UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Ashley Fern |

|MSI & MSII Patient Assessment Tool . |Assignment Date: 2/26/16 |

| ( 1 PATIENT INFORMATION |Agency: MPM |

|Patient Initials: TQ |Age: 80 years old |Admission Date: 2/23/16 |

|Gender: female |Marital Status: married |Primary Medical Diagnosis with ICD 10-code: |

| | |Influenza due to identified novel influenza A virus with other |

| | |respiratory manifestations (J09.X2) |

|Primary Language: German (first language) | |

|English (second language-fluent) | |

|Level of Education: high school graduation |Other Medical Diagnoses: (new on this admission) |

| |Hypoxemia (R09.02) |

| |Hypertension (I10) |

|Occupation (if retired, what from?): retired from working for an electric company | |

|Number/ages children/siblings: patient is an only child | |

|Patient has 3 children aged: 51, 49, and 48 | |

| | |

|Served/Veteran: No |Code Status: full |

|If yes: Ever deployed? Yes or No | |

|Living Arrangements: The patient lives at home with her husband in a one story home with no |Advanced Directives: yes |

|stairs needed to access. Her husband is elderly and had a CVA 1.5 years ago and ever since |If no, do they want to fill them out? |

|cannot use his left hand. She is his primary care-giver but states that he does not need | |

|much help. The patient herself is very independent. She uses a walker to help with mobility,| |

|but still drives, does housework, laundry, and cooking, and manages the family finances. | |

| |Surgery Date: N/A Procedure: N/A |

|Culture/ Ethnicity /Nationality: White/German-American | |

|Religion: Episcopalian (“or whatever church I feel like going to”) |Type of Insurance: Medicare |

|( 1 CHIEF COMPLAINT: |

|“I came in with a cough that I have had for about a week now. I asked my husband to call 911 on the 23rd when I started getting chills and feverish and I was |

|coughing so much that I just couldn’t seem to catch my breath. |

| |

| |

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

The patient was brought to Bardmoor Emergency Center in Largo, FL on 02/23/16 by ambulance after her husband had called in reporting difficulty breathing due to a persistent cough. Admitting vitals revealed an elevated temperature of 102.4 degrees Fahrenheit, respirations of 26 breaths per minute, O2 sats at 86%, and sinus tachycardia. The emergency physician decided that she should be admitted under the broad diagnosis of hypoxemia with suspected influenza, and possible sepsis (although later testing revealed that she did not meet sepsis criteria). The patient was transferred to Morton Plant Mease Hospital and placed on B3 which is currently accepting overflow from the Medical Surgical floors. She was placed on supplemental oxygen via nasal cannula and had blood drawn for microbiology culture before being started on azithromycin for broad spectrum treatment of the unidentified infection and daily respiratory therapy treatments of Solumedrol and DuoNeb. The microbiology results came back positive for influenza A and the patient was started on Tamiflu 30 mg PO q12 hours. The patient is currently still on 2 liters supplemental oxygen via nasal cannula and the current orders are to obtain a sputum sample for culture once the patient is able to cough up mucus for sample.

OLDCARTS

Onset: experiencing a cough for about a week, but it got really bad about a day before the patient was admitted

Location: thoracic cavity- severe congestion and cough

Duration: constant

Characteristics: dry, non-productive cough and tightness in chest (patient denies any actual chest pain though)

Associated factors: shortness of breath, sore throat, nasal congestion, fever

Relieving factors: patient states that coughing helps to move the congestion in her chest, but she can’t cough it up

Treatment: patient states that she didn’t try any treatment at home, only in the hospital

