolamide eye 2xd drops glaucoma agents. comprised of two glaucoma
opthalmic components:
Dorzolamide
Hydrochloride and
Timolol Maleate.
Each of these two
components
decreases elevated
intraocular
pressure

40 mg daily IV injection 0900 ntisecretory is a proton pump Treat reflux Monitor for headache,
esomeprazole compounds inhibitor that drowsiness, dry
suppresses mouth, naseau
gastric acid
secretion

1 application topical 0900 topical steroids exact mechanism Hemorrhoids Avoid prolonged use,
2xd 2100 of action is not especially near eyes,
hydrocortisone known in genital and rectal
topical areas, on face, and in
skin creases
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12
 MEDICATION PATIENT ROUTE TIMES CLASSIFICATION MECHANISM PATIENT NURSING
DOSE OF ACTION SPECIFIC IMPLICATIONS
RSD RATIONALE
500 mg IV Q8hr Anti-infectives, Unionized metronidazole is Pevention of doses may need to be
selective for anaerobic reduced in patients
metroidazole Injection antiprotozoals, infection with liver disease and
flagyl antiulcer agents bacteria due to their ability related to abnormal liver function
to intracellularly reduce
metronidazole to its active
ischemic
form. This reduced collits.
metronidazole then disrupts
DNA's helical structure,
inhibiting bacterial nucleic
acid synthesis and resulting
in bacterial cell death.
65 mg PO PRN nalgesic and On selective inhibitors of Fever reducer
acetaminophen antipyretic the enzyme cyclooxygenase
(COX), inhibiting both the
cyclooxygenase-1 (COX-1)
and cyclooxygenase-2 (COX-
2)
isoenzymes. COX catalyzes
the formation
of prostaglandins and
thromboxanefrom arachidonic
acid
3 mg IV Q2hr opiate The presynaptic action of Pain Monitor vital signs,
Injection PRN opioids to inhibit management do not give if
neurotransmitter release is respirations are
morphine considered to be their major less than 10.
effect in the nervous system

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 1. Health problem & data 2. Health problem & data
Pain: assess pain characteristics Quality: Impaired Mobility: Reluctance to attempt
Achy, sharp, throbbing. Severity (scale of 1 movement Limited range of motion
to 10) 8 Location (upper left and right (ROM)Decreased strength Imposed restrictions of
abdominal quads) movement including impaired coordination.
Onset (sudden) Duration (continuous) Inability to perform action as instructed. Assess for
Precipitating or relieving factors: moving, impediments to mobility Identifying the specific
walking touching/ reliving factors, lying still. cause (abdominal pain) Assess patients ability to
Observe or monitor signs and symptoms perform ADLs effectively and safely on a daily
associated with pain, BP 148/88, heart rate basis. suggested Code for Functional Level
86, temperature 98.2, color and moisture of Classification. 4 Is dependent, does not participate in
skin pink, dry, restlessness but able to focus. activity Restricted movement affects the ability to
perform most ADLs. Safety with ambulation is an
Medical/surgical problem & priority assessment data important concern.
Ischemic Cholitis: nausea, vomiting, blood in stool, pain
lower left abdominal region. Pain of 8 on scale of 1/10
onset sudden, duration, continuous. Patient unable to
consume food/ on full liquid diet-intolerable. Bowl signs
present x4. abdomen soft/ not distended, pain upon
palpation/ movement. No lacerations/moles/lesions.
Scarring from 2 previous cesarean sections.

3. Health problem & data

Deficient Fluid Volume: inadequate fluid

intake Active fluid loss (diuresis, abnormal
drainage or bleeding, diarrhea) Failure of
regulatory mechanisms Electrolyte and acid-
base imbalances Increased metabolic rate
(fever, infection) Fluid shifts (edema or
effusions). Obtain patient history to ascertain
the probable cause of the fluid disturbance
(diarrhea). Monitor and document vital signs
T 98.2 P 86 R 16 B/p 148/88 Assess skin
turgor 1 sec and mucous membranes
(pink/moist).

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 HEALTH PROBLEM: ________Pain_____________________________________________________________________________________
Behavioral Outcome (must be measurable and in a time frame):
The patient will _verbalize adequate relief of pain or ability to cope with incompletely relieved pain by end of day of care on
9/29/10_____________ _________________________________________________________________________________

Nursing Interventions (action to meet outcome) Rationale Patient Response

1.
Anticipate need for pain relief. One can
most effectively deal with pain by
preventing it. Early intervention may
decrease the total amount of analgesic
required
1.
One can most effectively deal with pain
by preventing it. Early intervention may
decrease the total amount of analgesic
required
1.
Patient responded well to pain interventions
such as assistance w/getting in and out of bed,
bathing, and reaching.

2. 2. In the midst of painful experiences a 2.

Respond immediately to complaint of patient’s perception of time may become
pain. distorted. Prompt responses to
complaints may result in decreased
anxiety in the patient. Demonstrated
concern for patient’s welfare and comfort
fosters the development of a trusting
relationship.
Patients intolerace of pain was reported to the
nurse and pain meds were given. After
appropriate time, patient experienced less pain
as stated “I feel a little better, but nothing helps
much”.

3.
Use relaxation exercises to bring about a
state of physical and mental awareness
and tranquility. Biofeedback, breathing
exercises, music therapy
3. 3.
The goal of these techniques is to reduce patient responded well to back Massage
tension, subsequently reducing pain. Massaging decrease muscle tension and
appeared to promoted comfort.

