UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Taylor Nolen |

|Patient Assessment Tool . |Assignment Date: |

| ( 1 PATIENT INFORMATION |Agency: STJ 6W |

|Patient Initials: P.R. |Age: 70 |Admission Date: 10-7-2013 |

|Gender: Female |Marital Status: Divorced |Primary Medical Diagnosis with ICD-10 code: |

|Primary Language: English |488.01 |

|Level of Education: Two years of business College |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): Retired, worked 30 years retail | |

|Number/ages children/siblings: Daughter- 42, Son- 52 (retired marine) | |

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|Served/Veteran: No |Code Status: Full code |

|Living Arrangements: At home with daughter |Advanced Directives: Yes, 10-07-2013 |

| |If no, do they want to fill them out? |

| |Surgery Date: Procedure: |

|Culture/ Ethnicity /Nationality: Caucasian | |

|Religion: Methodist |Type of Insurance: Medicare |

|( 1 CHIEF COMPLAINT: “ I was weak, had chills, shortness of breath, breathing problems from pneumonia” |

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

|This is a 70 year old female who was admitted on October 7th 2013 with pneumonia. The patient presented with chills, shortness of breath, and stated that she felt|

|weak. A chest x-ray was performed on the 7th and revealed a very small left pleural effusion, a prominent right cardiophrenic fat pad present and no infiltrates |

|were identified. Attending physicians are no discussing bronchitis. Patient has a history of the bird flu (2007) with a recurrent episode April 2013. However, |

|patient feels as If the medications are not working to kill the bacteria like they did back in 2007. Patient remains on medical surgical floor for monitoring of |

|respiratory system. |

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

|Date |Operation or Illness |

| |COPD |

| |HTN |

| |Hypothyroidism |

| |Obesity |

|February 2013 |Cataract surgery |

|April 2013 |Recurrence of H5N1 (Bird flu) |

|2007 |H5N1 (Bird flu) |

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|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

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|( 1 immunization History |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |

|Routine childhood vaccinations |X | |

|Routine adult vaccinations for military or federal service | |X |

|Adult Diphtheria (Date) | U | |

|Adult Tetanus (Date) Patient unsure of date |X | |

|Influenza (flu) (Date) 2013 |X | |

|Pneumococcal (pneumonia) (Date) 2013 |X | |

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

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

|REACTIONS |Causative Agent | |

|Medications |Codeine |Nausea |

| |IVP dye |Dry heaves |

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|Other (food, tape, latex, dye, | | |

|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) |

|Pneumonia is an infection found in the lower part of the respiratory tract and can be caused by many things such as: bacteria, viruses, fungi, protozoa or |

|parasites. The causative organism will depend on how the patient presents, how the patient will be treated and the prognosis. In this patients case the pneumonia |

|was caused by a recurrence of the avian (bird flu) virus. Risk factors for pneumonia include “advanced age, compromised immunity, underlying lung disease, |

|alcoholism, altered consciousness, impaired swallowing, smoking, endotracheal intubation, malnutrition, immobilization, underlying cardiac or liver disease, and |

|residing in a nursing home” (Huether, McCance, 2012, pp. 694). This patient developed pneumonia because of the recurrence of the avian (bird flu) virus; “influenza|

|and respiratory syncytial viruses are the most common causes of viral community-acquired pneumonia in adults” (Huether, McCance, 2012, pp. 695). |

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|Pneumonia can occur a few different ways. One it can be due to an aspiration of secretions, through inhalation of microorganisms or when bacteria are spread to the|

|lungs in the blood for bacteremia ” (Huether, McCance, 2012, pp. 695). Viral pneumonia is generally mild and self-limiting but can cause a secondary bacterial |

|infection, as a result of damaged ciliated epithelial cells; “Sloughing of destroyed bronchial epithelium occurs through the respiratory tract, preventing |

|mucociliary clearance, bronchial walls become edematous and infiltrated with leukocytes” (Huether, McCance, 2012, pp. 696). In severe cases of viral pneumonia, the|

|work load of breathing can be increased. |

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|Patients with pneumonia present with symptoms based on etiology. Common symptoms include, fever, chills, productive or dry cough, malaise, pleural pain, and |

|sometime dyspnea. Upon examination the patient may show signs of pulmonary consolidation, dullness upon percussion, crackers, increased tactile fremitus, egophony |