Severity of symptoms: 8/10

( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of disease

|Date |Operation or Illness |

|1951 |Appendectomy |

|1988 |Shoulder and right arm surgery (fix torn rotator cuff) |

|1998 |Hypothyroid- treated with levothyroxine 50mcg daily |

|2010 |Glaucoma- treated with timolol 0.5% ophthalmic solution, 1 drop in both eyes 2x daily |

|2013 |Bronchitis- pt was hospitalized and treated with azithromycin and DuoNeb nebulizer |

|2013 |Asthma- treated at home with DuoNeb 3ml nebulizer 4x daily |

|2013 |Peripheral neuropathy of feet- treated with Neurontin 300mg 3x daily |

|2015 |COPD- patient states that she takes no medication for this- although DuoNeb for asthma can help with sx |

|2016 |Hypertension- diltiazem 180mg daily started on 2/24/16 |

| | |

| | |

|( 2 FAMILY MEDICAL HISTORY |

|( 1 immunization History |

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

|Routine childhood vaccinations | | |

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

|Adult Diphtheria (Date) | | |

|Adult Tetanus (Date) Is within 10 years? “a few years ago” | | |

|Influenza (flu) (Date) Is within 1 years? | | |

|Pneumococcal (pneumonia) (Date) Is within 5 years? “2013” | | |

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

If yes: give date, can state “U” for the patient not knowing date received

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

|REACTIONS |Causative Agent | |

|Medications |No known allergies to |N/A |

| |medications | |

| | | |

| | | |

| | | |

| | | |

| | | |

|Other (food, tape, latex, dye, |No known allergies to food, |N/A |

|etc.) |tape, latex, dye, or | |

| |environmental substances | |

| | | |

| | | |

| | | |

|( 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) |

| Influenza or the flu is a commonly obtained respiratory disease usually caused by influenza A, B, or C, with A causing the most serious epidemics (Unbound |

|Medicine Inc., 2016). It is normally self-limiting and most patients will recover in 2-7 days with minimal treatment and without serious complication, however that|

|is not true for some cases, especially if the patient is younger than four years old or older than 50 with a history of chronic respiratory disease. Influenza is |

|typically transmitted through respiratory secretions containing the influenza virus via droplets. For example, an infected person could cough or sneeze and the |

|droplets containing the virus would travel through the air and either land on another person or an object that another person would touch, and then they would |

|bring their hands to their mouth before washing them. The incubation period is typically 18-72 hours before symptoms begin to show and it is usually limited to the|

|respiratory tract (Osborn, Wraa, Watson & Holleran, 2014). Common symptoms of a patient with influenza will include: cough, fever, sore throat, headache, and |

|muscle ache that usually began with a sudden onset. The main risk factor for contracting influenza is primarily being in any crowded environment such as schools, |

|airports, malls, and nursing homes where droplets can easily be spread. However, the risk factors for influenza complications can include, being a neonate, |

|pregnancy, chronic pulmonary disease, cardiovascular disease, immunosuppression, and neuromuscular diseases (Unbound Medicine Inc., 2016). |

|Normally during periods of outbreak, patients can be diagnosed by clinical suspicion alone based off of their symptoms, however if patients are immunocompromised |

|or hospitalized due to symptoms, diagnostic tests such as immunofluorescence assays, rapid antigen immunoassays, or reverse transcriptase polymerase chain reaction|

|tests can be done to see if the patient will need antiviral therapy (Osborn et al., 2014). With that being said, the main treatment for influenza is antiviral |

|therapy such as Zanamivir or oseltamivir which can usually be taken within 2 days of getting sick or if the patient is hospitalized. The prognosis for influenza is|

|typically positive and in most cases it will go away on its own. There are no known genetic factors that put a patient at risk for acquiring influenza and the best|

|defense against it is to get a yearly vaccine and practice good hygiene techniques (Osborn et al., 2014). |

| |

| |

| |

| |

| |

| |

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

|Name: benzonatate (Tessalon) |Concentration: |Dosage Amount: 100 mg |

|Route: PO |Frequency: 3x daily |

|Pharmaceutical class: antitussives |Home Hospital or Both |

|Indication: relief of nonproductive cough due to throat or bronchial irritations from colds |

|Adverse/ Side effects: headache, dizziness, sedation, constipation, GI upset, nausea, pruritus, chest numbness |

|Nursing considerations/ Patient Teaching: Assess frequency and nature of cough, lung sounds, and sputum production. Unless contraindicated increase fluid intake to|

|1500-2000mL daily to decrease and thin mucus secretions. Instruct patient not to crush the capsules but to swallow them whole as the release of medication from the|

