UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Amber Morin |
|MSI & MSII Patient Assessment Tool . |Assignment Date: 2/10/15 |
| ( 1 PATIENT INFORMATION |Agency: FHT |
|Patient Initials: ST |Age: 60 |Admission Date: 1/14/15 |
|Gender: M |Marital Status: Single |Primary Medical Diagnosis: Efferent limb obstruction; Cirrhosis |
|Primary Language: English | |
|Level of Education: Bachelors of Chemistry and Zoology |Other Medical Diagnoses: (new on this admission) |
|Occupation (if retired, what from?): Clinical Lab Technician | |
|Number/ages children/siblings: No children; Brother is 64 and sister is 53. | |
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|Served/Veteran: No |Code Status: Full resuscitation |
|If yes: Ever deployed? Yes or No | |
|Living Arrangements: Lives by himself; at discharge patient will stay at a skilled nursing |Advanced Directives: No |
|facility for 3 weeks, and then return home. |If no, do they want to fill them out? No |
| |Surgery Date: N/A Procedure: N/A |
|Culture/ Ethnicity /Nationality: White | |
|Religion: N/A |Type of Insurance: Optimum Health Care |
|( 1 CHIEF COMPLAINT: Nausea, vomiting, and abdominal pain. |
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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay) On 1/14/15 patient arrived to the emergency department|
|with nausea, vomiting, and abdominal pain. Pain, nausea, and vomiting have occurred intermittently since his pancreaticoduodenectomy surgery (whipple), performed |
|due to pancreatic cancer, in March of 2012. However, the pain, nausea, and vomiting got progressively worse over the 2 days prior to admission. Nausea, vomiting, |
|and pain most often followed meals, but could occur even when he had not eaten. Patient also reported dark spots in emesis, which was concluded to be partially |
|digested blood from anastomotic ulcer. A CT scan on 1/14/15 revealed a large volume of ascites with cirrhotic changes, and a dilated stomach and duodenum. On |
|1/15/15, patient underwent a paracentesis that removed 2 liters of fluid. On 2/4/15, an EGD confirmed efferent limb obstruction, diffuse esophagitis, stomach |
|mucosa that was diffusely erythematous, a patent anastomosis of the stomach and jejunum, but a large white ulcer on the site of the anastomosis, and a possible |
|efferent lumen obstruction. Due to vomiting, the patient presented to the ED hypovolemic and hypokalemic. Patient also presented anemic due to altered liver |
|function. The patient had 4 hospitalizations in 2014 due to the same presenting symptoms, the most recent being Christmas day of 2014. On 2/9/15 patient received |
|total parenteral nutrition due to lack of intake. Patient has also experienced two hypoglycemic episodes during hospitalization. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of disease
|Date |Operation or Illness |
|March 2012 |Pancreatic cancer |
|March 2012 |Pancreaticoduodenectomy surgery |
|March 2012 |Venous access port implanted |
|12/25/2014 & 3 other |Admission due to N/V and abdominal pain accompanied with dehydration and hypokalemia. |
|hospitalizations in 2014 | |
|1/14/15 |Admission to hospital with anemia, electrolyte imbalances (hypokalemia and hypocalcemia), and dehydration |
|1/15/15 |Paracentesis |
|1/16/15 |Esophagogastroduodenoscopy |
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|( 2 FAMILY MEDICAL HISTORY |
|( 1 immunization History |
|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |
|Routine childhood vaccinations | | |
|Routine adult vaccinations for military or federal service | | |
|Adult Diphtheria (Date) | | |
|Adult Tetanus (Date) Is within 10 years? U | | |
|Influenza (flu) (Date) Is within 1 years? U | | |
|Pneumococcal (pneumonia) (Date) Is within 5 years? 12/25/15 | | |
|Have you had any other vaccines given for international travel or occupational purposes? Please List | | |
If yes: give date, can state “U” for the patient not knowing date received
|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |
|REACTIONS |Causative Agent | |
|Medications | |N/A |
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|Other (food, tape, latex, dye, |Latex |Itching, burning dermatitis |
|etc.) | | |
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|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |
|genetic factors impacting the diagnosis, prognosis or treatment) |
|Mechanics of Disease: Obstruction of the efferent or afferent limbs of the gatrojejunal anastomosis is a complication of a pancreaticoduodenectomy or whipple |
|surgery (Kwong, Fehmi, Lowy, & Savides, 2014). |
|Risk Factors: technical errors, edema, malignancy, adhesions, radiation induced strictures, and internal hernias (Kwong, Fehmi, Lowy, & Savides, 2014). |
|How to diagnose: CT scan, abdominal pain, nausea, vomiting, and distension. |
|How to treat: efferent limb obstruction is fixed surgically, with balloon dilation, or stents (Kwong, Fehmi, Lowy, & Savides, 2014). |
|Prognosis: Surgical intervention is normally successful, but considering the malignancy of the pancreatic cancer, many patients still do not live more than 3 |
|months after the surgical correction (Kwong, Fehmi, Lowy, & Savides, 2014). |
( 5 Medications: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN medication . Give trade and generic name.]
