UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDACOLLEGE OF NURSINGStudent: Pricilla PuentePatient Assessment Tool .Assignment Date: 11 October 2013 -52705-105410+1 PATIENT INFORMATION: 00+1 PATIENT INFORMATION: FORMATIONAgency: Tampa General Hospital-5APatient Initials: R.R. Age: 63Admission Date: 07 October 2013Gender: Female Marital Status: Married Primary Medical Diagnosis with ICD-10 code:Acute on Chronic Renal Failure 584.9Primary Language: EnglishOther Medical Diagnoses:Abdominal Pain 789.00Leukocytosis 288.60Sepsis 995.91Tachycardia 785.0 Level of Education: GED Occupation (if retired, what from?): Retired CNA Number/ages children/siblings:1 son—39 y.o.2 daughters—42 y.o. & 45 y.o. 1 sister—68 y.o. 1 brother—52 y.o.Code Status: Full Code Advance Directives: NoneServed/Veteran: NoLiving Arrangements: Lives with fiancé in houseSurgery Date: no upcoming surgeries Procedure: n/a Culture/ Ethnicity /Nationality: AmericanReligion: Methodist Type of Insurance: Medicaid 3137535127000+1 CHIEF COMPLAINT: “I was sick for about 2 weeks. I came to the hospital when it got to the point that I couldn’t eat and began vomiting constantly.” +3 HISTORY OF PRESENT ILLNESS: R.R. is a 63 year-old female with past medical history of Crohn’s disease, left UPJ obstruction, interstitial cystitis, chronic UTIs, bilateral hydronephrosis, and a grade 4 vesicoureteral reflux who underwent radical cystectomy with urinary diversion on 8/05/2013 and presented to TGH with 3 weeks of nausea, 4 days of emesis. Per patient, eating made her symptoms worsen and was given Zofran at hospital which helped the nausea. In the ED she became hypotensive, was found to have AFib with RVR and was admitted to MICU. She was placed on a Ditiazem drip and is now in sinus rhythm. PT is on IV Vancosyn for urosepsis. In regards to the patient’s N/V, emesis was 12x per day for 3 days but has improved over the last day per patient. She says emesis was dark, liquidy, non-bloody. Pt denied any diarrhea and has not had a BM for 3 days. She normally has a BM every other day. PT states her BMs have not been bloody and is having abdominal pain around unclosed incision site. CT of abdomen pelvis shows no evidence of acute pathology, shows a surgical defect in the soft tissues of the anterior abdominal wall inferiorly with mild stranding. She was diagnosed with CD 5 years ago by colonoscopy. Pt was on Pentasa from diagnosis until 1 year ago. She has never been on steroids. Per pt last colonoscopy was 2 years ago with no findings. +2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORYDate Operation or Illness2000Crohn’s Disease 2011Kidney Stones 2011Pacemaker 2011Acid Reflux2011 Depression2011Irregular Heart Beat 2012Sick Sinus Syndrome 2012Anxiety +2 FAMILY MEDICAL HISTORYAge (in years)Cause of Death (if applicable)AlcoholismEnvironmental AllergiesAnemiaArthritisAsthmaBleeds EasilyCancerDiabetesGlaucomaGoutHeart TroubleHypertensionKidney ProblemsMental Health ProblemsSeizuresStomach UlcersStrokeTumorFather54Heart Attack FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mother82 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Brother52 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sister68 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comments: Patient states that HTN lead to her mother’s stroke. +1 IMMUNIZATION HISTORY: YesNoRoutine childhood vaccinations FORMCHECKBOX FORMCHECKBOX Routine adult vaccinations for military or federal service FORMCHECKBOX FORMCHECKBOX Adult Diphtheria (U) FORMCHECKBOX FORMCHECKBOX Adult Tetanus (Date) FORMCHECKBOX FORMCHECKBOX Influenza (flu) (Date) FORMCHECKBOX FORMCHECKBOX Pneumococcal (pneumonia) (Date) FORMCHECKBOX FORMCHECKBOX Have you had any other vaccines given for international travel or occupational purposes? Please List FORMCHECKBOX FORMCHECKBOX +1 ALLERGIES OR ADVERSE REACTIONSNAME of Causative AgentType of Reaction (describe explicitly)MedicationsErythromycin Rash, nausea/vomiting LopressorBP ↓Other (food, tape, latex, dye, etc.)