UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Mackenzie Kemp |

|Patient Assessment Tool. |Assignment Date: September 10, 2014 |

| ( 1 PATIENT INFORMATION |Agency: Bayfront Medical Center |

|Patient Initials: B.C.W |Age: 47 years old |Admission Date: September 3, 2014 |

|Gender: Male |Marital Status: Married |Primary Medical Diagnosis with ICD-10 code: |

|Primary Language: English |Otitis Externa (380.10) |

|Level of Education: High school, Some College |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): Used to be a chef, trying for disability now |Acute Mastoiditis (383.00) |

|Number/ages children/siblings: One son, age 20 One sister, age 49. | |

|Served/Veteran: No. |Code Status: FULL CODE. |

|Living Arrangements: |Advanced Directives: No. |

|Patient lives with his wife in a single story home in St. Petersburg. |If no, do they want to fill them out? No. |

|Culture/ Ethnicity /Nationality: Caucasian. |Surgery Date: n/a Procedure: n/a |

|Religion: Christian. |Type of Insurance: Uninsured. Currently trying for disability. Case |

| |pending. |

|( 1 CHIEF COMPLAINT: |

|Patient is a pleasant 47 year old male who reported to the ED on 9/3/2014 reporting a 24 hour history of left ear and jaw pain and a mucousy drainage. |

|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |

|Patient is a 47 year old male. He presented to the ED on 9/3/2013 with a one day history of left ear and jaw pain and drainage. The patient described a constant |

|stabbing pain in his left ear that was made worse by air pressure and chewing/ swallowing and slightly relieved by slight mechanical pressure and ibuprofen. |

|Patient rated the pain as a 10/10. Patient stated that he was treated in the ED in April 2014 with some ear drops but his symptoms never fully resolved. He |

|reported a long history of left sided ear malformation with a congenital absent tympanic membrane. A CT scan was performed in the ED; it showed inflammation and |

|swelling of the left external auditory canal and opacification of the left middle ear space and mastoid air cells. There was no evidence of abscess.The patient was|

|then transferred to 4N on 9/4/14 where he is currently being treated with Levaquin and Cindamycin. |

| |

( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation

|Date |Operation or Illness |

|Congenital | Ear anomaly affecting hearing- absent tympanic membrane in left ear |

|Congenital and progressing |Hearing Loss- Patient was born 100% deaf in left ear. He was born with 30% hearing in right ear but states that it has progressed to 75%|

| |deafness now. |

|July 15, 2013 |Hiatal hernia repair. Patient was born with small hiatal hernia. By 2013, patient states it had grown “to the size of tennis ball” and |

| |was surgically repaired. |

|July 15, 2013 |Diagnosed with Congestive Heart Failure. |

|October 17, 2013 |Surgical repair of incisional hernia. |

| | |

|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

| | |

| |Patient does not keep in touch with father. Unable to obtain paternal 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) | | |

|Influenza (flu) (Date) | | |

|Pneumococcal (pneumonia) (Date) | | |

|Have you had any other vaccines given for international travel or occupational purposes? Please List | | |

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |Codeine |Breaks out in hives, tongue swells |

| |Morphine |Breaks out in hives, tongue swells |

| |Penicillin |Breaks out in hives, tongue swells |

| | | |

| | | |

| | | |

|Other (food, tape, latex, dye, |Adhesive tape |Breaks out in hives where tape is present |

|etc.) | | |

| | | |

| | | |

| | | |

|( 5 PATHOPHYSIOLOGY: |

| |

|Otitis Externa is an inflammatory condition of the external auditory canal, usually caused by a bacterial infection. Symptoms include otalgia (pain) and otorrhea |

|(discharge) of the external auditory canal. Ear discomfort may range from pruritis to severe pain that is made worse by motion such as chewing. The structure of |

|the external auditory canal can contribute to the development of infection. It is dark, warm, and prone to becoming moist, which makes it a likely breeding ground |

|for bacteria. Furthermore, a curve between the junction of cartilage and bone at the outer end of the canal can impede the exit of debris and secretions. Like all |

|skin, the canal contains a normal bacterial flora and remains free of infection unless its defenses are impaired. Usually the canal has several natural defense |