|Name dextromethorphan (Mucinex) |Concentration |Dosage Amount 1 Tab |
|Route PO |Frequency BID |
|Pharmaceutical class allergy, cold, and cough; antitussive |Home Hospital or Both |
|Indication effective for nonproductive cough; relief of coughs caused by minor upper respiratory tract infections or inhaled irritants. |
|Adverse/ Side effects dizziness, sedation, nausea |
|Nursing considerations/ Patient Teaching May cause dizziness |
|Name furosemide (Lasix) |Concentration |Dosage Amount 20mg |
|Route INJ, IV |Frequency BID |
|Pharmaceutical class loop diuretics |Home Hospital or Both |
|Indication Edema due to hepatic impairment |
|Adverse/ Side effects erythemia multiform, stevens-johnson syndrome, toxic epidermal necrolysis, dehydration, hypocalcemia, hypochloremia, hypokalemia, |
|hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis, aplastic anemia, agranulocytosis |
|Nursing considerations/ Patient Teaching Assess fluid status, monitor BP and pulse, assess patient for skin rash and discontinue at first sign of rash. May be |
|taken with food or milk to minimize gastric irritation. Change positions slowly, eat a high potassium diet. Contact health care provider immediately if rash, |
|muscle weakness, cramps, nausea, dizziness, numbness or tingling of the extremities occur. |
|Name fluconazole (Diflucon) |Concentration |Dosage Amount 200mg |
|Route INJ, IV |Frequency BID |
|Pharmaceutical class antifungal |Home Hospital or Both |
|Indication Fungal infections |
|Adverse/ Side effects hepatotoxicity, stevens-johnson syndrome |
|Nursing considerations/ Patient Teaching assess patient for rash, monitor LFT before and during therapy (may increase AST, ALT, serum alkaline phosphate, and |
|bilirubin concentrations. |
|Name insulin lispro |Concentration |Dosage Amount sliding scale |
|Route Subcut |Frequency |
|Pharmaceutical class pancreatics |Home Hospital or Both |
|Indication Control of hyperglycemia in patients with diabetes mellitus |
|Adverse/ Side effects hypoglycemia, anaphylaxis |
|Nursing considerations/ Patient Teaching Assess for symptoms of hypoglycemia; administer 15 minutes before a meal, rotate injections sites. Instruct patient on |
|signs of hypoglycemia; teach patients to carry a form of glucose with them. |
|Name metoprolol (Lopressor) |Concentration |Dosage Amount 12.5mg |
|Route PO |Frequency BID |
|Pharmaceutical class beta blocker |Home Hospital or Both |
|Indication HTN, anxiety |
|Adverse/ Side effects fatigue, weakness, bradycardia, heart failure, pulmonary edema, |
|Nursing considerations/ Patient Teaching monitor BP, ECG, and pulse frequently; take apical pulse before administering; abrupt withdrawal may precipitate |
|life-threatening arrhythmias, HTN, or myocardial ischemia. Notify health care provider if slow pulse, difficulty breathing, wheezing, cold hands and feet, |
|dizziness, light-headedness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occurs. |
|Name pancrelipase (Creon) |Concentration |Dosage Amount 1 cap |
|Route PO |Frequency 3 times a day |
|Pharmaceutical class pancreatic enzymes |Home Hospital or Both |
|Indication chronic pancreatitis, pancreatectomy, ductal obstruction secondary to tumor |
|Adverse/ Side effects fibrosing colonopathy, abdominal pain, nausea, stomach cramps |
|Nursing considerations/ Patient Teaching assess patients nutritional status, monitor stools for high fat content; advise health care professional of symptoms of |
|abdominal pain, distension, vomiting, and constipation |
|Name pantoprazole (Protonix) |Concentration |Dosage Amount 40mg |
|Route IVJ, IV |Frequency BID |
|Pharmaceutical class proton pump inhibitor |Home Hospital or Both |
|Indication treatment and prevention of GI ulcers and erosive esophagitis |
|Adverse/ Side effects pseudomembranous colitis, abdominal pain, diarrhea, hypomagnesemia |
|Nursing considerations/ Patient Teaching assess for abdominal pain or for blood in stool or emesis. |
|Name saccharomyces boulardii (Probiotics) |Concentration |Dosage Amount 1 cap |
|Route PO |Frequency BID |
|Pharmaceutical class antidiarrheals |Home Hospital or Both |
|Indication treatment and prevention of diarrhea |
|Adverse/ Side effects bloating, contripation, fungemia |
|Nursing considerations/ Patient Teaching assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function |
|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |
|Diet ordered in hospital? Full liquid |Analysis of home diet (Compare to “My Plate” and |
|Diet patient follows at home? Solids as tolerated |Consider co-morbidities and cultural considerations): |