+5 PATHOPHYSIOLOGY:Acute renal failure (ARF) develops suddenly and can usually be reversed with treatment, but if the condition causing the failure is not treated, the patient will progress to end-stage renal disease, uremic syndrome, and death (Osborn, Wraa, & Watson, 2010, p. 1477). Acute kidney failure occurs when your kidneys suddenly become unable to filter waste products from your blood. When kidneys lose ther filtering ability, dangerous levels of wastes may accumulate and blood levels may get out of balance. The main pathomechanism of ARF is acute tubuar necrosis (ATN) due to reduced perfusion of the renal cortex resulting in ischemic injury. Acute renal failure is often complicated by pre-existing renal disease, ongoing toxic injury or nnon-recovery of systemic circulation. The reason of tubular injury may be based on pre-renal causes, glomerular and/or interstitial disorders or obstructive neuropathy. Therapy must be specifically targeted on the underlying causes to overcome ARF. ARF develops rapidly over a few hours or a few days. ARF is most common in people who are already hospitalized, particularly in ill people who need intensive care. If kidneys function is not reconstituted in an appropriate time period, renal replacement therapy must be initiated. Dialysis helps patients achieve a maximum of metabolic, volume, and electrolyte control (Mayo Clinic, 2013). ARF may be reversible. Chronic renal failure is generally not reversible and often gets progressively worse. The symptoms of chronic renal failure often appear when approximately two-thirds of filtration capacity is lost. When a patient reaches end stage renal disease (ESRD) it is the final stage of failure. If the patient continues without treatment, uremic toxins accumulate and cause potentially fatal physiologic changes in all of the major organ systems (Osborn, Wraa, & Watson, 2010, p. 1480).+5 Medications: Name Ciprofloxacin (CIPRO)Concentration 1 x 500mg tabletDosage Amount 500mgRoute POFrequency Q12 hours Pharmaceutical class fluoroquinolones Home Hospital X or Both Indication treatment of bacterial infections, such as urinary tract and gynecologic infections, skin and skin structure infectionsSide effects/Adverse effects elevated intracranial pressure, seizures, agitation confusion, depression, dizziness, drowsiness, hallucinations, headache, insomnia, nightmares, tremor, pseudomembranous colitis, abdominal pain, diarrhea, nausea, increased liver enzymes, vaginitis, photosensitivity, rash, hyperglycemia, hypoglycemia, phlebitis at IV site, tendinitis, peripheral neuropathy, anaphylaxis (Deglin, Vallerand, & Sanoski, 2012).Name Folic Acid (FOLVITE)Concentration 1 x mg tabletDosage Amount 1 mgRoute POFrequency Daily Pharmaceutical class vitamin Home Hospital X or Both Indication prevention of megaloblastic ad macrocytic anemias Side effects/Adverse effects rash, irritability, difficulty sleeping, malaise, confusion, fever (Deglin, Vallerand, & Sanoski, 2012).Name Heparin (PORCIN) InjectionConcentration 1mL = 5,000units Dosage Amount 5000 units Route Subcutaneous Frequency Q8 hours Pharmaceutical class antithromboticHome Hospital X or Both Indication prophylaxis and treatment of venous thromboembolism, pulmonary emboli, atrial fibrillation with emobilization Side effects/Adverse effects drug-induced hepatitis, alopecia, rashes, urticarial, bleeding, HIT, anemia, pain at injection site, osteoporosis, fever, hypersensitivity (Deglin, Vallerand, & Sanoski, 2012).Name Hydromorphone (DILAUDID)Concentration 0.5mg of 1mg/mLDosage Amount 0.5mgRoute Intravenous Frequency Q4 hours PRN Pharmaceutical class opioid agonists Home Hospital X or Both Indication moderate to severe pain Side effects/Adverse effects confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred vision, diplopia, miosis, respiratory depression, hypotension, bradycardia, constipation, dry mouth, nausea, vomiting, urinary retention, flushing, sweating, physical dependence (Deglin, Vallerand, & Sanoski, 2012).Name Ondansetron (ZOFRAN)Concentration 4mg/2mL Dosage Amount 4mg Route IntravenousFrequency Q4 hours PRNPharmaceutical class five HT3 antagonistHome Hospital X or Both Indication prevention of nausea and vomiting Side effects/Adverse effects headache, dizziness, drowsiness, fatigue, weakness, torsade de pointes, QT interval prolongation, constipation, diarrhea, abdominal pain, dry mouth, increased liver enzymes, extrapyramidal reactions (Deglin, Vallerand, & Sanoski, 2012).Name Pantoprazole (PROTONIX)Concentration 40mgDosage Amount 40mgRoute Intravenous Frequency Every morning before breakfast Pharmaceutical class proton pump inhibitorHome Hospital X or Both Indication erosive esophagitis associated with GERD, pathologic gastric hypersecretory conditions Side effects/Adverse effects headache, abdominal pain, diarrhea, flatulence, hyperglycemia, hypomagnesaemia, bone fracture (Deglin, Vallerand, & Sanoski, 2012).