om pain
NUR 106 Clinical Worksheet Student Name:
Clinical Week of Care: 2/9-2/13/15 Facility: Cottonwood Room #: A08
Pt. Initials: Pt. Age: 68 Pt. Gender :M
Allergies: Adhesive, Amitriptyline, Hydromorphone, Zolpidem-tartrate, Clindamycin Ethnicity: Cauc. Religion: Protestant
Social Support: Wife in Dgo, Education: Police academy Occupation: Retired police
Admit Date: 01/26/15
Present Diagnosis: Rehabilitation procedure NEC, Orthopedic aftercare NEC, Depressive disorder, Chronic pain NEC, Hypertension NEC, Insomnia NOS, Alcohol cirrhosis liver. Stump is still draining, swollen (2/19)
Code Status: I (full)
Reason for admission to Facility: Rehab for AKA (Above the Knee Amputation)
Past Medical History (from chart):Chronic pain, traumatic blindness right eye, COPD, Asthma, restless leg syndrome, obstructive sleep apnea, AFIB, sick sinus syndrome, HTN, venous insufficiency, cirrhosis(liver),esophageal varices with bleed. Admitting/ Attending Physician: Dr Andreas/ Burnside
Diet ordered:Regular Activity Ordered: Up as tolerated/PT
Transfer Assistance: 1-person

Toileting:Assist Isolation: No Oxygen: 3 L/min
Finger Sticks: NA

Vital Signs from Previous Shift: T:98.2f P:84 R:18 BP:129/83
Height: 6’1” Weight:232lbs. BMI:30.6

IV Site: none IV Fluids: none Last 24 hrs intake: na Output: na

Patient Introduction (2-3 sentences):RM is a a 68 year old male. A former Los Angeles police sergeant (25 yrs), and most recently a Redi-Mix concrete driver, RM is a real class act. He is facing the fact that he “might not live as long as he previously thought”. But he is accepting his condition rather than wallowing in pity, and is grateful to have some relief from his chronic pain. He experiences PLP (phantom limb pain). He previously had a total left knee arthroplasty that his