Name: Akuba Nketsiah. Date: 11/19/2021 1
Patient Profile Worksheet: Part 1
Clinical Date: __11 / _19_ / _2021_
A. Personal Information
Room # _36_ Gender _F_ Ethnicity _W_ Age if <90 __77
Place of Residence: Home MD Shawn Michael
Emergency Contact: Not Listed_ Marital Status Divorced
Admitting Diagnosis & any additional current diagnosis: Abscess breast right, Type 2 diabetes and hypertension.
Co-Morbidities: _ Paroxysmal atrial fibrillation, venous stasis dermatitis, coronary artery disease DM neuropathies, Hypercholestemia, lower extremity edema and morbid obesity. _
Date of Admission: 11/01/2021__ Date of Surgery: _NA_ Allergies: Penicillin, erythromycin, statins and sulfamethoxazole
Code Status: Full Code_ Mental Status: Alert X4
B. Activity and Nutrition
Diet order: ADA/Diabetic 3 meals_ Enteral Nutrition _Not listed Route/Rate if enteral: _Not listed Last Wt: 111.8 kg
Level of Activity (bedrest, up ad lib, BRP, turning): _ _ADLS_ _
Level of self-care: _Assist X 1
C. Nursing Care
Drainage devices (foley, NGT, JPs, T-tube, etc.): Not Listed_ NGT Flushes: Not Listed_
Wound care/Dressing (be specific): Right breast wound, saline, irrigate with saline
IV access (peripheral, central, location, care): Peripheral IV upperarm right 22 guage
IVF: _not listed_ @ _not listed_ mL/hr Saline Lock? No_ TPN? _Not Listed_
Frequency of vital signs (including pulse oximetry): Every shift_
Frequency of Glucometer: ACHS Supplemental oxygen: __not Listed OSA Yes
Falls Risk _Yes
Most Recent Labs
If H/L: Why?
Sign of infection
There is too much sugar in the blood.
(Van Leeuwen & Bladh, 2017)
Date & Time
(Cardiac, Pulmonary, Radiological, other)
Vital Signs – 3 most recent
Breast consult/ right breast abscess status post I&D
History of Present Illness:
Ms. Williams, a 77 year old female with a medical history significant for insulin dependent diabetes, hyperlipdemia, hypertension, morbid obesity, paraxymal atrial fibrillation, pacemaker placement, coronary artey disease and chronic venous stasis disease. She was admitted to the hospital on 10/25/21 secondary to a right breast abscess. She was initially evaluated in the outpatient clinic and recommendation was for urgent surgical intervention. She underwent an incision and drainage of a right breast abscess as well as debridement of necrotic tissue. She was seen initially treated with vancomycin. Once cultures returned she was transitioned to Rocephin. Her hemoglobin A1C was found to be greater than 9. She was seen in consultant by the hospital diabetes management sever. She was also seen by the hospital due to hypertension. Her antihypertensives were increased. She continues to have episode of hypertension. Admitted for further management for ongoing wound management, hypertension and improve diabetic care.
Past Medical History:
Abnormal weight gain
Risk for fall
Long term use if insulin
Type 2 diabetes
Venous stasis dermatitis
Past Surgical History:
Father- coronary artery disease/ heart attack
Grandparent- coronary artery disease
Tobacco N/A__ Alcohol __N/A Non-prescribed Drugs (including vitamins, homeopathic remedies, illicit/illegal, etc.) N/A__
Occupational Status _Retired_
Religious Preference _Baptist_
Cultural Support Needs _Not Listed
Plan for Shift Care
Prioritize the Hypothesis:
Patient care priority for shift (List top priority issue based on ABC. What is the patient care priority for the shift?) Click or tap here to enter text.
Recognize and Analyze Cues:
What information from the worksheet part 1 lead you to choose this priority? .
Desired patient outcome for the shift (using priority above)
List three interventions for this shift that will your help patient to attain this desired outcome
Evaluation of Outcome:
(Generic & Trade)
Dosage & Frequency
Use for this specific patient
(Why is this specific patient receiving this specific medication?)
Potential Side Effects for this Patient
(List up to 5 possible s/e for which you will monitor this specific patient.)
Nursing Implications: Pre-administration
(What will you do prior to administration?)
Nursing Implications: Post-administration
(What cues will indicate this medication’s positive effect?)
(Humulin R U-500)
* PRN medications administered within the past 24 hours (Vallerand & Sanoski, 2017)
Patient Profile Worksheet: Part 2
GENERAL: (overall assessment)
Appearance consistent with stated age
HEENT: (ED only)
Ears poor hearing, nose patent without lesions, No JVD or accessory muscle
CARDIAC: (heart sounds, rate, rhythm, pulses, circulation, etc)
Regular rate and rhythm
RESPIRATORY: (lung sounds, work of breathing, O2 sat)
No rales or wheezes and cough
ABDOMEN/GI: (bowel sounds, overall assessment)
No masses, Soft non tender, non-tender, non-distended with normoactive bowel sounds, bowel sounds present
GU: (urinary output, catheters, etc.)
Voiding no catheters
MUSCULOSKELETAL: (strength, gait, mobility status)
Weak, assist X 2
INTEGUMENT: (list any wounds, dressings, other issues)
Stage 3 sacral decubitus, wound vac
NEURO: (A&O x 4, pupils, etc.)
Alert oriented X 2, eyes pupil equally round and reactive
Student name: Akuba Nkestiah
Planning and Evaluation
Data that you gathered from your assessment and chart review that will guide your ongoing care of this patient. Subjective and objective information. Examples: Abnormal Labs, abnormal diagnostic tests, and abnormal assessment findings. What is the proof you have selected the correct nursing dx?
Analyze Cues to Prioritize Hypothesis
For each nursing diagnosis include:
1) “Actual” vs “Risk for”
2) Nursing diagnosis
3) r/t statement
Desired Patient Outcomes (Goals) and Post-shift Evaluation
List 2 Nursing Action Interventions.
Do not use assessments.
within _4_ hours.
__ not met (no progress)
Timeframe: within 2 hours
The patient will:
Patient demonstrates appropriate motor behavior.
within _throughout the shift.
__ not met (no progress)
(Ackley et al., 2020)
Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
Vallerand, A.H. & Sanoski, C.A. (2019). Davis’s drug guide for nurses (16th ed.). F.A. Davis. https://tinyurl.com/ez7s8ccu
Van Leeuwen, A., & Bladh, M. (2017). Davis’s comprehensive handbook of laboratory and diagnostic tests with nursing implications (7th ed.). F. A. Davis Company. https://tinyurl.com/4p74nhhl