+5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.Diet ordered in hospital? Regular Diet pt follows at home? Regular24 HR average home diet: Breakfast-Patient states that she usually eats eggs, bacon, toast. Lunch- Patient usually eats a sandwich or fast food for lunch. Dinner- Patient usually eats hamburger, chicken, turkey, with mashed potatoes or another side.Snack-Patient states that she snacks on “small things” throughout the day, such as popcorn, or crackers.Liquids (include alcohol)-Patient states she does not consume alcohol. She usually drinks water, tea, or soda. Analysis of home diet (Compare to “MyPlate” and consider co-morbidities and cultural considerations): Due to the patient’s present diet, I will focus on teaching her how to consume a smart nutritious diet. I will educate the patient on how to follow the “My Plate” values when making smart food choices. I will teach patient how a controlled protein diet is recommended o control uremia. Following a protein-modified diet is associated with a decreased risk of death associated with renal disease in patients with eisting kidney failure (Osborn, Wraa, & Watson, 2010, p. 311). To achieve the most efficient metabolism, the majority of protein consumed should be of high biological value having all essential aminio acids, such as animal proteins (meats, poulty, fish, dairy) and soy. Nutrition management of altered fluid status and plasma electrolyte mineral abnormalities also is recommended with renal failure patients. Protein and potassium restrictions vaary according to treatment mode and lab values so a registered dietician consult should be ordered. Noncompliance with a potassium restriction can result in quick deterious consequences with elevated blood potassium leading to lethal cardiac dysrhythmias and cardiac arrest (Osborn, Wraa, & Watson, 2010, p. 312). Some foods high in potassium that the patient should avoid include, bananas, dried fruits, green leafy vegetables, legumes, melon, organes, potato, tomato, whole grains. +1 COPING ASSESSMENT/SUPPORT SYSTEM: Who helps you when you are ill? “My fiancé”How do you generally cope with stress? “Cry or screaming helps”What do you do when you are upset? “Cry or scream”Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life): All of the above r/t “being sick all the time.” +2 DOMESTIC VIOLENCE ASSESSMENT: Have you ever felt unsafe in a close relationship? YesHave you ever been talked down to? YesHave you ever been hit punched or slapped? YesHave you been emotionally or physically harmed in other ways by a person in a close relationship with you?? YesIf yes, have you sought help for this? Patient states she did not seek help for this as it was her ex-husband. Are you currently in a safe relationship? Yes +4 DEVELOPMENTAL CONSIDERATIONS: Erikson’s stage of psychosocial development: FORMCHECKBOX Trust vs. FORMCHECKBOX Mistrust FORMCHECKBOX Autonomy vs. FORMCHECKBOX Doubt & Shame FORMCHECKBOX Initiative vs. FORMCHECKBOX Guilt FORMCHECKBOX Industry vs. FORMCHECKBOX Inferiority FORMCHECKBOX Identity vs. FORMCHECKBOX Role Confusion/Diffusion FORMCHECKBOX Intimacy vs. FORMCHECKBOX Isolation FORMCHECKBOX Generativity vs. FORMCHECKBOX Self absorption/Stagnation FORMCHECKBOX Ego Integrity vs. FORMCHECKBOX DespairGenerativity versus stagnation is the seventh stage of Erikson’s theory of psychosocial development. This stage takes place during middle to late adulthood. In middle adulthood (age 40s, 50s, and later for some). During this stage, adults strive to create or nurture things that will outlast them; by having children or contributing to positive changes that benefits other people. Contributing to society and doing things to benefit future generations are important needs at the generativity versus stagnation stage of development. Generativity refers to "making your mark" on the world, through caring for others, creating things and accomplishing things that make the world a better place. Stagnation refers to the failure to find a way to contribute. R.R. exhibits generativity as she feels that she has transmitted something positive to the next generation (her outlook on life to her children). R.R as taught her family good family values and that her and her family’s lives have improved since she left her husband causing her to make a positive change in life. She believes she has set a good example for her daughter by finding someone who treats her as s a wife should be treated. R.R. does not exhibit any evidence of stagnation as she does not feel disconnected with society as a whole (Osborn, Wraa, & Watson, 2010, p. 253).