|24 HR average home diet: | |
|Breakfast: 1 egg, half a piece of white bread (if he can tolerate it) |The patient is low on all food groups. The patient also has a low calorie intake |
| |at 765 calories a day. Also, this is on a very good day for the patient. His diet|
| |is often not tolerated like this. Some days he may be getting as little as half |
| |of the calories. The patient should consider drinking more Ensure shakes since |
| |they have high calories and are nutrient dense. Considering the size of his GI |
| |tract, it will be difficult to increase his food intake by very much so the |
| |shakes will really be beneficial for him. Also, the patient needs to be on |
| |vitamin supplements since he is not getting all the vitamins and minerals he |
| |needs. |
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|Lunch: Half a can of soup (tomato, pea soup) | |
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|Dinner: Half a small chicken breast, half a cup of broccoli (if tolerated) | |
|Lately the patient has not been able to keep most of these foods down without | |
|vomiting. Even water has been an issue at home. These are foods he eats when he | |
|can tolerate food. | |
|Snacks: apple sauce, jello, | |
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|Liquids (include alcohol): Ensure shakes, water | |
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|[pic] |Use this link for the nutritional analysis by comparing the patients 24 HR |
| |average home diet to the recommended portions, and use “My Plate” as a reference.|
|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |
|Who helps you when you are ill? |
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|How do you generally cope with stress? or What do you do when you are upset? |
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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |
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|+2 DOMESTIC VIOLENCE ASSESSMENT |
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|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |
|am going to ask some questions that help me to make sure that you are safe.” |
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|Have you ever felt unsafe in a close relationship? __________No_____________________________________________ |
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|Have you ever been talked down to?___No____________ Have you ever been hit punched or slapped? ____No__________ |
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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? |
|____________No___________ If yes, have you sought help for this? ___________N/A___ Are you currently in a safe relationship? N/A |
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|( 4 DEVELOPMENTAL CONSIDERATIONS: |
|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |
|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair |
|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |
|patient’s age group: The stage of Generativity vs. self-absorption/stagnation is a period where “we establish our careers and families and develop a sense of being|
|a part of the bigger picture” (McLeod). During this time, many feel as though they give back to the community by raising their children and being involved in the |
|community. If we do not feel as though we are giving back, we can become stagnant (McLeod). |
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|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |
|I believe the patient is in the stage of stagnation. The patient has a history of alcohol abuse, is single, and has no children. He also has a fair amount of guilt|
|about his brother’s over dose. The patient feels he cannot thoroughly enjoy his hobby of gardening due to his inability to eat food with high fiber content. Since |
|he has not appeared to give anything back to the community and seems unhappy, the stage of stagnation seems appropriate. |
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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |
|Not being able to do the activities he enjoys would certainly affect his developmental stages, leading to stagnation. |
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|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” |
|The patient does not think anything caused his illness. |
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|What does your illness mean to you? |
|Patient said that it does not mean anything to him. |