|capsules can cause an anesthetic affect in the throat and cause choking. Teach patient how to cough effectively: to sit upright and take several deep breaths |

|before attempting to cough. This may cause dizziness so caution the patient to be careful or to call for help before attempting to stand. Notify the provider of |

|symptoms of overdose such as seizures, restlessness, or trembling. |

|Name: azithromycin (Zithromax) |Concentration: |Dosage Amount: 500 mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: macrolide |Home Hospital or Both |

|Indication: Prophylactic treatment of possible bacterial infection in addition to influenza |

|Adverse/ Side effects: dizziness, drowsiness, fatigue, torsades de pointes, chest pain, hypotension, palpitations, c-diff, abdominal pain, nausea, vaginitis, |

|anemia, photosensitivity, rash, ototoxicity, angioedema |

|Nursing considerations/ Patient Teaching: Assess for signs of infection such as colored sputum or elevated WBC throughout therapy. Obtain specimens for culture |

|before giving the first dose. Observe for signs and symptoms of anaphylaxis such as rash, pruritus, laryngeal edema, and wheezing. Instruct the patient to continue|

|taking the medication until therapy is completed, even if they are feeling better. Teach patient not to take this medicine with food or antacids. Warn patient |

|about the side effect of photosensitivity and the importance of using sunscreen and sunglasses when going outside. Educate patient on signs of superinfection such |

|as thrush, vaginal itching or discharge, or loose stools, and to notify provider if fever develops or if stools contain blood or mucus. |

|Name: methylprednisolone (Solu-Medrol) |Concentration: |Dosage Amount: 40 mg |

|Route: IV push |Frequency: q8 hrs |

|Pharmaceutical class: corticosteroid |Home Hospital or Both |

|Indication: decrease inflammation in the lungs and bronchi |

|Adverse/ Side effects: depression, headache, hypertension, peptic ulceration, n/v, acne, delayed wound healing, petechiae, thromboembolism, weight gain, muscle |

|wasting, osteoporosis, Cushing syndrome |

|Nursing considerations/ Patient Teaching: Assess patient for signs of adrenal insufficiency during therapy such as hypotension, weight loss, weakness, n/v, |

|lethargy, confusion, and restlessness. Monitor glucose levels as corticosteroids can increase serum glucose. Do not stop this medication suddenly as it can result |

|in adrenal insufficiency (see above). Need to assess harder for infections since corticosteroids can often mask the signs of infection and can also cause |

|immunosuppression. It is important to review the side effects with the patient and tell them to notify a provider if any severe abdominal pain or tarry stools as |

|this can be a sign of peptic ulcers. Discuss the possible effects of this medication on body image and explore coping mechanisms. |

|Name: diltiazem (Cardizem) |Concentration: |Dosage Amount: 180 mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: calcium channel blocker |Home Hospital or Both- started on 2/24/16 and will continue at home |

|Indication management of hypertension |

|Adverse/ Side effects: dizziness, drowsiness, headache, blurred vision, dyspnea, arrhythmias, heart failure, peripheral edema, syncope, postural hypotension, n/v, |

|dyspepsia, diarrhea, photosensitivity, hyperglycemia, muscle cramps |

|Nursing considerations/ Patient Teaching: Monitor blood pressure and pulse prior to giving, and consult doctor’s orders about parameters of when not to give. |

|Monitor input and output ratios as well as daily weights for signs of heart failure such as edema, crackles, weight gain, or jugular vein distension. Instruct |

|patient not to take this medication with grapefruit juice. Teach patient how to take a radial pulse and instruct them to call a provider if it less than 50 beats |

|per minute. Educate patient about orthostatic hypotension and to change positions slowly. Teach patient about photosensitivity and the importance of wearing |

|sunscreen and sunglasses when going outside. Encourage the patient to comply with other recommendations for hypertension such as a low sodium diet, regular |