+3 CULTURAL ASSESSMENT: What do you think is the cause of your illness? Patient believes kidney stones were the cause of her ilnness, She states that she was “fine until having surgery for removal” and feels that she has “fallen apart since then.” What does your illness mean to you? “It’s affected my life as /I now have a permanent urostomy to care for.” +3 SEXUALITY ASSESSMENT: Have you ever been sexually active? Yes Do you prefer women, men, or both genders? MenAre you aware of ever having a sexually transmitted infection? NoHave you or a partner ever had an abnormal pap smear? Yes r/t infection Have you or your partner received the Gardasil (HPV) vaccination? NoAre you currently sexually active? Seldomly When sexually active what measures do you take to prevent acquiring a sexually transmitted disease or unintended pregnancy? Nothing b/c pt states she had a tubal ligation How long have you been with your current partner? 11 yearsHave any medical or surgical conditions changed your ability to have sexual activity? Yes Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? No+1 SPIRITUALITY ASSESSMENT: What importance does religion or spirituality have in your life? High importanceDo your religious beliefs influence your current condition? Per patient, somewhat +3 Smoking, Chemical use, Occupational/Environmental Exposures:Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes, smoked cigarettes from age 18 through 48. Smoked 1 pack every 3 days. She quit 5 years ago, Does the patient drink alcohol or has he/she ever drunk alcohol? Yes, drank mixed drinks from her early 20s through age 53. She quit 10 years ago. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? NoHave you ever, or are you currently exposed to any occupational or environmental Hazards/Risks? No+10 Review of Systems:General ConstitutionGastrointestinalImmunologic FORMCHECKBOX Recent weight loss r/t illness FORMCHECKBOX Nausea, diarrhea FORMCHECKBOX Chills with severe shaking (Hx)Integumentary FORMCHECKBOX Constipation FORMCHECKBOX Irritable Bowel FORMCHECKBOX Night sweats FORMCHECKBOX Changes in appearance of skin FORMCHECKBOX GERD FORMCHECKBOX Cholecystitis FORMCHECKBOX Fever FORMCHECKBOX Problems with nails FORMCHECKBOX Indigestion FORMCHECKBOX Gastritis / Ulcers FORMCHECKBOX HIV or AIDS FORMCHECKBOX Dandruff FORMCHECKBOX Hemorrhoids FORMCHECKBOX Blood in the stool FORMCHECKBOX Lupus FORMCHECKBOX Psoriasis FORMCHECKBOX Yellow jaundice FORMCHECKBOX Hepatitis FORMCHECKBOX Rheumatoid Arthritis FORMCHECKBOX Hives or rashes—rashes FORMCHECKBOX Pancreatitis FORMCHECKBOX Sarcoidosis FORMCHECKBOX Skin infections FORMCHECKBOX Colitis FORMCHECKBOX Tumor FORMCHECKBOX Use of sunscreen yes SPF: n/a FORMCHECKBOX Diverticulitis FORMCHECKBOX Life threatening allergic reactionBathing routine: every other day FORMCHECKBOX Appendicitis FORMCHECKBOX Enlarged lymph nodesOther: FORMCHECKBOX Abdominal AbscessOther: FORMCHECKBOX Last colonoscopy? 3 years ago HEENTOther:Hematologic/Oncologic FORMCHECKBOX Difficulty seeing (blurry vision)Genitourinary FORMCHECKBOX Anemia FORMCHECKBOX Cataracts or Glaucoma FORMCHECKBOX nocturia FORMCHECKBOX Bleeds easily FORMCHECKBOX Difficulty hearing FORMCHECKBOX dysuria FORMCHECKBOX Bruises easily FORMCHECKBOX Ear infections FORMCHECKBOX hematuria FORMCHECKBOX Cancer FORMCHECKBOX Sinus pain or infections FORMCHECKBOX polyuria FORMCHECKBOX Blood Transfusions (Hx) FORMCHECKBOX Nose bleeds FORMCHECKBOX kidney stones—history of Blood type if known: O+ FORMCHECKBOX Post-nasal dripNormal frequency of urination: 4-5 x/dayOther: FORMCHECKBOX Oral/pharyngeal infection FORMCHECKBOX Bladder or kidney infections FORMCHECKBOX Dental problems—dentures Other: constant UTI, painful urinationMetabolic/Endocrine FORMCHECKBOX Routine brushing of teeth 1 x/dayUrostomy FORMCHECKBOX Diabetes Type: FORMCHECKBOX Routine dentist visits x/year FORMCHECKBOX Hypothyroid /Hyperthyroid FORMCHECKBOX Vision screening FORMCHECKBOX Intolerance to hot or coldOther: Denture care FORMCHECKBOX OsteoporosisOther:PulmonaryWomen Only FORMCHECKBOX Difficulty Breathing (SOB) FORMCHECKBOX Infection of the female genitaliaCentral Nervous System FORMCHECKBOX Cough FORMCHECKBOX Monthly self breast exam FORMCHECKBOX CVA FORMCHECKBOX Asthma FORMCHECKBOX Frequency of pap/pelvic exam FORMCHECKBOX Dizziness FORMCHECKBOX Bronchitis Date of last gyn exam? “yearly” FORMCHECKBOX Severe Headaches FORMCHECKBOX Emphysema FORMCHECKBOX menstrual cycle regular irregular FORMCHECKBOX Migraines FORMCHECKBOX Pneumonia FORMCHECKBOX menarche age? 9/10 y.o FORMCHECKBOX Seizures FORMCHECKBOX Tuberculosis FORMCHECKBOX menopause age late 30s y.o FORMCHECKBOX Ticks or Tremors FORMCHECKBOX Environmental allergiesDate of last Mammogram &Result: FORMCHECKBOX Encephalitis FORMCHECKBOX last CXR? Date of DEXA Bone Density & Result: FORMCHECKBOX MeningitisOther:Other: Other: numbness to left armCardiovascularMen OnlyMental Illness FORMCHECKBOX Hypertension FORMCHECKBOX Infection of male genitalia/prostate? FORMCHECKBOX Depression FORMCHECKBOX Hyperlipidemia FORMCHECKBOX Frequency of prostate exam? FORMCHECKBOX Schizophrenia FORMCHECKBOX Chest