|systems in place such as lysosome-containing cerumen and epithelial migration that pushes debris from the inside out to protect it from infections. However, when |

|these defenses fail or damage to the canal occurs, a new pathogenic flora of bacteria can develop including Pseudomonas aeruginosa and Staphylococcus aureus. |

|Otitis externa results. Symptoms include otalgia (pain) and otorrhea (discharge) of the external auditory canal. Ear discomfort may range from pruritis to severe |

|pain that is made worse by motion such as chewing. Treatment usually begins with a cleansing process to remove discharge that may be occluding the ear canal. This |

|is best done by suctioning under direct visualization with an operating otoscope head and a malleable suction cup tip with low suction. If secretions are thick, |

|antibiotic drops may be used to soften debris for removal. Once the canal has been cleansed, topical antibacterial therapy can begin. A 2% acetic acid solution is|

|usually effective. Steroids may also be added to the eardrops to reduce inflammation. It is usually recommended that drops be given up to three days after symptoms|

|disappear (5-7 days), however in more severe infections, a treatment course of 10-14 days is preferred. Oral antibiotics are sometimes initated if the infection is|

|persistent. Such medications as cephalosporins, penicillins, and floroquinalones may be used. Prognosis depends on the severity of the infection and the underlying|

|etiology but will usually resolve within one to two weeks with appropriate treatment (Sander, 2001). |

( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]

| |

|Name Ibuprofen |Concentration 600 mg= 1 tab |Dosage Amount 1 tab |

|Route PO |Frequency Q6H, PRN for pain |

|Pharmaceutical class nonopioid analgesics |Home Hospital or Both |

|Indication treatment of mild to moderate pain |

|Side effects/Nursing considerations headache, dizziness, drowsiness, arrhythmias, GI BLEEDING, constipation, dyspepsia, nausea, ALLERGIC REACTIONS, STEVEN JOHNSON |

|SYNDROME. Chronic use with acetaminophen may increase use of adverse renal reactions. |

| |

|Name Ciprofloxacin- dexamethasone (Cipro) |Concentration 0.3% otic suspension |Dosage Amount 4 drops |

|Route Otic- left ear |Frequency BID |

|Pharmaceutical class fluoroquinolones |Home Hospital or Both |

|Indication treatment of bacterial outer and middle ear infections |

|Side effects/Nursing considerations discomfort, pain, or itching in ear; anaphylaxis |

|Name Cirpofloxacin- hydrocortisone otic |Concentration 0.2%- 1% otic suspension |Dosage Amount 4 drops |

|Route Otic- left ear |Frequency BID |

|Pharmaceutical class fluoroquinolones |Home Hospital or Both |

|Indication used to treat bacterial outer ear infection |

|Side effects/Nursing considerations headache, anaphylaxis |

| |

|Name Clindamycin |Concentration 900 mg/50 ml |Dosage Amount 50 ml/hr over 60 minutes |

|Route IVPB |Frequency Q8h |

|Pharmaceutical class lincosamide |Home Hospital or Both |

|Indication treatment of bacterial infections |

|Side effects/Nursing considerations PSEUDOMEMBRANOUS COLITIS, diarrhea, dizziness, headache |

| |

|Name Levofloxacin |Concentration 500 mg/100 ml |Dosage Amount 100 ml/hr, over 60 minutes |

|Route IVPB |Frequency daily |

|Pharmaceutical class fluoroquinalones |Home Hospital or Both |

|Indication treatment of bacterial infection |

|Side effects/Nursing considerations ELEVATED INTRACRANIAL PRESSURE, SEIZURES, TORSADE DE POINTES, HEPATOTOXICITY, PSEUDOMEMBRANOUS COLITIS, nausea, diarrhea, |

|STEVEN JOHNSON SYNDROME, ANAPHYLAXIS |

| |

|Name Lisinopril |Concentration 5 mg = 1 tab |Dosage Amount 1 tab |

|Route PO |Frequency daily |

|Pharmaceutical class Ace inhibitors |Home Hospital or Both |

|Indication management of heart failure |

|Side effects/Nursing considerations dizziness, cough, hypotension, hyperkalemia, ANGIOEDEMA, monitor BP and pulse |