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|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |
|Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |
|usually related to either infection, changes with aging and/or quality of life. All of these questions are confidential and protected in your medical record” |
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|Have you ever been sexually active?____Yes________________________________________________________________ |
|Do you prefer women, men or both genders? ________women_____________________________________________________ |
|Are you aware of ever having a sexually transmitted infection? __No_____________________________________________ |
|Have you or a partner ever had an abnormal pap smear?_________No______Have you or your partner received the Gardasil (HPV) vaccination? |
|_______No____________________________________ |
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|Are you currently sexually active? __No________If yes, are you in a monogamous relationship? ______N/A_____When sexually active, what measures do you take to |
|prevent acquiring a sexually transmitted disease or an unintended pregnancy? ____condoms______________________________ |
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|How long have you been with your current partner?__N/A_____________________________ |
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|Have any medical or surgical conditions changed your ability to have sexual activity? __abdominal pain and N/V__________________ |
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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |
|No |
±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
_______________N/A_______________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
____________No__________________________________________________________________________________________
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|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |
|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |
| If so, what? |How much?(specify daily amount) |For how many years? N/A X years |
| | |(age thru ) |
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|Pack Years: N/A | |If applicable, when did the patient quit? N/A |
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|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? No|Has the patient ever tried to quit? N/A |
| |If yes, what did they use to try to quit? N/A |
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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |
| What? Liquor |How much? Patient responded with “too much” |For how many years? |
| |Volume: |(age 20 thru 55 ) |
| |Frequency: Used to be everyday | |
| If applicable, when did the patient quit? 2010 | | |
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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |
| If so, what? Marijuana |
| |How much? unknown |For how many years? |
| | |(age 20 thru present ) |
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| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |
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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |
|X-ray exposure when working in healthcare. |
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|5. For Veterans: Have you had any kind of service related exposure? |
|N/A |
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( 10 Review of Systems Narrative
| |Gastrointestinal |Immunologic |
| | Nausea, vomiting, or diarrhea (no diarrhea) | Chills with severe shaking |
|Integumentary | Constipation Irritable Bowel | Night sweats |
| Changes in appearance of skin (edema has caused | GERD Cholecystitis | Fever |
|weeping of skin) | | |
| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |
| Dandruff | Hemorrhoids Blood in the stool | Lupus |
| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |
| Hives or rashes | Pancreatitis | Sarcoidosis |
| Skin infections | Colitis | Tumor |
| Use of sunscreen SPF: | Diverticulitis | Life threatening allergic reaction |
|Bathing routine: Every other day |Appendicitis | Enlarged lymph nodes |
|Other: | Abdominal Abscess |Other: |
| | Last colonoscopy? 2012 | |
|HEENT |Other: |Hematologic/Oncologic |
| Difficulty seeing (need new prescription) |Genitourinary | Anemia |
| Cataracts or Glaucoma | nocturia | Bleeds easily |
| Difficulty hearing | dysuria | Bruises easily |
| Ear infections | hematuria | Cancer (pancreatic) |
| Sinus pain or infections | polyuria | Blood Transfusions |
