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Make an NCP (ADPIE)

Make an NCP (ADPIE)

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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Make an NCP (ADPIE)
List the subjective data described in this case study. 2. List the objective data described in this case study CASE STUDY 2 Mark Lyons is a 41-year-old man on the orthopedic unit. Listed in the next paragraph are data collected by the nurse during an interview and assessment. Interview Data Mark states, "I fell eff my horse while riding. The horse stepped on my leg and crushed the bone in my upper leg." He complains of pain in his right leg and states that the pain medication helps only a little. He wants to move but cannot because of an external fixator device. Mark says, "My butt hurts because I can't move around." He tells the nurse, "I have not had a bowel movement for 3 days; the last time I had a bowel movement the stool looked like hard, dry rabbit turds. Normally at home I go every day." Mark has not been hungry either. He says that "the food is horrible." He also complains that he is so bored he can't stand it. "I'm used to being active, being stuck in bed is driving me crazy. Television shows aren't worth watching." xamination Data Vital signs: BP, 108/72 mm Hg; pulse, 88 beats/min; respiration, 16 breaths/min; temperature, 98.1° F (36.7° C); height, 5 ft 5 in (165 cm); weight, 135 lb (61 kg). • Medication: Percocet 1 or 2 by mouth every 4 to 6 hours as needed for pain. He has taken 2 every 6 hours over the last several days. ml/day. • Diet: Regular diet. Has eaten, on average, 30% of meals. Fluid intake has averaged 1000 • Activity: Patient is on complete bed rest. • Respiratory: Breathing even/unlabored. Lungs clear to auscuitation bilaterally. • Cardiovascular: All distal pulses in lower extremities palpable. Heart rate and rhythm regular. No peripheral edema. • Abdomen: Slightly distended. Bowel sounds auscultated throughout abdomen. • Musculoskeletal: Right leg in skeletal traction. Reports sensation to foot/toes, rapid capillary refill. Other extremities: full range of motion. No pain over joints and muscles. • Integument: Skin warm and dry. Pin sites for external fixation device without redness or drainage. 2 in-diameter redness over sa rum. Skin intact. Prepared by: GIRLIE ACCAD, RN,MSN
Transcribed Image Text:List the subjective data described in this case study. 2. List the objective data described in this case study CASE STUDY 2 Mark Lyons is a 41-year-old man on the orthopedic unit. Listed in the next paragraph are data collected by the nurse during an interview and assessment. Interview Data Mark states, "I fell eff my horse while riding. The horse stepped on my leg and crushed the bone in my upper leg." He complains of pain in his right leg and states that the pain medication helps only a little. He wants to move but cannot because of an external fixator device. Mark says, "My butt hurts because I can't move around." He tells the nurse, "I have not had a bowel movement for 3 days; the last time I had a bowel movement the stool looked like hard, dry rabbit turds. Normally at home I go every day." Mark has not been hungry either. He says that "the food is horrible." He also complains that he is so bored he can't stand it. "I'm used to being active, being stuck in bed is driving me crazy. Television shows aren't worth watching." xamination Data Vital signs: BP, 108/72 mm Hg; pulse, 88 beats/min; respiration, 16 breaths/min; temperature, 98.1° F (36.7° C); height, 5 ft 5 in (165 cm); weight, 135 lb (61 kg). • Medication: Percocet 1 or 2 by mouth every 4 to 6 hours as needed for pain. He has taken 2 every 6 hours over the last several days. ml/day. • Diet: Regular diet. Has eaten, on average, 30% of meals. Fluid intake has averaged 1000 • Activity: Patient is on complete bed rest. • Respiratory: Breathing even/unlabored. Lungs clear to auscuitation bilaterally. • Cardiovascular: All distal pulses in lower extremities palpable. Heart rate and rhythm regular. No peripheral edema. • Abdomen: Slightly distended. Bowel sounds auscultated throughout abdomen. • Musculoskeletal: Right leg in skeletal traction. Reports sensation to foot/toes, rapid capillary refill. Other extremities: full range of motion. No pain over joints and muscles. • Integument: Skin warm and dry. Pin sites for external fixation device without redness or drainage. 2 in-diameter redness over sa rum. Skin intact. Prepared by: GIRLIE ACCAD, RN,MSN
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