pain / Angina Date of last prostate exam? FORMCHECKBOX Anxiety FORMCHECKBOX Myocardial Infarction FORMCHECKBOX BPH FORMCHECKBOX Bipolar FORMCHECKBOX CAD/PVD FORMCHECKBOX Urinary RetentionOther: FORMCHECKBOX CHFMusculoskeletal FORMCHECKBOX Murmur FORMCHECKBOX Injuries or Fractures—cracked tailbone Childhood Diseases FORMCHECKBOX Thrombus FORMCHECKBOX Weakness—difficulty ambulating FORMCHECKBOX Measles FORMCHECKBOX Rheumatic Fever FORMCHECKBOX Pain FORMCHECKBOX Mumps FORMCHECKBOX Myocarditis FORMCHECKBOX Gout FORMCHECKBOX Polio FORMCHECKBOX Arrhythmias –afib FORMCHECKBOX Osteomyelitis FORMCHECKBOX Scarlet Fever FORMCHECKBOX Last EKG screening, when? 2013 FORMCHECKBOX Arthritis FORMCHECKBOX Chicken PoxIs the any problem that is not mentioned that your patient sought medical attention for with anyone? No Any other questions or comments that your patient would like you to know? No+10 PHYSICAL EXAMINATION: (Describe abnormal assessment below non checked boxes) Orientation and level of Consciousness: Patient is alert and oriented to person, place, and time. She responds appropriately to questions. Patient appropriately groomed and obese. General Survey: Patient is well developed, well-nourished 66 year-old white female. Height: 5’5” (165.1 cm)8001004635500Weight: 210lbs (in bed)BMI: 35.99kg/(m^2) Pain: 0/10 Pulse: 70 BPMBlood Pressure: 120/65 right armTemperature:97.8 F (36.6 C) oralRespirations: 20SpO2 100%Is the patient on Room Air or O2: room airOverall Appearance: [Dress/grooming/physical handicaps/eye contact] FORMCHECKBOX clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicapsOverall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] FORMCHECKBOX awake, calm, relaxed, interacts well with others, judgment intactPatient was AOx4, awake, interacts well with others, calm, cooperative, appropriate judgments; relaxedSpeech: [e.g.: clear/mumbles /rapid /slurred/silent/other] FORMCHECKBOX clear, crisp dictionClear with appropriate pace Mood and Affect: FORMCHECKBOX pleasant FORMCHECKBOX cooperative FORMCHECKBOX cheerful FORMCHECKBOX talkative FORMCHECKBOX quiet FORMCHECKBOX boisterous FORMCHECKBOX flat FORMCHECKBOX apathetic FORMCHECKBOX bizarre FORMCHECKBOX agitated FORMCHECKBOX anxious FORMCHECKBOX tearful FORMCHECKBOX withdrawn FORMCHECKBOX aggressive FORMCHECKBOX hostile FORMCHECKBOX loud Other: depressed Integumentary x—rash x—rash x—4023360-1841500surgical sites FORMCHECKBOX Skin is warm, dry, and intact FORMCHECKBOX Skin turgor elastic FORMCHECKBOX No rashes, lesions, or deformities FORMCHECKBOX Nails without clubbing FORMCHECKBOX Capillary refill < 3 seconds FORMCHECKBOX Hair evenly distributed, clean, without vermin Skin appropriate color for ethnicity. Scars from surgical history. Rashes on upper extremities. FORMCHECKBOX Peripheral IV site Type: 22G peripheral IV Location: left hand Date inserted: 10/11/2013 FORMCHECKBOX no redness, edema, or discharge Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what? FORMCHECKBOX Central access device Type: PICC line Location: left arm Date inserted: November 2012? FORMCHECKBOX no redness, edema, or discharge Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what? HEENT: FORMCHECKBOX Facial features symmetric FORMCHECKBOX No pain in sinus region FORMCHECKBOX No pain, clicking of TMJ FORMCHECKBOX Trachea midline FORMCHECKBOX Thyroid not enlarged FORMCHECKBOX No palpable lymph nodes FORMCHECKBOX sclera white and conjunctiva clear; without discharge FORMCHECKBOX Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness Functional vision: right eye - left eye - FORMCHECKBOX without corrective lenses right eye - left eye - FORMCHECKBOX with corrective lensesFunctional vision both eyes together: FORMCHECKBOX with corrective lenses or FORMCHECKBOX NA FORMCHECKBOX PERRLA pupil size / 3 mm FORMCHECKBOX Peripheral vision intact FORMCHECKBOX EOM intact through 6 cardinal fields without nystagmus FORMCHECKBOX Ears symmetric without lesions or discharge FORMCHECKBOX Whisper test heard: right ear- 2 inches & left ear- 2 inches FORMCHECKBOX Weber test, heard equally both ears Rinne test, air time(s) longer than bone FORMCHECKBOX Nose without lesions or discharge FORMCHECKBOX Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesionsDentition: patient has dentures Comments: Pulmonary/Thorax: FORMCHECKBOX Respirations regular and unlabored FORMCHECKBOX Transverse to AP ratio 2:1 FORMCHECKBOX Chest expansion symmetric -1384305778500 FORMCHECKBOX Lungs clear to auscultation in all fields without adventitious soundsCL – Clear FORMCHECKBOX Percussion resonant throughout all lung fields, dull towards posterior bases WH – Wheezes FORMCHECKBOX Tactile fremitus