| |

|Name Pantoprazole |Concentration 40 mg= 1 tab |Dosage Amount 1 tab |

|Route PO |Frequency daily |

|Pharmaceutical class proton pump inhibitors |Home Hospital or Both |

|Indication GI ulcer prophylaxis |

|Side effects/Nursing considerations PSEUDOMEMBRANOUS COLITIS, hypomagnesemia, headache, abdominal pain |

| |

|Name Acetaminophen- hydrocodone |Concentration 325 mg =1 tab |Dosage Amount 2 tabs |

|Route PO |Frequency PRN for pain, Q4H |

|Pharmaceutical class combination of non-opioid analgesic and opioid |Home Hospital or Both |

|analgesic | |

|Indication used to relieve moderate to severe pain |

|Side effects/Nursing considerations nausea, vomiting, constipation, dizziness |

| |

|Name ALPRAZolam (Xanax) |Concentration 0.25 mg= 1 tab |Dosage Amount 1 tab |

|Route PO |Frequency BID, PRN for anxiety |

|Pharmaceutical class benzodiazepines |Home Hospital or Both |

|Indication management of anxiety |

|Side effects/Nursing considerations dizziness, drowsiness, lethargy, blurred vision, constipation, diarrhea, tolerance |

| |

|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |

|Diet ordered in hospital? Regular |Analysis of home diet (Compare to “My Plate” and |

|Diet pt follows at home? Regular |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: | |

|Breakfast: Patient does not usually eat breakfast. |According to the patient’s report of an average day’s diet at home, he is doing |

| |okay nutritionally. The patient meets the requirement of 5 ½ ounces of protein |

| |with his chicken breast and tuna fish for lunch and dinner. These are relatively |

| |healthy meats to meet the protein requirement with. The patient also meets the |

| |required 2 ½ cups of vegetables requirement with his potato and broccoli for |

| |dinner. The client does report eating refined grains in his crackers with lunch |

| |or for the occasional snack, however this only meets 3 out of the 6 oz daily |

| |recommendation for grains. Also the patient is under the recommended daily dose |

| |of dairy of 3 cups by about 2 cups. Also atleast 2 cups of fruit are recommended |

| |daily, and the client did not report consuming any sort of fruit. These deficits |

| |could be easily mended by the patient consuming a small but nutritious breakfast |

| |each day instead of skipping this meal entirely. A piece or two of whole grain |

| |toast or English muffin, a cup of yogurt and fruit, and a glass of orange juice |

| |would be enough to reach the recommended daily amounts of dairy, fruit, and |

| |grains. According to the patient’s report and My Plate, he is only consuming 1476|

| |calories of his 2000 calorie daily allowance.Yet, the patient is still considered|

| |obese according to his BMI. This could be partially due to the fluid accumulation|

| |from CHF but I would also recommend the patient exercise more, atleast 150 |

| |minutes per week. Finally with a CHF diet, salt should be minimized. The patient |

| |seems to do okay with this but I would recommend that he be particular when |

| |choosing crackers and things that have no or reduced sodium (Supertracker, 2014) |

| | |

|Lunch: Tuna fish on crackers. | |

| | |

|Dinner: Skinless chicken breast, 1 serving of vegetables, 1 potato. | |

| | |

|Snacks: rarely eats snacks. Occasionally cheese and crackers. | |

| | |

|Liquids (include alcohol): | |

|8 glasses of water a day. Sometimes a glass or two of ice tea. 1 cup of coffee | |

|for breakfast. | |

|[pic] | |

|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? |

|The patient’s wife helps him when he is ill. |

|How do you generally cope with stress? or What do you do when you are upset? |

|The patient stated that he and his wife usually go for a walk, a drive, or go to the beach to relieve stress. |

