LA County Medical Center School of Nursing - Rx Yearbook (Los Angeles, CA)

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CUURT DEW. No man is an island entire of itself, every rnan is a piece of the continent, a part ofthe main. .. Any man's death diminishes l am involved in mankind. me, because John Donne Occupational Therapy 'I7

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Checking out those keys. ,Li

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CLINICAL NURSING WORKSHEET Dates of Care 2-17, 2-18 1971 Nursing Problem Emphasis lclassl O2!CO2 Amitting Diagnosis Chronic alcoholism, G-I bleeder, cirrohosis of the liver, RXO esophageal va rices, seizu re disorder, CVA Final Diagnosis Cirrohosis of liver, esophageal va rices, CVA, seizure disorder Patient's initial 81 PF if A.S. Age 45 years Sex Male . Developmental Task lpredictedl Level Dependency vs lndependency Nursing Problems land needsl I. lmmobilityz leftsided hemiparesis KNO aphasia, eyesight difficulty. Unable to support wt. on L. side or move extremities Able to contract muscles in affected hand, arm and leg, has sensation A. Difficulty carrying out ADL B. More prone to URI and pneumonia C. More prone to constipation and bladder stasis D. Tends to be dependent Cthe more you do for him the more demanding he seems to becomej E. More prone to skin breakdown CHas reddened areas on buttocksb Relate Knowledge fCite Sourcel Respiratory complications plague the disabled. , ,The pt. who has suffered a CVA with resultant paralysis is prone to hypostatic pneumonia Beland, p. 832 Skin breakdown is always a matter of grave concern to the paralyzed pt. , , Lack of sensation andfor motor paralysis chances of skin breakdown. Prolonged pressure over bony prominence causes a lack of circulation which is the etiology of a pressure sore. Beland, p. 828 Decreased mobility and lack of exercise can create problems of stasis Cperistalsis and bladder tone decreasedb