|and whispered pectoriloquy. To diagnosis pneumonia a chest x-ray is done, WBC count checked, stains and cultures of respiratory secretions. If cultures reveal a |

|microorganism, empiric antibiotics are chosen based on organism (some may requires multiple drugs, as seen in this patients case). (Huether, McCance, 2012, pp. |

|695-696) |

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|The H5N1 avian (bird flu) was first reported in 2003 in domestic poultry in parts of Asia and the Middle East . This stain usually did not affect humans but in |

|since 2003, 600 cases have been reported in 15 countries. The bird flu is highly pathogenic, however, human cases of this flu is rare. Symptoms in people with the |

|H5N1 virus include fever, cough, acute respiratory distress, shortness of breath, abdominal pain, and diarrhea. The two most seen complications of H5N1 is death |

|and pneumonia. The best way to prevent getting the H5N1 is to not handle uncooked poultry. If uncooked poultry is handled, wash hands. Currently no meat is |

|allowed to enter the United States if they have had an outbreak of the H5N1 virus. (U.S. Department of Health and Human Services). |

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|Huether, S.E., & McCance, K. L. (2012). Understanding pathophysiology. (5th edition., p. 964-696). St. Louis: Mosby |

|U.S Department of Health and Human Services. (n.d). H5N1 avian flu (H5N1 bird flu). Retrieved from |

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

|Name Albuterol- ipratropium (DuoNeb) |Concentration (mg/ml) |Dosage Amount (mg) 3mL |

|Route NEB |Frequency Rtq6h |

|Pharmaceutical class: Adrenergics |Home Hospital or Both |

|Indication: To control and prevent reversible airway obstruction caused by COPD, shortness of breath, wheezing |

|Side effects/Nursing considerations: nervousness, tremor, headache, chest pain, palpitations, angina, arrhythmias, HTN, nausea, vomiting, hyperglycemia, |

|hypokalemia. |

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|Name Budesonide |Concentration 0.05mg/2mL |Dosage Amount 2mL |

|Route NEB |Frequency RtBID |

|Pharmaceutical class: corticosteroids |Home Hospital or Both |

|Indication: Maintenance treatment and prophylactic therapy of asthma. |

|Side effects/Nursing considerations: headaches, rash, otitis mesia, dysphonia, epistaxis, oropharyngeal fungal infections, pharyngitis, rhinitis, sinusitis, |

|bronchospasm, cough, abdominal pain, diarrhea, dyspepsia, gastroenteritis, nausea, vomiting, adrenal suppression, back pain, anaphylaxis |

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|Name Calcium- vitamin d (calcium 500 with D) |Concentration |Dosage Amount 500 mg |

|Route PO |Frequency once daily |

|Pharmaceutical class: Mineral and electrolyte replacement/supplement |Home Hospital or Both |

|Indication: Treatment and prevention of hypocalcemia, adjunct in the prevention of postmenopausal osteoporosis |

|Side effects/Nursing considerations: headache, tingling, arrhythmias, bradycardia, constipation, nausea, vomiting, calculi, hypercalciuria |

|Name: Diltiazem (Cardizem) |Concentration |Dosage Amount: 240 mg |

|Route: PO |Frequency: once daily |

|Pharmaceutical class: Calcium Channel blockers |Home Hospital or Both |

|Indication: Hypertension |

|Side effects/Nursing considerations: anxiety, abnormal dreams, confusion, dizziness, drowsiness, headache, nervousness, psychiatric disturbance, weakness, blurred |

|vision, disturbed equilibrium, epistaxis, tinnitus, cough, dyspnea, arrhythmias, HF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, syncope,|

|tachycardia, elevated liver enzymes, anorexia, constipation, diarrhwa, dry mouth, dysguesia, dyspepsia, nausea, vomiting, dysuria, nocturia, polyuria, sexual |

|dysfunction, stevens-johnson syndrome, dermatitis, erythema, flushing, sweating, hyperglycemia, anemia, leukopenia, thrombocytopenia, joint stiffness, muscle |

|cramps, paresthesia, tremor, gingival hyperplasia |

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|Name: Ethambutol (Myambutol) |Concentration |Dosage Amount: 400 mg |

|Route: PO |Frequency: Sunday, Wednesday, Friday |

|Pharmaceutical class: antituberculars |Home Hospital or Both |

|Indication: mycobacterial disease (used in combination with another medication) |

|Side effects/Nursing considerations: confusion, dizziness, hallucinations, headache, malaise, optic neuritis, hepatitis, abdominal pain, anorexia, nausea, |

|vomiting, hyperuricemia, joint pain, peripheral neuritis, pulmonary infiltrates, anaphylactoid reactions, fever |