|exercise, and stress management. |

|Name: enoxaparin (Lovenox) |Concentration: |Dosage Amount: 40 mg |

|Route: subcutaneous injection |Frequency: 1x daily |

|Pharmaceutical class: antithrombotic |Home Hospital or Both |

|Indication: prevent blood clots and DVT in the hospital |

|Adverse/ Side effects: dizziness, headache, n/v, urinary retention, bleeding, anemia, erythema and pain at injection site, osteoporosis |

|Nursing considerations/ Patient Teaching: Assess patient for signs of bleeding such as bleeding gums, nosebleeds, unusual bruising, or black tarry stools. Observe |

|the injection site for hematomas, ecchymosis, or inflammation, which could be signs of complications. Monitor the platelet count for any decreases which could be |

|signs anemia. Know that the antidote for overdose is protamine sulfate, and have access to it should you need it. Instruct patient to report any unusual signs of |

|bleeding to a heal care provider (see above). Instruct patient to use a soft toothbrush and an electric razor. Educate patient not to take any NSAIDs while on this|

|medication as it can increase the risk for bleeding. |

|Name: oseltamivir (Tamiflu) |Concentration: |Dosage Amount: 30 mg |

|Route: PO |Frequency: q12 hrs |

|Pharmaceutical class: antiviral |Home Hospital or Both |

|Indication: treatment for influenza infection |

|Adverse/ Side effects: seizures, confusion, vertigo, hallucination, n/v |

|Nursing considerations/ Patient Teaching: Monitor influenza symptoms such as fever, cough, headache, fatigue, muscle weakness, and sore throat during therapy and |

|notify provider if they get worse. Instruct the patient to take this medication for the full course of therapy, even if they are feeling better. Remind patient |

|that this is not a substitute for the flu vaccine and they should still get a flu shot every year. |

|Name: albuterol sulfate (2.5mg) + ipratropium bromide |Concentration: |Dosage Amount: 3 mL |

|(0.5 mg) (DuoNeb) | | |

|Route: nebulizer inhalation |Frequency: 4x daily |

|Pharmaceutical class: bronchodilator |Home Hospital or Both |

|Indication: to control and prevent airway obstruction caused by asthma and COPD |

|Adverse/ Side effects: nervousness, restlessness, tremor, headache, paradoxical bronchospasm, chest pain, palpitations, hypertension, n/v, hyperglycemia, |

|hypokalemia |

|Nursing considerations/ Patient Teaching: Monitor pulmonary function tests before and during therapy to determine effectiveness of medication. Observe for |

|paradoxical bronchospasm (wheezing) and hold medication and notify provider if it occurs. Instruct patient to take as directed on a scheduled regimen, and if a |

|dose is missed to not double the next dose. Educate patient to contact provider or 911 immediately if shortness of breath is not relieved by medication or is |

|accompanied by diaphoresis, dizziness, palpitations, or chest pain. Teach patient the proper use of a metered dose inhaler or nebulizer, have them teach it back to|

|you to ensure adequate understanding. Advise patient to rinse mouth out with water after each inhalation. |

|Name: levothyroxine (Synthroid) |Concentration: |Dosage Amount: 50 mcg |

|Route: PO |Frequency: 1x daily |

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

|Indication: thyroid supplement for hypothyroidism |

|Adverse/ Side effects: headache, insomnia, arrhythmias, tachycardia, abdominal cramps, diarrhea, vomiting, heat intolerance, weight loss |

|Nursing considerations/ Patient Teaching: Assess apical pulse and blood pressure as well as tachyarrhythmias and chest pain before administering medication and |

|consult doctor’s orders if these are present. Instruct patient to take this medication early in the morning on an empty stomach to increase absorption. Remind |

|patients that this is not a cure for hypothyroidism and is a lifelong therapy that they must continue. Instruct patient to inform other healthcare providers of |

|thyroid therapy. |

|Name: timolol (Istalol) |Concentration: 0.5% ophthalmic solution |Dosage Amount: 1 drop per affected eye |

|Route: eye drop |Frequency: 2x daily |

|Pharmaceutical class: beta blocker |Home Hospital or Both |

|Indication: treatment of open angle glaucoma by decreasing the formation of aqueous humor |