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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |

|Patient denies. |

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|+2 DOMESTIC VIOLENCE ASSESSMENT |

| |

|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.” |

| |

|Have you ever felt unsafe in a close relationship? ___________no____________________________________________ |

| |

|Have you ever been talked down to?_________no____ Have you ever been hit punched or slapped?  _____no______ |

| |

|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?  ______________________ |

| |

|Are you currently in a safe relationship? |

|yes |

| |

|( 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: Generativity refers to the adult's ability to look outside oneself and care for others. Erikson suggested that adults need children as much as|

|children need adults, and that this stage reflects the need to create a living legacy. The positive outcome of this phase would be to create a legacy by having |

|and nurturing children or helping the next generation in other ways. On the other hand, stagnation and self absorption could result if this stage was not |

|successfully resolved (Clifton, 1995). |

| |

|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |

|The patient is successfully completing the Generativity stage. He is a 47 year old male who is married and has a 20 year old son. Throughout our interview he |

|expressed multiple times how proud he was of his son and told me about his life and accomplishments. It appeared to me that the patient was proud of the legacy he |

|had created. |

| |

|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |

|It appears that the disease has not negatively impacted this patient’s developmental stage. He has still had a child and raised him to be a successful adult. |

| |

| |

|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” |

|The patient believes in medical causes of illness. |

| |

| |

|What does your illness mean to you? |

|The patient is already 75% deaf and expressed a fear that it would get to 100% soon. |

| |

| |

|+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” |

| |

|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___________________________________ |

| |

|Are you currently sexually active?   _______yes______________When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or|

|an unintended pregnancy?  ______condoms___________________ |

| |

|How long have you been with your current partner?________five years____________________________________ |

| |

|Have any medical or surgical conditions changed your ability to have sexual activity?  _________no_________ |

| |

|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?

___The patient and is wife believe in God but are not very religious.

___________________________________________________________________________________

Do your religious beliefs influence your current condition?

_____________no______________________________________________________________________

______________________________________________________________________________________________________

|+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? 31 years |

|Yes, ultra light cigarettes |3 or 4 cigarettes/ day |(age 16 thru 47 ) |

| | | |

|Pack Years: approximately 134 | |If applicable, when did the patient quit? |

| | |n/a |

|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? |

|No yes |

| |

|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |

| What? |How much? (give specific volume) |For how many years? |

|Used to drink rum punch or wine occasionally |1 glass, “hardly ever” |(age 21 thru 41 ) |

| | | |

| If applicable, when did the patient quit? | | |

|Yes, 6 years ago |

| |

|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |

| If so, what? |

| |How much? |For how many years? |

| | |(age thru ) |

| | | |

| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |

| | | |

| | | |

|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |

| |

|no |

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( 10 Review of Systems

|General Constitution |Gastrointestinal |Immunologic |

| Recent weight loss or gain | Nausea, vomiting, or diarrhea | Chills with severe shaking |

|Integumentary | Constipation Irritable Bowel | Night sweats |

| Changes in appearance of skin | GERD Cholecystitis | Fever |

| 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: 50 | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: daily |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing |Genitourinary | Anemia |

| Cataracts or Glaucoma | nocturia | Bleeds easily |

| Difficulty hearing | dysuria | Bruises easily |

| Ear infections | hematuria | Cancer |

| 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 | |Metabolic/Endocrine |

| Routine brushing of teeth 2 x/day | | Diabetes Type: |

| Routine dentist visits 1x/year |Fundamental students do not turn in | Hypothyroid /Hyperthyroid |

|Vision screening |the check list, instead they do the narrative | Intolerance to hot or cold |

|Other: |MSI/MSII will do the check boxes only | Osteoporosis |

| | |Other: |

|Pulmonary | | |

| Difficulty Breathing | |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? July 2014 |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

| | | |

|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |

|no |

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|Any other questions or comments that your patient would like you to know? |

|no |

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|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |

|General Survey: Patient is well |Height: 6’ 3” |Weight: 255 BMI: 31.9 |Pain: (include rating & location) |

|developed, friendly 47 y.o. male. Alert | | | |

|and oriented X 3. | | |10/10 left ear and jaw |

| |Pulse: 72 |Blood 138/86 in left arm | |

| | |Pressure: | |

| | |(include location) | |

|Temperature: (route taken?) |Respirations: 16 | | |

|97.6 oral | | | |

| |SpO2 96% |Is the patient on Room Air or O2: room air |

|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |

| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |

| |

| |

|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |

| awake, calm, relaxed, interacts well with others, judgment intact |

| |

|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |

| clear, crisp diction |

| |

|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 | |

| No rashes, lesions, or deformities | |

| Nails without clubbing | |

| Capillary refill < 3 seconds | |

| Hair evenly distributed, clean, without vermin | |

| | |

| | |

| | |

| Peripheral IV site Type: 22 gauge Location: left forearm Date inserted: 9/4/14 |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? Levaquin IVPB,Cleocin IVPB, Normal Saline |