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|Name: Furosemide (Lasix) |Concentration |Dosage Amount: 40 mg |

|Route PO |Frequency BID |

|Pharmaceutical class: loop diuretics |Home Hospital or Both |

|Indication: edema due to heart failure, hepatic impairment or renal disease, hypertension |

|Side effects/Nursing considerations: blurred vision, dizziness, headache, vertigo, hearing loss, tinnitus, hypotension, anorexia, constipation, diarrhea, dry |

|mouth, dyspepsia, increased liver enzymes, nausea, pancreatitis, vomiting, increase BUN, excessive urination, nephrocalcinosis, stevens-johnson syndrome, toxic |

|epidermal necrolysis, puritis, rash, hypercholesterolemia, hyperglycemia, hypertriglyceridemia, dehydration, hyopcalcemia, hypokalemia, hypomagnesemia, |

|hyponatremia, hypovolemia, metabolic alkalosis, aplastic anemia, agranulocytosis, leukopenia, muscle cramps, paresthesia, fever |

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|Name: Guaifenesin (mucinex) |Concentration |Dosage Amount: 600 mg |

|Route: PO |Frequency BID |

|Pharmaceutical class: Allwegy, cold and cough remedies expectorant |Home Hospital or Both |

|Indication: coughs associated with viral upper respiratory tract infections |

|Side effects/Nursing considerations: dizziness, headache, nausea, diarrhea, stomach pain, vomiting, rash, urticarial |

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|Name: levothyroxine (Synthroid) |Concentration |Dosage Amount: 0.01 mg |

|Route: PO |Frequency once daily |

|Pharmaceutical class: thyroid preparations |Home Hospital or Both |

|Indication: thyroid supplementation in hypothyroidism |

|Side effects/Nursing considerations: headache, insomnia, irritability, angina pectoris, arrhythmias, tachycardia, abdominal cramps, diarrhea, vomiting, sweating, |

|hyperthyroidism, menstrual irregularities, heat intolerance, weight loss |

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|Name: Lisinopril (Prinivil) |Concentration |Dosage Amount: 40 mg |

|Route: PO |Frequency once daily |

|Pharmaceutical class: antihypertensive |Home Hospital or Both |

|Indication: management of heart failure, management of hypertension, reduction of risk of death or development of heart failure after myocardial infarction |

|Side effects/Nursing considerations: dizziness, fatigue, headache, weakness, cough, hypotension, chest pain, abdominal pain, diarrhea, nausea, vomiting, erectile |

|dysfunction, impaired renal function, rashes, hyperkalemia, angioedema |

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|Name: Pantoprazole (protonix) |Concentration |Dosage Amount: 40 mg |

|Route: PO |Frequency: Once daily, AC |

|Pharmaceutical class: proton pump inhibitor |Home Hospital or Both |

|Indication: prophylaxis for stomach ulcers |

|Side effects/Nursing considerations: headache, abdominal pain, diarrhea, flatulence, hyperglycemia, hypomagnesaemia, |

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|Name: Potassium- chloride |Concentration |Dosage Amount 20 mEq |

|Route: PO |Frequency BID |

|Pharmaceutical class: mineral and electrolyte replacement/supplements |Home Hospital or Both |

|Indication: treatment/prevention of potassium depletion |

|Side effects/Nursing considerations: confusion, restlessness, weakness, arrhythmias, ECG changed, abdominal pain, diarrhea, flatulence, nausea, vomiting, |

|paralysis, paresthesia, GI ulceration |

|Name: Zafirlukast (Accolate) |Concentration |Dosage Amount: 20 mg |

|Route: PO |Frequency: BID |

|Pharmaceutical class: leukotriene antagonists |Home Hospital or Both |

|Indication: long- term control agent in the management of asthma |

|Side effects/Nursing considerations: suicidal thoughts, headache, agitation, aggression, anxiety, depression, dizziness, dream abnormalities, hallucinations, |