|Adverse/ Side effects: conjunctivitis, decreased visual acuity, ocular burning, and rash. Systemic absorption can lead to adverse cardiovascular effects such as |

|bradycardia and hypotension. Other systemic reactions include bronchospasm and delirium. |

|Nursing considerations/ Patient Teaching: Educate the patient of the proper way to instill the eye drops or show family member how to do it for them if they are |

|not able to. Use sterile saline to have the patient or family member practice giving the eye drops so as not to have an overdose of the medication. Caution the |

|patient that concurrent use with ophthalmic epinephrine may decrease the effectiveness of the medication. Educate the patient about the systemic affects and to |

|notify a provider if any develop. |

|Name: gabapentin (Neuontin) |Concentration: |Dosage Amount: 300 mg |

|Route: PO |Frequency: 3x daily |

|Pharmaceutical class: analgesic adjunct |Home Hospital or Both |

|Indication: management of peripheral neuropathic pain |

|Adverse/ Side effects: confusion, depression, dizziness, drowsiness, abnormal vision, hypertension, weight gain, rhabdomyolysis, ataxia, paresthesia |

|Nursing considerations/ Patient Teaching: Monitor closely and also instruct family members to monitor for emergence of suicidal thoughts or behavior, and |

|depression. Assess the location, characteristics, and severity of neuropathic pain before and during therapy. Instruct patient not to take this medication within 2|

|hours of an antacid as it will decrease the absorption. This medication may cause drowsiness or dizziness so instruct the patient not to drive until they know how |

|it affects them. Educate patient to take the medication at the same time every day, and if a dose is missed to not take a double dose at the next dose time. |

*Medication references from (Unbound Medicine, Inc., 2016)

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

|Diet ordered in hospital? Regular |Considering the patient’s age, height, weight, and moderate physical activity level,|

| |MyPlate recommends that she should consume, on average, 2000 calories a day to |

| |maintain her current weight. According to the Supertracker, she almost meets this |

| |recommendation and only falls short by about 400 calories. However, while she |

| |consumes an adequate amount of calories, they may not be calories of the kinds she |

| |needs, as Supertracker shows that she is deficient in nutrients like calcium but far|

| |exceeds to the recommendation for other nutrients such as sodium. |

|Diet patient follows at home? Regular |According to the food tracker analysis of the patient’s average 24 hour diet recall,|

| |she adequately meets the recommendation for vegetables and protein, but she is |

| |deficient in the recommendation of grains, fruits, and dairy. It also shows that she|

| |surpasses the daily recommendation of saturated fats and sodium. |

|24 HR average home diet: | |

|Breakfast: 2 scrambled eggs cooked with nonstick spray, a dash (1/16 teaspoon) of|According to MyPlate, the average amount of grains that is recommended for the |

|salt, a dash (1/16 teaspoon) of black pepper, 1 slice of whole wheat toast, 1 |patient to consume is 6 ounces. However, the patient falls short on this amount and |

|tablespoon of strawberry jam, 1 mug (8oz) of black decaffeinated coffee |only consumes, on average, 3.5 ounces of grains. It is good that the patient eats |

| |whole wheat bread with breakfast, but that should continue over to other meals of |

| |the day. It would be recommended that she also use whole wheat or 12 grain bread on |

| |her lunch sandwich, and possibly replace her mashed potatoes at dinner with whole |

| |wheat pasta or brown rice to cut down on the saturated fats. A diet rich in fiber |

| |will help keep digestion regular as some side effects of her medications include |

| |constipation. |

| | |

|Lunch: grilled ham and cheese sandwich made with margarine, 1 medium raw apple, 1|According to MyPlate, the recommended intake of vegetables for the patient is 2.5 |

|cup (8oz) of 2% reduced fat milk |cups. The patient meets and even exceeds this recommendation by consuming, on |

| |average, 3.25 cups of vegetables a day. While this is not necessarily a bad thing, |

| |as vegetables provide good nutritional value, but her over-intake of vegetables |

| |could be keeping her from consuming nutrients she is lacking in, such as fruits. It |

| |could be suggested to the patient that she replace her snack of carrots with some |