4.
notify physician if interventions are
unsuccessful or if current complaint is a
significant change from patient’s past
experience of pain.
4.
Patients who request pain medications at
more frequent intervals than prescribed
may actually require higher doses or
more potent analgesics.
4.
After continuous interventions the patient still
quoted a pain rating of 8 on a 1/10 scale.
Nurse was notified.

May add more if appropriate on back of sheet

Summarize overall progress toward outcome. Was the outcome met, partially met or unmet (explain)?__Outcome was patially met. Patient
verbalized some relief with assistance with ADL’s and therapy such as back massage, but still continued to have a high rating and low tolerance
for pain._________________________________

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 HEALTH PROBLEM: _______Impaired mobility_____________________________________________________________
Behavioral Outcome (must be measurable and in a time frame):
The patient will __ perform physical activity independently or with assistive devices as needed by end of day of care on
09/29/10 .____________________________ __________________________________________________________________________

Nursing Interventions (action to meet outcome) Rationale Patient Response

1. 1. 1.
Assess for developing thrombophlebitis (e.g., Bed rest or immobility promotes clot Patient did not complain of leg pain and
calf pain, Homans’ sign, redness, localized formation. bilateral legs did not show any signs of
swelling, and rise in temperature). swelling or redness

2.
Encourage and facilitate early ambulation and
other ADLs when possible. Assist with each
initial change: dangling, sitting in chair,
ambulation.
2. 2.
The longer the patient remains immobile the Patient complained of pain with movement but
greater the level of debilitation that will occur. was able to ambulate to and from the bedside
commode with assistance.

3. 3. This optimizes circulation to all tissues and 3.Patient was able to turn self and two hour
Turn and position every 2 hours or as needed. relieves pressure. turning schedule was adhered to.

4. 4. 4.
Use prophylactic antipressure devices as This prevents tissue breakdown. Patient was compliant with use of SED’s to
appropriate. promote circulation.

May add more if appropriate on back of sheet

Summarize overall progress toward outcome. Was the outcome met, partially met or unmet (explain)? Overall progress toward outcome was fully
met. Patient was compliant with use of SED’s, and was able to ambulate and perform ADL’s with assistance.
_________________________

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 HEALTH PROBLEM: _____Deficient Fluid Volume_________________________________________________________________
Behavioral Outcome (must be measurable and in a time frame):
The patient will _ experience adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr,
normal blood pressure, heart rate 100 beats/min, and normal skin
turgor____________________________________________________________

Nursing Interventions (action to meet outcome) Rationale Patient Response

1.
Assess skin turgor and mucous
membranes for signs of dehydration.
1. 1.mucous membranes remained pink and moist
The skin in elderly patients loses its throughout the day.
elasticity; therefore skin turgor should be
assessed over the sternum or on the
inner thighs.

2. 2. 2.Patient was encouraged to drink liquids but

Encourage patient to drink prescribed Oral fluid replacement is indicated for this was difficult as she was nauseated. She
fluid amounts. If oral fluids are tolerated, mild fluid deficit. Elderly patients have a was able to tolerate 460ml of tea and a few
provide oral fluids patient prefers. Place decreased sense of thirst and may need bites of green jello before the day’s end.
at bedside within easy reach. Provide ongoing reminders to drink.
fresh water and a straw. Be creative in
selecting fluid sources (e.g., flavored
gelatin, frozen juice bars, sports drink).

3. 3.
Provide oral hygiene. This promotes interest in drinking.
4. 4. Patients need to understand the
Teach interventions to prevent future importance of drinking extra fluid during
episodes of inadequate intake. bouts of diarrhea, fever, and other
conditions causing fluid deficits.
3.
Oral hygiene was provided but effectiveness
could not be determined as the PIC line team
came in right after her bath/oral hygiene.
4.Patient was informed of interventions for
preventing dehydrations.

May add more if appropriate on back of sheet.

Summarize overall progress toward outcome. Was the outcome met, partially met or unmet (explain)? __Overall progress toward outcome was
partially met. Patient did void twice during time of care and drank at least 400 ml of decaffeinated tea, however, adequate intake of fluids were
not met. Blood pressure remained elevated throughout the day pulse remained WNL as did skin turgor._________________________________

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___________________________________________________________________________________________________________
__________

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Patient Information:

Age _________71____Allergies ________nka__________

Code Status _____full_____ Physical Handicaps none______________

Primary Language ___English_________ Fall Precautions __y______ Isolation precautions

n________________
Medical Diagnosis/Illnesses:
Ischemic Cholitis, Acute Renal Failure

Event of current illness: Pertinent past medical history:

Patient admitted to hospital with chronic Chronic hypertension, chronic leg pain, malaise,
diarrhea and vomiting, unable to keep down last several days, left colon inflamed, UTI,
food or liquids, pain in left lower abdominal Leukocytosis, abdominal pain, glaucoma
region, malaise last several days

Results of X-rays, labs, cultures, or scans Anticipated tests, labs, surgeries, procedures,
related to disease process: appointments for clinical day:

PICC line insertion

Priority Health Problem & Nursing Notes:

Assessments: (s/s indicate pt is experiencing
complications)
Ischemic Cholitis: nausea, vomiting, blood in
stool, pain lower left abdominal region. Pain
of 8 on scale of 1/10 onset sudden, duration,
continuous. Patient unable to consume food
or liquids.

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