| Peripheral IV site Type: Location: Date inserted: |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

| Central access device Type: Location: Date inserted: |

|Fluids infusing? no yes - what? |

| |

|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 3/3 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |

| Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches |

| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |

|Dentition: okay |

|Comments: mucousy discharge from left ear. Ear red and swollen. |

| |

|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |

| | | Lungs clear to auscultation in all fields without adventitious sounds |

| |CL – Clear |Percussion resonant throughout all lung fields, dull towards posterior bases |

| |WH – Wheezes |Sputum production: thick thin Amount: scant small moderate large |

| |CR - Crackles | Color: white pale yellow yellow dark yellow green gray light tan brown red |

| |RH – Rhonchi | |

| |D – Diminished | Diminished sounds in right and left lower lobes |

| |S – Stridor | |

| |Ab - Absent | |

| | | |

| | | |

|Cardiovascular: No lifts, heaves, or thrills PMI felt at: 5 ICS, MCL |

|Heart sounds: S1 S2 Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |

|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |

| Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |

|Apical pulse: 2 Carotid: 2 Brachial: 2 Radial: 2 Femoral: 2 Popliteal: 2 DP: 2 PT: 2 |

|No temporal or carotid bruits Edema: 2+ [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |

|Location of edema: left and right legs pitting non-pitting |

|Extremities warm with capillary refill less than 3 seconds |

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|GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |

|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation |

|Urine output: Clear Cloudy Color: yellow Previous 24 hour output: mLs N/A |

|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |

|CVA punch without rebound tenderness |

|Last BM: (date 09 / 04 / 14 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |

|Hemoccult positive / negative (leave blank if not done) |

|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |

| Other – Describe: |

| |

| |

|Musculoskeletal: ( Full ROM intact in all extremities without crepitus |

|Strength bilaterally equal at __5__ RUE _5__ LUE ___5_ RLE & _5___ 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] |

|vertebral column without kyphosis or scoliosis |

|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 |

|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |

|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride |

|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |

|Triceps: +2 Biceps: +2 Brachioradial: +2 Patellar: +2 Achilles: +2 Ankle clonus: positive negative Babinski: positive negative|

| |

| |

|±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): |

| |

| |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|WBC |

|10.8 |

| |

|6.9 |

|Normal (4.5-11) |

| |

|(09/03/2014) |

| |

|(09/05/2014) |

|Upon admit, the patients WBC were towards the upper normal range. Over two days though, this number has dropped to the middle of the normal range. |

|Number of infection fighting cells were higher upon admit and have begun to return to a lower normal range indicating that the infection is beginning to subside. |

| |

|Culture- ear with smear |

| |

|09/04/2014 |

|Done upon admittance and not repeated. Showed rare white blood cells, many squamous epithelial cells, moderate gram positive cocci in pairs and chains, moderate gram|

|negative rods, and few budding yeast |

|Indicative of severe ear infection due to presence of gram negative and gram positive bacteria. |

| |

|RBC |

|4.71 |

| |

|4.53 |

|Normal (3.81-5.81) |

| |

|(09/03/2014) |

| |

|(09/05/2014) |

|Upon admission, patient’s RBC count was within normal range. It did decrease slightly over two days but remained within normal range. |

|RBC’s within normal ranges rule out anemia or hemorrhage. |

| |

|Hgb |

|14.3 |

| |

|13.6 |

|Normal (12.6-17.4) |

| |

|(09/03/2014) |

| |

|(09/05/2014) |

|Upon admission, patient’s hgb was within normal range. It did decrease slightly over two days but remained within normal range. |

|Hgb within normal range rules out hematological disorders and blood loss. |

| |

|Hct |

|41.8 |

| |

|39.7 |

|Normal (36-52) |

| |

|(09/03/2014) |

| |

|(09/05/2014) |

|Upon admission, patient’s hct was within normal range. It did decrease slightly over two days but remained within normal range. |

|Hct within normal range rules out hematological disorders and blood loss. |

| |

| |

| |

| |

| |

| |

| |

|List all labs that were done recently (both normal and abnormal); if allowed by the hospital, you may attach the printout from the hospital with the patient’s |