|insomnia, irritability, restlessness, tremor, weakness, hepatoxicity, abdominal pain, diarrhea, dyspepsia, nausea, vomiting, arthralgia, back pain, myalgia, |

|churg-strauss stndrome, fever, infection, pain |

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|Name: Zithromax - dextrose 5% (azithromycin) |Concentration 250mL/500 mg |Dosage Amount500 mg |

|Route: IVPB |Frequency: once daily |

|Pharmaceutical class: macrolides |Home Hospital or Both |

|Indication: treatment of upper respiratory infections, lower respiratory tract infections, |

|Side effects/Nursing considerations: dizziness, seizures, drowsiness, fatigue, headache, torsades de pointes, chest pain. Hypotension, palpitations, |

|hepatotoxicity, pseudomembranous colitis, abdominal pain, diarrhea, nausea, jaundice, increased liver enzymes, dyspepsia, flatulence, melena, anemia, leukopenia, |

|stevens-johnsons syndrome, toxic epidermal necrolysis, ototoxicity, hyperkalemia, angioedema. |

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|Name: prednisone (sterapreda) |Concentration |Dosage Amount: 15 mg |

|Route: PO |Frequency: once daily |

|Pharmaceutical class: anti-inflammatories )steroidal) |Home Hospital or Both |

|Indication: Used systemically and locally in chronic inflammatory diseases |

|Side effects/Nursing considerations: depression, euphoria, headache, personality changed, psychoses, restlessness, cataracts, hypertension, peptic ulceration, |

|anorexia, nausea, vomiting, acne, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression, hyperglycemia, fluid retention, hypokalemia, thrombolism, |

|weight gain/loss, muscle wasting, muscle pain, cushingoid appearance, increased susceptibility to infection. |

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|Name: Rifampin (Rifadin) |Concentration |Dosage Amount: 600mg |

|Route: PO |Frequency: Sunday, Wednesday, Friday |

|Pharmaceutical class: rifamycins |Home Hospital or Both |

|Indication: elimination of meningococcal carriers |

|Side effects/Nursing considerations: ataxia, confusion, drowsiness, fatigue, headache, weakness, rash, puritus, red discoloration of tears, urine, and saliva, |

|abdominal pain, diarrhea, flatulence, heart burn, nausea, vomiting, increased liver enzymes, flu-lik symptoms, muscle weakness, thrombocytopenia. |

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|Name: Rocephin- dextrose 5% (ceftriaxone) |Concentration 50ml/1g |Dosage Amount 1g |

|Route: IVPB |Frequencyq24hr |

|Pharmaceutical class: third generation cephalosporins |Home Hospital or Both |

|Indication: treatment of lower respiratory tract infections |

|Side effects/Nursing considerations: seizures, pseudomembranous colitis diarrhea, cholelithiasis, gallbladder slugging, rashes, urticarial, bleeding, eosinophilia,|

|hemolytic anemia, p allergic reaction, superinfection |

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|Name: acetaminophen (Tylenol) |Concentration 650mg/20.3 ml |Dosage Amount 650mg |

|Route: PO liquid |Frequency PRN q4hr |

|Pharmaceutical class: nonopiod analegesics |Home Hospital or Both |

|Indication: pain and fever |

|Side effects/Nursing considerations: renal failure, neutropenia, pancytopenia, rash, urticarial |

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|Name: acetaminophen-hydrocodone (Norco) |Concentration 5/325 |Dosage Amount 5mghydrocodone/352mg acetaminophen |

|Route: PO |Frequency: PRN q4hr |

|Pharmaceutical class: opioid agonists nonopioid analgesic combination |Home Hospital or Both |

|Indication: pain |

|Side effects/Nursing considerations: confusion, dizziness, sedation, euphoria, hallucinations, headache, blurred vision, diplopid, miosis, respiratory depression, |

|hypotension, bradycardia, constipation, nausea, vomiting, urinary retention, sweating, physical dependence, |