|Nose bleeds | kidney stones |Blood type if known: |
| Post-nasal drip |Normal frequency of urination: x/day |Other: |
| Oral/pharyngeal infection | Bladder or kidney infections | |
| Dental problems |Patient complains of dribbling and pressure |Metabolic/Endocrine |
| |occasionally. | |
| Routine brushing of teeth 1 x/day | | Diabetes Type: |
| Routine dentist visits x/year | | Hypothyroid /Hyperthyroid |
|Vision screening | | Intolerance to hot or cold (from anemia) |
|Other: | | Osteoporosis |
| | |Other: |
|Pulmonary | | |
| Difficulty Breathing; COPD | |Central Nervous System |
| Cough - dry or productive |Women Only | CVA |
| Asthma | Infection of the female genitalia | Dizziness |
| Bronchitis | Monthly self breast exam | Severe Headaches |
| Emphysema | Frequency of pap/pelvic exam | Migraines |
| Pneumonia | Date of last gyn exam? | Seizures |
| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |
| Environmental allergies | menarche age? | Encephalitis |
|last CXR? | menopause age? | Meningitis |
|Other: |Date of last Mammogram &Result: |Other: |
| |Date of DEXA Bone Density & Result: | |
|Cardiovascular |Men Only |Mental Illness |
|Hypertension | Infection of male genitalia/prostate? | Depression |
| Hyperlipidemia | Frequency of prostate exam? | Schizophrenia |
| Chest pain / Angina | Date of last prostate exam? | Anxiety |
|Myocardial Infarction | BPH | Bipolar |
| CAD/PVD |Urinary Retention |Other: |
|CHF |Musculoskeletal | |
|Murmur | Injuries or Fractures |Childhood Diseases |
| Thrombus | Weakness | Measles |
|Rheumatic Fever | Pain | Mumps |
| Myocarditis | Gout | Polio |
| Arrhythmias | Osteomyelitis | Scarlet Fever |
| Last EKG screening, when? 12/2015 |Arthritis | Chicken Pox |
|Other: |Other: |Other: |
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|General Constitution |
|Recent weight loss or gain |
|How many lbs? 35lbs |
|Time frame? 3 years |
|Intentional? No, from nausea, vomiting, and stomach pain. |
|How do you view your overall health? “Not very good.” Patient obviously thinks it is a concern that he cannot eat very much due to vomiting. |
|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |
|Ascites, cirrhosis, and an inguinal hernia. |
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|Any other questions or comments that your patient would like you to know? |
|The patient asked me to tell the nurse that he has an inguinal hernia. |
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|±10 PHYSICAL EXAMINATION: |
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|General Survey: |
|60 y/o male; sunken in face due to weight loss; flat affect |
|Height: unknown |
|Weight 60kg |
|BMI: unknown |
|Pain: (include rating and location) 4 out of ten in abdomen. |
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|Pulse 109 |
|Blood Pressure: (include location) |
|113/92 brachial |
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|Respirations 24 |
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|Temperature: (route taken?) 97.9 oral |
|SpO2 99 |
|Is the patient on Room Air or O2 |
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|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |
| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |
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|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |
| awake, calm, relaxed, interacts well with others, judgment intact |
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|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |
| clear, crisp diction |
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|Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat |
| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |
|Other: |
|Integumentary |
| Skin is warm, dry, and intact Skin turgor elastic (fair) No rashes, lesions, or deformities (edema) |
| Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin |
|If anything is not checked, then use the blank spaces to |
|describe what was assessed in the physical exam that |
|was not WNL (within normal limits) |
| Central access device Type: 20 gage Location: upper arm Date inserted: 2/4/15 |
|Fluids infusing? no yes - what? |
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|HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline |
| Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge |
| Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |
| PERRLA pupil size 3 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |
| Ears symmetric without lesions or discharge Whisper test heard: (not necessary) right ear- inches & left ear- inches |
| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |
|Dentition: |
|Comments: |
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|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |
|Percussion resonant throughout all lung fields, dull towards posterior bases |
|Sputum production: thick thin Amount: scant small moderate large |
|Color: white pale yellow yellow dark yellow green gray light tan brown red |
|Lung sounds: |
|RUL clear LUL clear |
|RML diminished LLL diminished |
|RLL diminished |
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|CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent |
|Cardiovascular: No lifts, heaves, or thrills |
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|Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |
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|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |
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|Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |
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|Apical pulse: Carotid: Brachial: Radial: +2 Femoral: Popliteal: DP: +2 PT: |
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|No temporal or carotid bruits Edema: +4 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |
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|Location of edema: pitting non-pitting |
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|Extremities warm with capillary refill less than 3 seconds; feet were cold, but pulses and color were good. Rest of extremities were warm. |
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|GI Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |
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|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation; slightly tender |
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|Last BM: (date 2 / 9 / 15 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |
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|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |
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|Nausea emesis Describe if present: |
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|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |
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|Other – Describe: |
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|GU Urine output: Clear Cloudy Color: Previous 24 hour output: mLs N/A |
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|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |
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|CVA punch without rebound tenderness |
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|Musculoskeletal: ( Full ROM intact in all extremities without crepitus |
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|Strength bilaterally equal at ___5____ RUE ____5___ LUE __4_____ RLE & ____4___ in LLE |
|[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] |
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|vertebral column without kyphosis or scoliosis |
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|Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia |
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|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |
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|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |
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|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride; difficulty walking due to weakness. |
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|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |
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|Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: |
|positive negative |
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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |
|diagnostic tests): |
|Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need prior to and after surgery, and pertinent to |
|hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that |
|is done preop) then include why you expect it to be done and what results you expect to see. |
| |
|Lab |
|Dates |
|Trend |
|Analysis |
| |
|ALT H 76 |
|2/4/15 |
| |
|This was the only value listed. |
|Assesses liver function. The normal range for a 60 year old male is 10-40 units/L. ALT is increased in cirrhosis, pancreatitis, AIDS, hepatic carcinoma, and chronic |
|alcohol abuse (Van Leeuwen, Poelhuis-Leth, & Bladh, 2013). |
| |
|Na L 129, L 133, 135 |