bilaterally equal without overt vibrationCR – Crackles FORMCHECKBOX Sputum production: thick thin Amount: scant small moderate large RH – Rhonchi Color: white pale yellow yellow dark yellow green gray light tan brown redD – Diminished S – Stridor Lung sounds D in right and left lower lobesAb – AbsentLung sounds CL in right and left upper lobes Cardiovascular: FORMCHECKBOX No lifts, heaves, or thrills PMI felt at: 5th intercostal space mid-clavicular lineHeart sounds: S1 S2 Regular FORMCHECKBOX No murmurs, clicks, or adventitious heart sounds FORMCHECKBOX No JVD FORMCHECKBOX Calf pain bilaterally negative FORMCHECKBOX Pulses bilaterally equal Apical pulse: 3+ Carotid: 3+ Brachial: 2+ Radial: 2+ Femoral: 1+ Popliteal: 1+ DP: 2+ PT: 2+ FORMCHECKBOX No temporal or carotid bruits Edema: 0 FORMCHECKBOX Extremities warm with capillary refill less than 3 secondsGI/GU: FORMCHECKBOX Bowel sounds normal x 4 quadrants; no bruits auscultated FORMCHECKBOX No organomegaly Liver span 3.5 cm FORMCHECKBOX Percussion dull over liver and spleen and tympanic over stomach and intestine FORMCHECKBOX Abdomen tender to palpation around incision site. Dressing clear, dry, in tact Urine output: FORMCHECKBOX Clear FORMCHECKBOX Cloudy Color: clear Previous 24 hour output: 30CC/hour FORMCHECKBOX Foley Catheter FORMCHECKBOX Urinal or Bedpan FORMCHECKBOX Bathroom Privileges with minimal assistance FORMCHECKBOX CVA punch without rebound tenderness Last BM: (date 10 / 11 / 2013 ) Loose stool Color: BrownGenitalia: FORMCHECKBOX Clean, moist, without discharge, lesions or odor FORMCHECKBOX Not assessed, patient alert, oriented, denies problems Other: urostomy bag, mid incision wound OTA Musculoskeletal: Full ROM intact in all extremities without crepitus FORMCHECKBOX Strength bilaterally equal at _3_ in UE & _3_ in LE [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] FORMCHECKBOX vertebral column without kyphosis or scoliosis FORMCHECKBOX Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesiasNeurological: FORMCHECKBOX Patient awake, alert, oriented to person, place, time, and date FORMCHECKBOX Confused; if confused attach mini mental exam FORMCHECKBOX CN 2-12 grossly intact FORMCHECKBOX Sensation intact to touch, pain, and vibration FORMCHECKBOX Romberg’s Negative FORMCHECKBOX Stereognosis, graphesthesia, and proprioception intact FORMCHECKBOX Gait smooth, regular with symmetric length of the strideDTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: negative Babinski: negative Comments: Moves all extremities. PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS: Lab/TestResultPertinent NormalsDatesTrendRationale/AnalysisBUN29 ↑23 ↑6-20 MG/DL10/10/1310/11/13BUN levels have remained elevated. Increased BUN levels are not as reliable an indicator of renal damage as serum creatinine levels, because BUN is easily changed by protein intake. Indicated glomerular filtration. (Osborn, Wraa, & Watson, 2010, p. 1477)Creatinine 2.1 ↑2.0 ↑0.5-1.2 MG/DL10/10/1310/11/13Creatinine levels have remained elevated. Indicates impaired glomerular filtration (Osborn, Wraa, & Watson, 2010, p. 1477). Potassium3.63.53.5-5.3 MMOL/L10/10/1310/11/13Within normal range. Increased potassium can indicate impaired filtration (Osborn, Wraa, & Watson, 2010, p. 1477).Sodium138139135-148 MEQ/L10/10/1310/11/13Within normal range. Decreased sodium can indicate dilution occurring (Osborn, Wraa, & Watson, 2010, p. 1477).Phosphorus2.4 ↓3.32.7-4.5 MG/DL 10/10/1310/11/13Phosphorus was low and has increased. Increased phosphorus indicates impaired filtration (Osborn, Wraa, & Watson, 2010, p. 1477).Calcium 7.7 ↓7.6 ↓8.5-10.5MG/DL10/10/1310/11/13Calcium has remained low. Decreased calcium is a response to increased phosphorus (Osborn, Wraa, & Watson, 2010, p. 1477). CT Abdomen 4.6-10.2 K/UL10/7/2013 A CT may identify cause of kidney dysfunction. No evidence of acute pathology or significant change when compared to prior examination. Postsurgical changes r/t cystectomy RLQ ileal conduit reconstruction. There is a surgical defect in the soft tissues of the anterior abdominal wall inferiorly with mild stranding. The fascia layers appear to remain intact. No evidence of renal stones or significant hydronephrosis. Focal 1cm hypodensity w/I left kidney may represent a cyst, a dilated calyx, or scarring. +2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:Control any pain patient may have Place patient on Fall Precautions and assistance out of bed Vitals Q4 hours to monitor that there are no significant changes Strict bed rest with activity in bed to promote independence (OOB with PT or lift team)Measure I & O’s with every meal, IV, fluids (per 24hours)3160 ml PO