|information cut out entirely. DON’T violate HIPPA. Highlight the abnormal values and provide the normal limits. |

|Why was this lab ordered? What is your analysis of the result? Also include and answer these same questions for diagnostic tests (CXR, MRI, CAT scan, etc.). |

|Include dates with all labs and diagnostic tests. Compare baseline labs on admission to most recent. What is the trend? |

|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing , multidisciplinary treatments and procedures, such as diet, vitals, activity, |

|scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.) |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |

|1.Use your care plan book!!! |

|Keep your abc’s in mind- it is a key issue to have the nursing diagnoses listed in order of priority. |

| |

|2.Do not use the same care plan from previous semesters. |

| |

| |

|3.If the nursing diagnosis is ACTUAL, make sure it is a 3 step diagnosis (it should include a problem, r/t, and AEB). |

|To help you with the AEB section, look at the “defining characteristics” in your care plan book. If the nursing diagnosis is |

|potential, make sure it is a 2 step diagnosis. |

|4. |

| |

| |

|5. |

| |

|Fundamental: 1 Nursing Diagnosis in History II; 2 Nursing Diagnosis and 1 care plan in the full PAT |

|Med Surge I: 3 Nursing Diagnosis, 2 of which must have complete care plans |

|Med Surge II: 4+ Nursing Diagnosis (you must identify ALL possible nursing diagnoses for that patient and have 2 complete care plans |

|Points are taken off if you are MISSIN key nursing diagnoses that you should have here based on the information provided in the previous pages of the tool. |

| |

|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and |

|frequency if applicable.) |

| |

|Patient is currently being treated with antibiotics and analgesics on 4N. He is following a normal diet. Is able to ambulate on own, BR privileges. Vitals Q2H. |

|Expected to be discharged this evening. |

| |

| |

|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |

|1. Acute pain related to inflammation of ear as evidenced by patient report of 10/10 pain and facial grimacing. |

| |

| |

|2. Anxiety related to progressive debilitating disease as evidenced by patient reporting concerns of becoming 100% deaf. |

| |

| |

|3. Impaired comfort related to illness related symptoms as evidenced by patient reporting tinnitus and pressure in ear. |

| |

| |

|4.Risk for infection related to congenital ear defects. |

| |

| |

|5. |

| |

| |

± 15 CARE PLAN

Nursing Diagnosis: Acute pain related to inflammation of ear as evidenced by patient report of 10/10 pain and facial grimacing.

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |

| | |Provide References | |

|Patient will report pain as less than 3/10 by end of |Assess the patient for pain presence every two hours |Pain assessment is as important as physiological |Patient did report pain as 2/10 after analgesic |

|my shift. |and each time vital signs are taken. |vital signs and pain is considered the fifth vital |administration by end of my shift. |

| | |sign (Ackley, 2011). | |

| |Administer prescribed pain medicine as needed. |Multimodal analgesia combines two or more medications| |

| | |or methods from different pharmacological classes | |

| | |that target different mechanisms along th pain | |

| |Manage pain using a multimodal approach. |pathway. This way, the lowest effevtive dose of each | |

| | |drug can be given and cause less severe adverse | |

| | |effects (Ackley, 2011). | |

|Patient will describe nonpharmacological methods that|Teach and implement nonpharmacological interventions |Nonpharmacological interventions should be used to |Patient verbalized other nonpharmacological measures |

|can be used to help increase comfort by end of my |when pain is relatively well controlled with |supplement, not replace, pharmacological |that would help reduce his pain. |

|shift. |pharmacological interventions. |interventions (Ackley, 2011). | |

| |In addition to administering analgesics, support |Cognitive behavioral strategies can restore the | |

| |patient’s use of nonpharmacological methods such as |patient’s sense of self-control and personal | |

| |distraction, imagery, and relaxation to relieve pain.|participation in his own care (Ackley, 2011). | |

|Patient will verbalize understanding of pain |Teach the patient to use the self-report pain tool to|The use of comfort function goals provides direction |Patient set to be discharged later today and did |

|management plan by time of discharge. |rate intensity of pain. Ask the ptient to set a |for the treatment plan. Changes are made according to|verbalize understanding of pain management discharge |