|2/9, 2/8, 2/7 respectively |
|On 2/7, the patient’s Na was WNL. The Na has trended downwards. |
|Assesses sodium which is related to hydration levels and disorders such as diarrhea and vomiting, and to monitor diuretic use (Van Leeuwen, Poelhuis-Leth, & Bladh, |
|2013). Decreased in excessive use of diuretics, hepatic failure, hypoproteinemia, and insufficient intake (Van Leeuwen, Poelhuis-Leth, & Bladh, 2013). |
| |
|K 3.9, 4.0, L 3.3 |
|2/9, 2/8, 2/7 respectively |
|The patient’s potassium levels have been fluctuating. |
|Used to assess potassium levels which is related to disorders such as acidosis, renal failure, and dehydration. Decreased in alcoholism, alkalosis, vomiting, |
|diarrhea, nasogastric sunction, hyperaldoteronism, and sweating (Van Leeuwen, Poelhuis-Leth, & Bladh, 2013). |
| |
|Cl L 93, L 95, L 96 |
|2/9, 2/8, 2/7 |
|Patient’s chloride level has been trending downward. |
|Used to assess chloride level which is related to water balance, digestion, and acid-base balance (Van Leeuwen, Poelhuis-Leth, & Bladh, 2013). Decreased in DKA, HF, |
|excessive sweating, vomiting, diarrhea, nasogastric suction, alkalosis, and overhydration (Van Leeuwen, Poelhuis-Leth, & Bladh, 2013). |
| |
|Ca C 6.9, L 7.2, L 7.3 |
|2/9, 2/8, 2/7 |
|Calcium is trending downwards. |
|Calcium is involved in coagulation, neuromuscular conduction, intracellular regulation, glandular secreation, and control of skeletal and cardiac muscle (Van |
|Leeuwen, Poelhuis-Leth, & Bladh, 2013). Decreased in pancreatitis, alcoholism, alkalosis, renal failure, cirrhosis, hypoalbuminemia, inadequate nutrition, and renal |
|tubular disease (Van Leeuwen, Poelhuis-Leth, & Bladh, 2013). |
| |
|Alkaline Phosphatase H 151 |
|2/4/15 |
|This was the only value listed |
|To assist in the diagnosis of liver cancer and cirrhosis (Van Leeuwen, Poelhuis-Leth, & Bladh, 2013). Increased in liver disease and bone disease (Van Leeuwen, |
|Poelhuis-Leth, & Bladh, 2013). |
| |
|CT |
|1/14/15 |
|No trend |
|CT scan revealed a large volume of fluid and dilation of the GI tract. |
| |
|Paracentesis |
|1/15/15 |
|No trend |
|This patient had removal of 2 L of fluid. |
| |
|EGD |
|2/4/15 |
|No trend |
|The EGD revealed an efferent limb obstruction and an ulcer |
| |
|TPN |
|2/9/15 |
|No trend |
|Given due to malnutrition and GI narrowing and efferent limb obstruction. |
| |
| |
|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: |
|ACHS, Full liquid diet, Physical Therapy, Occupational Therapy, Case Management |
| |
| |
|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
| |
|1. Electrolyte imbalance r/t vomiting aeb hypokalemia, hypocalcemia, and hyponatremia |
| |
| |
| |
|2. Deficient fluid volume r/t vomiting aeb hypotension, tachycardia, and electrolyte imbalances |
| |
| |
| |
|3. Imbalanced nutrition: less than body requirements r/t nausea, vomiting, abdominal pain, and cirrhotic changes aeb efferent limb obstruction, cirrhosis, |
|electrolyte imbalances, significant weight loss, and ascites |
| |
| |
| |
|4. Activity intolerance r/t imbalanced nutrition, edema, and nausea aeb musculoskeletal weakness |
| |
| |
| |
|5. Constipation r/t decreased fluid and food intake aeb less bowel movements, abdominal pain, and abdominal distension |
| |
| |
| |
| |
| |
± 15 CARE PLAN
Nursing Diagnosis: Electrolyte imbalance r/t vomiting aeb hypokalemia, hypocalcemia, and hyponatremia
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |
| | |Provide References | |
|The patient will maintain a normal sinus rhythm with |Monitor vital signs and heart rhythm. |Electrolyte imbalances can lead to orthostatic |The patient maintained a normal sinus rhythm with a |
|a regular rate. | |hypotension, bradycardia, tachycardia, respiratory |regular rate. |
| | |depression, and EKG changes (Ackley & Ladwig, 2011, | |
| | |p. 343). | |
|The patient will maintain normal serum potassium, |Review laboratory data and report deviations to |Lab data can include serum electrolytes, serum pH, |Lab data was reviewed regularly but, the patient had |
|sodium, calcium, and pH. |provider. |comprehensive metabolic panel, and atrial natriuretic|low sodium and calcium. |
| | |peptide (Ackley & Ladwig, 2011, p. 343). | |
| |Monitor the effects of diuretics and heart |These medications can have an adverse effect on |Medication effects were monitored. |
| |medications. |electrolyte balance such as depleting or increasing | |
| | |potassium levels (Ackley & Ladwig, 2011, p. 344). | |
| |Review the patient’s medical and surgical history. |Certain conditions and surgeries such as this |The patient’s history was reviewed. |