| |fresh seasonal fruit. Also, it is recommended that when she does eat vegetables, she|

| |eats them fresh or frozen instead of out of a can, because this will help to reduce |

| |sodium intake. |

| | |

|Dinner: 1 breaded and baked pork chop, 1 cup of mashed potatoes made with milk |According to MyPlate, the recommended intake of fruits for the patient is 2 cups. |

|and margarine, 1 cup of canned low sodium green beans |The patient fails to meet this recommendation by only consuming, on average, 1.25 |

| |cups of fruit daily. The patient makes an effort to include fruit in her diet with |

| |the fruit jam and the apple at lunch, but she should be encouraged to add more. She |

| |could either replace her daily snack of carrots with fresh fruit, or she could add |

| |fruit to another meal since she did not meet the full 2000 daily calorie |

| |recommendation. It could be suggested that she have a banana as a snack or with a |

| |meal, or perhaps some freshly squeezed orange juice with breakfast (although she |

| |should be careful to choose a “no sugar added” variety). |

| | |

|Snacks: 1 cup raw baby carrots and 1 packet of Ranch salad dressing |According to MyPlate, the recommended intake of dairy for the patient is 3 cups. The|

| |patient fails to meet this recommendation by only consuming, on average, 1.5 cups of|

| |dairy daily. It is important for a postmenopausal woman, such as this patient, to be|

| |consuming an adequate amount of dairy daily to get the recommended amount of calcium|

| |per day to prevent osteoporosis. It would be recommended that the patient add more |

| |sources of dairy to her diet such as a favorite type of cheese as a snack or a |

| |low-fat yogurt with breakfast. The patient should be careful to consume low-fat |

| |dairy products to reduce saturated fats in her diet. |

| | |

|Liquids (include alcohol): 1 mug of coffee, 1 cup of milk, and about 5 cups of |According to MyPlate, the recommended intake of protein for the patient is 5.5 |

|water |ounces. The patient meets and exceeds this amount by consuming, on average, 7 ounces|

| |of protein daily. This is also not necessarily a bad thing, however the patient |

| |should be careful about the types of protein she consumes. From her dietary recall |

| |she names ham, pork chops, and eggs as her primary sources of protein. Ham and pork |

| |especially can be loaded with extra sodium and saturated fats which probably caused |

| |her to exceed the limits for both of those. It could be suggested that she replaces |

| |those with leaner meats such as chicken or white meat turkey. And it also could be |

| |suggested that her scrambled eggs be made with just egg whites for a healthier |

| |option. |

| | |

|[pic] |See below both the daily food tracker for patient’s average daily intake as well as |

| |well as daily food plan with recommended amounts of daily intake for the patient’s |

| |2000 calorie diet. |

| |

| |

|[pic] |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

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

|Who helps you when you are ill? |

|“Usually my kids, even if they are far away, I know that I can always count on them if I need something.” |

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

|“I would say that I very seldom ever get truly upset. I kind of just accept that things happen and you can’t really change that. Sometimes I talk about it but then |

|it’s pretty much just over and I move on.” |

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

|“I guess being in the hospital is a recent difficulty, but I wouldn’t say that I am depressed about it.” |

| |

| |

|+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?  N/A |

| |

|Are you currently in a safe relationship? “Yes, definitely” |

| |

| |

|( 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: |

|Ego Integrity vs. Despair is the eighth and final stage of Erickson’s psychosocial development theory. “The task of this |

|stage is acceptance of one’s life worth, and eventual death. Ego integrity reflects a satisfaction with life and an understanding of one’s place in the life cycle. A |

|sense of loss, discomfort with life and aging, and fear of death are seen in despair” (Treas & Wilkinson, 2014, p.164). |

| |

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

|The patient is currently in Erikson’s eighth stage of psychosocial development entitled “Ego Integrity vs. Despair” with |

| |

|“Ego Integrity” being the option best applicable to her life. Being 80 years old, the patient knows that she is nearing the |

| |

|end of her life, but still has a remarkably positive outlook. She states that she is grateful to have lived so long and to have |