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

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

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

|24 HR average home diet: |After comparing the patient’s “average “home diet to My Plate, the patient is |

| |under the daily value in food groups: vegetables, fruits, and dairy. The patient |

| |is only at 28% of their total intake for vegetables. A recommendation to increase|

| |the intake of vegetables would be to add more the salad the patient eats at |

| |lunch; adding carrots, tomatoes, cucumbers, olives and corn would help increases |

| |the daily percentage of vegetables. Another food group the patient was not at |

| |daily goals according to My Plate would be in fruits. The patient was only at 10%|

| |for the daily value of fruits. A recommendation for increasing fruit intake would|

| |be to add a fruit cup or yogurt parfait to breakfast, adding fruit to the salad |

| |for lunch (mandarin oranges, apples, strawberries) or switching a pack of cheese |

| |crackers for a fruit cup for an afternoon snack. Lastly, the patient was below in|

| |the dairy food group. After reviewing the patient average diet, the patient |

| |hardly consumers any dairy product. The patient is at 25% of the daily value |

| |recommended for dairy. A recommendation would be to add a class of milk to |

| |breakfast and or dinner, and a yogurt to lunch. If any of these recommendations |

| |are made, the patient’s nutritional status would be increased. The patient does a|

| |good job at meeting daily goals or protein, and grains. The patient is over 100% |

| |daily value in both food groups. Again, substituting a food choice for one of the|

| |recommendations could not only increase values of other food groups but also |

| |decreases food groups that are above daily values. As far as sodium, oils, and |

| |fats are concerned, the patient is almost at the daily recommendation for sodium,|

| |however, the patient only has consumes about 1/3 of the daily goal for oils and |

| |fats. After comparing the nutritional status, this patient can improve their diet|

| |in many food groups to help have a more balanced and healthier diet. |

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| |USDA (n.d). Supertracker: Food tracker. |

|Breakfast: rye- toast with butter, one cup of coffee | |

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|Lunch: salad with chicken | |

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|Dinner: lean meats- chicken, green beans, kale, squash, | |

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|Snacks: almonds, walnuts, apples, cheese crackers, yogurt, whole wheat crackers | |

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|Liquids (include alcohol): coffee, diet soda, fruit juice | |

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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 reference. |

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

|Who helps you when you are ill? “my daughter” |

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|How do you generally cope with stress? or What do you do when you are upset? “ I am not as stressed now that I am retired. I had a lot of stress when I was |

|department manager at JC Pennys. I would smoke to relieve my stress.” |

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

|“ I have been depressed lately because I can’t do anything anymore. I used to be very active, now I have to use a walker and oxygen” |

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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?  ______________________ |

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|Are you currently in a safe relationship? Not in a relationship |

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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. X 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: |

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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: |

|“Generativity encompasses the evolutionary development which has made man the teaching, instituting, and learning animal” (Jensen, 2011, p. 182). “Adults who seen |

|to think of themselves as their “own spoiled child” or who demonstrate physical or psychological invalidism have, in Erickson’s model, fallen into the trap of |

|stagnation” (Jensen, 2011, p. 182). While conversing with the patient, the patient mentioned that she lived with her daughter and that her daughter helps her do a|

|lot. The patient stated that she used to be very active, engaged in many activities, and energetic. After having some issues with her health the patient started to|

|rely more on her daughter and does not try to do as much as she did before, even though she seems capable of still performing some of the simple activities of |

|daily living, The patient does not take as much control over her situation, and relies on someone else to do things for her. The writer of this paper believes |

|that the reason why the patient is in the stagnation phase because of the fact that they rely on someone else and act as if they have given up on life. |

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|Jensen, S. (2011). Assessment of developmental stages. Nursing health assessment. (pp.. 182). Location: Philadelphia |

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

|The writer of this paper believes that the illness have had a huge impact on the developmental stage the patient is currently in. Before her illness she used to be|

|very active, involved in activities and found enjoyment in life. Now that her illness has prevented her from performing activities because they are too strenuous, |

|and depending on her daughter the patient has forgotten that she can still impact peoples life’s and help them as they are currently helping her, such as her |

|daughter. If the patient did not suffer from her medical illnesses the writer of this paper believes the patient could still be in the generativity stage. |

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|+3 CULTURAL ASSESSMENT: |

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

|“ my past smoking habits” |

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|What does your illness mean to you? |

|“That I should have stopped smoking along time ago” |

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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? _Men________________________________________________________ |

|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________________________When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease|

|or an unintended pregnancy?  _No_________________________________ |

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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?  “I’m sure my respiratory issues have” _____________________ |

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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?

“I pray every night, to let me get through tomorrow” ___________________________________________________________________________________________________

______________________________________________________________________________________________________

Do your religious beliefs influence your current condition?