| | |patient’s cirrhosis and whipple surgery, can effect | |
| | |electrolyte balance. Periods of fluid loss can lead | |
| | |to loss of electrolytes (Ackley & Ladwig, 2011, p. | |
| | |344). | |
| |Complete pain assessment. |Muscle cramps, parathesias, abdominal cramps, and |Pain assessments were completed. |
| | |tetany can be symptoms of electrolyte imbalance and | |
| | |dehydration (Ackley & Ladwig, 2011, p. 344). | |
| |Administer parenteral fluids as ordered and monitor |Fluids may be necessary to restore intravascular |Fluids were administered when needed. |
| |effects. |volume, hemodynamic stability, and tissue perfusion. | |
| | |Excess fluid replacement can lead to electrolyte | |
| | |imbalances (Ackley & Ladwig, 2011, p. 344). | |
|The patient will have a decrease in edema. |Monitor for abdominal distension and discomfort. |Fluid and electrolyte imbalances can cause changes in|The patient was monitored for these symptoms and did |
| | |GI mucosal perfusion and GI tract edema, which leads |experience them. |
| | |to pain (Ackley & Ladwig, 2011, p. 344). | |
|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
|Consider the following needs: |
|□SS Consult |
|□Dietary Consult |
|□PT/ OT |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appointments |
|□Med Instruction/Prescription |
|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
± 15 CARE PLAN
Nursing Diagnosis: Imbalanced nutrition: less than body requirements r/t nausea, vomiting, abdominal pain, and cirrhotic changes aeb efferent limb obstruction, cirrhosis, electrolyte imbalances, significant weight loss, and ascites
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |
| | |Provide References | |
|The patient will progressively gain weight toward |Provide the patient with small quantities of |Since the patient has narrowing of the GI tract, |The patient was only able to tolerate a liquid diet, |
|goal. |energy-dense and protein-enriched food. |small meals will be necessary to maintain nutrition |but was given high protein drinks. |
| | |(Ackley & Ladwig, 2011, p. 577). | |
| |Monitor state of oral cavity. Provide good oral |Poor oral hygiene interferes with food intake. The |The patient’s oral hygiene was assessed. |
| |hygiene. |oral mucosa must be moist, with adequate salvia | |
| | |production to aid in digestion (Ackley & Ladwig, | |
| | |2011, p. 577). | |
| |Consult with a dietician regarding the use of liquid |The patient has a minimally functioning GI tract and |The patient drank these supplement drinks. |
| |product that contains an increased amount of protein |is malnourished. | |
| |and calories. | | |
|The patient will be free of signs of malnutrition. |Monitor for signs of malnutrition: brittle hair, dry |Monitoring for signs of malnutrition can help |Goal not met. |
| |skin, pale skin and conjunctiva, muscle wasting, rash|understand the patient’s nutrition state (Ackley & | |
| |over lower extremities, and disorientation. |Ladwig, 2011, p. 577). | |
| |Review laboratory results such as serum albumin, |An albumin level of less than 3.5 is considered poor |These laboratory results were not listed in the |
| |prealbumin, serum total protein, hemoglobin, |nutritional status (Ackley & Ladwig, 2011, p. 576). |patient’s chart. |
| |hematocrit, and electrolytes | | |
| |Watch for signs of symptoms of infection. |Protein-energy malnutrition is associated with |No infection signs or symptoms were observed. |
| | |decrease in immunity (Ackley & Ladwig, 2011, p. 577).| |
|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
|Consider the following needs: |
|□SS Consult |
|□Dietary Consult |
|□PT/ OT |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appointments |
|□Med Instruction/Prescription |
|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
References
Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, Missouri: Mosby, Inc., an affiliate of Elsevier Inc.
Kwong, W. T., Fehmi, S. M., Lowy, A. M., & Savides, T. J. (2014). Enteral stenting for gastric outlet obstruction and afferent limb syndrome following pancreaticoduodenectomy. Annals of Gastroenterology, 27(4), 413-417.
McLeod, S. A. (2008). Erik Erikson. Retrived from
Vallerand, A. H., Sanoski, C. A., & Deglin, J. H., & Mansell, H. G. (2014). Davis’s Drug Guide for Nurses (13th ed.). F.A. Davis Company.
Van Leeuwen, A. M., Poelhuis-Leth, D. J., & Bladh, M. L. (2013). Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests with Nursing Implication. F.A. Davis Company.
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