and IV intake at 10/11/13 07501100 ml output urine Monitor lab valuesRegular mechanical soft diet b/c of dentures No current planned procedures Wound care x2 daily Potential D/C 10/13/2013 +8 NURSING DIAGNOSES: (actual and potential –listed in order of priority)Risk for ineffective renal perfusion r/t renal disease aeb acute renal failure on chronic renal failure (Ackley, & Laddwig, 2011, p. 96)Risk for electrolyte imbalance r/t renal dysfunction aeb increased creatinine and decreased calcium blood levels (Ackley, & Laddwig, 2011, p. 96)Imbalanced nutrition, less than body requirements r/t nausea, vomiting, altered taste sensation, dietary restrictions aeb c/o nausea/vomiting upon admission (Ackley, & Laddwig, 2011, p. 96)Excess fluid volume r/t decreased urine output, sodium retention, inappropriate fluid intake aeb sodium restrictions and UO of 1100cc (Ackley, & Laddwig, 2011, p. 96)Ineffective coping r/t depression resulting from chronic disease aeb clinical diagnosis of depression and anxiety (Ackley, & Laddwig, 2011, p. 96). +15 CARE PLANNursing Diagnosis: Risk for ineffective renal perfusion r/t renal disease aeb acute renal failure on chronic renal failure (Ackley, & Laddwig, 2011, p. 96)Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Interventions on Day Care is ProvidedPatient will maintain normal blood urea nitrogen and serum creatinine levels. (Ackley, & Laddwig, 2011, p. 630)Assess client for history of risk factors for renal insufficiencyMonitor vital signs and compare blood pressure to client’s normal range (Ackley, & Laddwig, 2011, p. 630)Clients who have undergone cardiac and thoracoabdominal surgeries are at risk for acute renal failure due to renal parenchymal damage possibly related to such factors as hypovolemia, inflammation, ischemia-reperfusion, and other factors (Ackley, & Laddwig, 2011, p. 630)Patient’s blood urea nitrogen and serum creatinine levels did not remain within range. Patient will maintain urine output that is yellow and clear (Osborn, Wraa, & Watson, 2010, p.630)Measure intake and output on a regular basisCalculate intake against output to monitor fluid status (Ackley, & Laddwig, 2011, p. 630)Oliguria and/or anuria are signs of acute renal failure. Intake greater than output is a sign of fluid retention and renal insufficiency which may be caused by ineffective renal perfusion (Ackley, & Laddwig, 2011, p. 630)Patients urine remained yellow and clear throughout the shift. Patient will maintain serum electrolytes within normal limits (Osborn, Wraa, & Watson, 2010, p. 630)Utilize continuous cardiac monitoring as needed (Ackley, & Laddwig, 2011, p. 630)Monitor for dysrhythmias due to possible increased serum potassium and phosphorus due to poor kidney function from ineffective renal perfusion (Ackley, & Laddwig, 2011, p. 630)Patients serum electrolytes did not remain within normal limits +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:F/U appts with primary care physician Med Instruction/Prescription –discuss side effects of any new prescription medications and to take medications as directed Dietary consult upon discharge to remind patient of foods high in potassium +15 CARE PLANNursing Diagnosis: Risk for electrolyte imbalance r/t renal dysfunction aeb increased creatinine and decreased calcium blood levels (Ackley, & Laddwig, 2011, p. 96)Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Interventions on Day Care is ProvidedPatient will maintain a normal sinus heart rhythm with a regular rate. (Ackley, & Laddwig, 2011, p. 343)Monitor vital signs at least 3 times per day. Notify provider of significant deviation from baselineMonitor cardiac rate and rhythm(Ackley, & Laddwig, 2011, p. 343)Electrolyte imbalance can lead to changes in vital signs including orthostatic hypotension, bradycardia, tachycardia, respiratory depression, and EKG changes. Hyperkalemia can result in EKG changes and can lead to cardiac arrest from complete heart block or ventricular dysrhythmias. (Ackley, & Laddwig, 2011, p. 343)Patient’s VS remained within range. Cardiac rate and rhythm remained normal sinus rhythm throughout shift. Patient will maintain normal serum potassium, sodium, and calcium(Ackley, & Laddwig, 2011, p. 343)Monitor for abdominal distention and discomfortReview laboratory data as ordered and report deviation to provider (Ackley, & Laddwig, 2011, p. 344)Fluid and electrolyte imbalance can cause an adverse effect on GI function due to changes in GI mucosal perfusion and GI tract edema. (Ackley, & Laddwig, 2011, p. 344)Patient’s serum, potassium and sodium remained within range. Calcium remained low. Patient will maintain normal serum pH(Ackley, & Laddwig, 