“No, they just help me cope” _____________________________________________________________________________________________________

______________________________________________________________________________________________________

|+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? 45 X years |

|Cigarrets |1 pack per day |(age 17 thru 62 ) |

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|Pack Years: 365 | |If applicable, when did the patient quit? 8 |

| | |years ago, (2005) |

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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? YES |

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|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? 53 |

|Wine |A glass at dinner, occasionally or a glass or two at |(age 17 thru 70 ) |

| |social events | |

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

|April of 2013 |

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|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 ) |

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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 |

|No. |

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( 10 Review of Systems

|General Constitution |Gastrointestinal |Immunologic |

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

|Integumentary | Constipation Irritable Bowel |X 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 |

|X Use of sunscreen SPF:30 | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: 2x daily |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing |Genitourinary | Anemia |

|X Cataracts or Glaucoma | nocturia |X Bleeds easily |

|X Difficulty hearing | dysuria | Bruises easily |

| Ear infections | hematuria | Cancer |

| Sinus pain or infections | polyuria | Blood Transfusions |

|Nose bleeds | kidney stones |Blood type if known: A+ |

| Post-nasal drip |Normal frequency of urination: x/day |Other: |

| Oral/pharyngeal infection | Bladder or kidney infections | |

| Dental problems | |Metabolic/Endocrine |

|X Routine brushing of teeth 3 x/day | | Diabetes Type: |

|X Routine dentist visits 2 x/year | |X Hypothyroid /Hyperthyroid |

|X Vision screening | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

| | |Other: |

|Pulmonary | | |

|X Difficulty Breathing | |Central Nervous System |

| Cough - dry or productive |Women Only | CVA |

|X Asthma | Infection of the female genitalia | Dizziness |

|X Bronchitis | Monthly self breast exam |X Severe Headaches |

| Emphysema | Frequency of pap/pelvic exam | Migraines |

|X Pneumonia | Date of last gyn exam? | Seizures |

| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |

| Environmental allergies | menarche age? | Encephalitis |

|X last CXR? 10-7-2013 |X menopause age? 56 | Meningitis |

|Other: |Date of last Mammogram &Result: |Other: |

| |Date of DEXA Bone Density & Result: | |

|Cardiovascular |Men Only |Mental Illness |

|X Hypertension | Infection of male genitalia/prostate? |X Depression |

|X 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 |X Weakness |X Measles |

|Rheumatic Fever |X Pain | Mumps |

| Myocarditis | Gout | Polio |

| Arrhythmias | Osteomyelitis | Scarlet Fever |

|X Last EKG screening, when? 10-7-2013 |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

| | | |

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

|“Just wondering why my medication is not working like it did the first time” |

| |

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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: A&Ox3 |Height: 62 inches |Weight: 104.545 kg BMI: |Pain: (include rating & location) |

| | | |0 out of 10 |

| |Pulse:93 |Blood 175/75 left arm | |

| | |Pressure: | |

| | |(include location) | |

|Temperature: (route taken?) |Respirations: 20 | | |

|98.2 Oral | | | |

| |SpO2 95 (3 liters NC) |Is the patient on Room Air or O2:O2 |

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

|X 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] |

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

| |

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

|X clear, crisp diction |

| |

|Mood and Affect: X pleasant X cooperative X cheerful X talkative quiet boisterous flat |

| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |

|Other: |

|Integumentary | |

|X Skin is warm, dry, and intact | |

|X Skin turgor elastic | |

|X No rashes, lesions, or deformities | |

|X Nails without clubbing | |

|X Capillary refill < 3 seconds | |

|X Hair evenly distributed, clean, without vermin | |

| | |

| | |

| | |

| | |

|X Peripheral IV site Type: 22 Location: right forearm Date inserted: 10-7-2013 |

| X no redness, edema, or discharge |

| Fluids infusing? no X yes - what? D5 NS |

| 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: X Facial features symmetric X No pain in sinus region No pain, clicking of TMJ X Trachea midline |

| Thyroid not enlarged No palpable lymph nodes X sclera white and conjunctiva clear; without discharge |

|X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |

|X PERRLA pupil size 4 / mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmus |

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

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

|Dentition: |

|Comments: |

| |

|Pulmonary/Thorax: Respirations regular and unlabored X Transverse to AP ratio NOT 2:1 X 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 | |

| |S – Stridor | |

| |Ab - Absent | |

| | | |

| | | |

|Cardiovascular: X No lifts, heaves, or thrills PMI felt at: 5th intercostal space midclavicular line |

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

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

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

|Apical pulse: Carotid: Brachial: 3 Radial: 3 Femoral: Popliteal: 3 DP: 3 PT:3 |

|X 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: bilateral lower extremities pitting non-pitting |

|X Extremities warm with capillary refill less than 3 seconds |

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

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

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

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

|CVA punch without rebound tenderness |

|Last BM: (date 10 / 6 / 2013 ) 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 X Not assessed, patient alert, oriented, denies problems |

| Other – Describe: |

| |

| |

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

|X 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] |

|vertebral column without kyphosis or scoliosis |

|X Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias |

| |

| |

| |

|Neurological: X Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |

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

|Stereognosis, graphesthesia, and proprioception intact X 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: 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): |

|. |

| |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|WBC |

|9.4 |

|Normal (4.5-11) |

| |

|(10/7/2013) |

| |

| |

|Only have admitting lab values. Second lab panel is pending. |

|Number of infection fighting cells. High WBC indicates the presence of an infection or inflammation. High WBC can be related to the pneumonia. |

| |

|RBC- 4.07 |

|(10/7/2013) |

| |

|Normal levels for a female patient is 3.75-5.11. The patient has adequate RBC levels. |

| |

|HGB -12.2 |

|(10/7/2013) |

| |

|Normal levels for a female patient is 11.7-15.5. The patient has adequate hemoglobin levels. |

| |

|PLT- 256 |

|(10/7/2013) |

| |

|Normal levels for a female patient is 185-335. The patient has adequate platelet counts. |

| |

|Lymphs -15.5 (L) |

|(10/7/2013) |

| |

|Normal values are 24-44. The low lymph levels can cause an increase in infection, and could be related to the reoccurrence of the bird flu. |

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| |

|Sodium- 140 (10/7/2013) Normal sodium is 135-145. Patients sodium is within normal range. |

|Potassium- 3.5 (10/7/2013) Normal potassium is 3.5-5. Patients potassium is on the low side. Patient is currently on a potassium supplement to help increase |

|potassium levels. The patients low potassium level can be related to malnutrition. |

|Carbon dioxide 32(H) (10/7/2013) Normal levels for a female patient is 22-26. This patient has high CO2 and it can be related to patients COPD. COPD patients retain |

|potassium |

|BUN- 3 (L) (10/7/2013) Normal values for an adult are 10-31. This patients BUN is relatively low and can result from malnutrition, low protein/high carbohydrate diet|

|Creatinine- 0.70 (10/7/2013) Normal value in a female adult is 0.51-1.11. The patient is within normal values and patients kidneys seem to be functioning properly. |

|Protein tot 5.8 (L) (10/7/2013) Normal values in an adult are 6-8.5. The patients low protein tot can be related to the bad nutritional status. (look at My Plate |

|analysis). |

|Albumin 3.2 (L) (10/7/2013) Normal values in an adult are 6-8. This patients low albumin can be related to malnutrition (also look at My Plate analysis), also as |

|evidence by patient bilateral lower edema. |

|Troponin- 0.07 (10/7/2013) Normal values are >0.2. The patient is currently inside of normal value. However it slightly elevated which could be a result of patients |

|uncontrolled hypertension on time. |

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

|frequency if applicable.) |

|Consult with ID- need to find out why past medications are not working to kill of bacteria causing respiratory infections. |

|CBC and BMP pending (10-8-2013) |

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

|Risk for decreased cardiac output related to uncontrolled hypertension as evidence by bilateral lower extremity edema. |

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| |

|Reoccurring infection related to avian flu as evidence by onset of pneumonia. |

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| |

|Ineffective coping |

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| |

|4. |

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|5. |

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| |

± 15 CARE PLAN

Nursing Diagnosis: Risk for decreased cardiac output related to uncontrolled hypertension as evidence by bilateral lower extremity edema.

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

| | |Provide References | |

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|±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: Reoccurring infection related to avian flu as evidence by onset of pneumonia.

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

| | |Provide References | |

| | | | |

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| | | | |

|± 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: Ineffective coping

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

| | |Provide References | |

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| | | | |

| | | | |

| | | | |

|± 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

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