| |comfort-function goal by selecting a pain level that |the patient’s response and achievement of the goals |plan. |

| |makes it easy to perform desired ADLs. If the pain is|of recovery (Ackley, 2011). | |

| |above that goal the patient should take action to | | |

| |decrease the pain or notify a member of the health | | |

| |care team so that effective interventions can be | | |

| |provided. | | |

| |Reinforce the importance of taking pain medications |Teaching patients to stay on top of their pain and | |

| |to maintain the comfort function goal. |prevent it from getting out of control will improve | |

| | |the ability to accomplish the goals of recovery | |

| | |(Ackley, 2011). | |

|±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 appts |

|*□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: Anxiety related to progressive debilitating disease as evidenced by patient reporting concerns of becoming 100% deaf.

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |

| | |Provide References | |

|Patient will verbalize decrease in subjective |Encourage the patient to use positive self-talk. |Cognitive therapies focus on changing behaviors and |Patient did verbalize a positive attitude upon news |

|distress by end of my shift. | |feelings by changing thoughts. Replacing negative |of discharge and after talking to me for a while |

| | |self-statements with positive ones helps to decrease |seemed much more positive. He did not require anxiety|

| | |anxiety (Ackley, 2011). |medications today. |

| |If the patient becomes acutely anxious during my |Medications may be effective in the treatment of | |

| |shift, administer prn anxiety medicine as prescribed.|anxiety that interferes with daily functioning | |

| | |(Ackley, 2011). | |

|Patient will identify and verbalize anxiety |Assess the patient’s level of anxiety and physical |Anxiety is a risk factor for major adverse cardiac |Patient identified circumstances and fears that |

|precipitants,conflicts, and threats by end of my |reactions to anxiety. |events (Ackley, 2011). |trigger his feelings of anxiety. |

|shift. | | | |

| | | | |

|Patient will verbalize effective coping strategies to|Teach the patient nonpharmacological means to reduce |Anxiety was decreased with the use of guided imagery |Patient did discuss with me preferred healthy |

|deal with anxiety by end of my shift. |anxiety such as guided imagery or yoga. |during an intervention for postoperative pain. |techniques for managing stress such as going for a |

| | |Studies have supported the benefits of yoga as an |walk or going to the beach. |

| | |effective modality for reducing anxiety (Ackley, | |

| | |2011). | |

|± 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 appts |

|□*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: Impaired comfort related to illness related symptoms as evidenced by patient reporting tinnitus and pressure in ear.

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |

| | |Provide References | |

|Patient will report improved comfort by end of my |Assess client’s current level of comfort. |Sources of assessment data to determine level of |Patient did report improved comfort by end of shift. |

|shift. | |comfort can be subjective, objective, primary, | |

| | |focused, or even special needs (Ackley, 2011). | |

| |Manipulate the environment to improve comfort (no |In two experimental studies, the protocol included | |

| |air/direct pressure on infected ear, preferred |that clients be asked about their preferences for | |

| |positioning). |light, furnishings, body position, television | |

| | |settings, etc. (Ackley, 2011). | |

|Patient will identify and perform strategies to |Provide distraction techniques such as music, compute|In an experiment, music therapy was found to reduce |Patient distracted himself with computer games and |

|improve or maintain acceptable comfort level by end |games, and television. These helps to distract the |reported discomfort and anxiety compared to a control|television to improve comfort. |

|of my shift. |client from discomforting sensations. |condition of no music in a study of individuals | |

| | |undergoing flexible sigmoidoscopy (Ackley, 2011). | |

| |Inform the client of options for control of | A study found that female breast cancer clients | |

| |discomfort such as hypnosis and guided imagery and |treated with guided imagery while undergoing | |

| |provide these interventions if appropriate. |radiation therapy had significant improvements in | |

| | |comfort compared with the control group (Ackley, | |

| | |2011). | |

|± 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 appts |

|*□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. St. Louis, MO: Mosby Elsevier.

Clifton, A., & Davis, D. (1995, January 1). Erikson's Stages. Retrieved September 10, 2014, from



Sander, R. (2001). Otitis Externa: A Practical Guide to Treatment and Prevention. American Family

Physician,927-937. Retrieved September 11, 2014, from

SuperTracker. (2014, January 1). Retrieved September 15, 2014.

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