2011, p. 343)Assess neuro status including LOC and mental status Monitor electrolyte levels with both increased and decreased levels possible (Ackley, & Laddwig, 2011, p. 344)Electrolyte imbalance can cause changes in neurologic status including confusion, seizures, agitation, delirium, and coma. Elderly are prone to electrolyte abnormalities because of failure of regulatory mechanism associated with heart and kidney disease. (Ackley, & Laddwig, 2011, p. 344)Patient remained AOx4 throughout shoift with no changes in LOC. Normal pH maintained throughout shift. +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:F/U appts with primary care physician Med Instruction/Prescription –discuss side effects of any new prescription medications and to take medications as directed (discuss what to do when SE occur) Provide medication information printouts and self-care plan printouts describing daily and PRN medications, and how to maintain a healthy heart for reference +15 CARE PLANNursing Diagnosis: Imbalanced nutrition, less than body requirements r/t nausea, vomiting, altered taste sensation, dietary restrictions aeb c/o nausea/vomiting upon admission (Ackley, & Laddwig, 2011, p. 96)Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Interventions on Day Care is ProvidedNormal intake of balanced diet without side effects (Osborn, Wraa, & Watson, 2010, p.291)Perform a complete physical assessment and nutritional history Weigh patient daily before breakfast, after urination, using the same scale Consult dietician(Osborn, Wraa, & Watson, 2010, p.291)Perform a complete physical assessment to assess current nutritional status and to provide a nutritional baseline of data for plan development. Weighing patient to monitor weight gain, if any. Dietician will give detailed nutritional analysis and specialized planning. (Osborn, Wraa, & Watson, 2010, p.291)Weight is still not at recommended level for the height and musculature for the patient. Treatment of gastrointestinal clinical manifestations if effective. Patient will recognize changes to increase food intake(Osborn, Wraa, & Watson, 2010, p.292)Reassess patient for nutritional status Encourage balanced nutritionEncourage small, frequent meals of food that patient enjoys*Monitor electrolytes, vitamins and lab test results Provide a pleasant , communal environment during mealtime (Osborn, Wraa, & Watson, 2010, p.292)Nutritional status to assess progress toward normal BMI. Encourage small frequent meals to potentially increase caloric intake. Lab results are indicative of nutritional status. Pleasant environment to encourage patient’s appetite. (Osborn, Wraa, & Watson, 2010, p.292)Patient did not gain any weight during this shift, but she did verbalize changes to make right dietary choices. .Patient will maintain normal nutrition/ BMI within normal limits (Osborn, Wraa, & Watson, 2010, p. 291)Explore nutritional beliefs, cultural and religious attitudes toward food, food taboos, use of drugs and alcohol, medication and OTC use, and problems with dentition difficulties Document the caloric count for each food consumed—can also monitor food take and patient keep a food diary* Offer small quantities of energy-dense and protein-enriched food, serving in appetizing fashion, at frequent intervals (Osborn, Wraa, & Watson, 2010, p.291)Explore nutritional beliefs to determine factors that impact food intake. Document calories to determine adequacy of caloric intake. Monitoring food intake helps the nurse and patient examine usual foods eaten, patterns of eating, and presence of deficiencies in the diet. (Osborn, Wraa, & Watson, 2010, p.292)Food intake is more than energy expenditure. Patient remains over normal BMI. 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:F/U appts with primary care physician Med Instruction/Prescription –discuss side effects of any new prescription medications and to take medications as directed Advise patient to avoid risk factors associated with malnutrition such consumption of unhealthy foods Dietary consult upon discharge to remind patient of foods to increase calories and nutrients and encourage appetite and prevent further malnutrition HH for self-care assistance and support ReferencesAckley, B.J., & Laddwig, G. B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby, Inc. Deglin, J.H., Vallerand, A.H., & Sanoski, C.A. (2012). Davis’s Drug Guide [computer software]. F.A. Davis Company. Mayo Clinic. (2013). Acute Kidney Failure. Retrieved from . Osborn, K.S., Wraa, C.E., & Watson A.B. (2010). Medical Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson. ................
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