| |

|had such a wonderful life with her family. She states that her “greatest pride and joy in life” is her children and grandchildren, and she feels “blessed” to have |

|been able to watch them grow. |

| |

| |

| |

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

|The patient denies being discouraged by being hospitalized and realizes that declining health is a part of her aging. She |

| |

|states that she is very grateful to have lived so long with very few hospitalizations or health problems. |

| |

| |

| |

|+3 CULTURAL ASSESSMENT: |

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

|“I don’t really think there is any cause of it. Things just happen.” (Patient paused for a moment to reflect and adds) “Well maybe I should have gotten a flu shot, |

|huh?” (Patient laughs) |

|What does your illness mean to you? |

|“It doesn’t really mean anything. Nobody likes getting sick, but it is what it is.” |

| |

| |

|+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? “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” |

| |

|Are you currently sexually active?  “No, not anymore”  If yes, are you in a monogamous relationship? “I was always in a monogamous relationship” When sexually |

|active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?  “We never really used anything” |

| |

|How long have you been with your current partner? “Since 1984” – 32 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?

“It doesn’t really have much importance in my life anymore. I used to go to church a lot when I was younger but I don’t really anymore.”

Do your religious beliefs influence your current condition?

“No, I wouldn’t say so.”

_____________________________________________________________________________________________________

|+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? 41 years |

|Yes, the patient admits to previously smoking cigarettes. |“about 1 pack a day” |(age 20 thru 61 ) |

| | | |

|Pack Years: 41 pack years | |If applicable, when did the patient quit? |

| | |1997 |

| | | |

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

|No, her husband quit at the same time she did |If yes, what did they use to try to quit? “will power” |

| |

| |

|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No- “even when I lived in Germany, I |

|just never liked alcohol.” |

| What? N/A |How much? N/A |For how many years? N/A |

| |Volume: N/A |(age thru ) N/A |

| |Frequency: N/A | |

| If applicable, when did the patient quit? N/A | | |

| |

| |

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

| If so, what? N/A |

| |How much? N/A |For how many years? N/A |

| | |(age thru ) N/A |

| | | |

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

|N/A | | |

| | | |

| | | |

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

| “No, I don’t think so.” |

| |

| |

|5. For Veterans: Have you had any kind of service related exposure? |

|N/A |

| |

| |

| |

| |

( 10 Review of Systems Narrative

| |Gastrointestinal |Immunologic |

| | 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 No SPF: N/A | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: 1x daily |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

|Be sure to answer the highlighted area | Last colonoscopy? 10 years ago | |

|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: unkown |

| Post-nasal drip |Normal frequency of urination: 8x/day |Other: |

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

| Dental problems pt has top and bottom dentures | |Metabolic/Endocrine |

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

| Routine dentist visits No | | Hypothyroid /Hyperthyroid |

|Vision screening | | Intolerance to hot or cold |

|Other: | | 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? 12 years old | Encephalitis |

|last CXR? 2/23/16 | menopause age? 45 years old | Meningitis |

|Other: |Date of last Mammogram &Result: 10 years ago- normal |Other: Peripheral neuropathy |

| |Date of DEXA Bone Density & Result: 10 years ago- | |

| |normal | |

|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? 2/23/16 |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

| | | |

|General Constitution |

|Recent weight loss or gain No |

|How many lbs? |

|Time frame? |

|Intentional? |

|How do you view your overall health? “It’s pretty good I’d say. I made it to this age.” |

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

|“No, I don’t go to the doctor that often.” |

| |

| |

| |

| |

| |

| |

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

|“No.” |

| |

| |

| |

| |

|±10 PHYSICAL EXAMINATION: |

| |

|General Survey: The patient is an elderly pleasant woman who is groomed and appropriately dressed for the hospital. She is sitting comfortably in a chair as we talk,|

|and has occasional coughing episodes. |

|Height: 5 ft. 6 in. |

|Weight: 152.6 lb. |

|BMI: 24.6 |

|Pain: (include rating and location) |

|0/10 |

|“I don’t have pain, just kind of a tightness in my chest from all this mucus.” (Patient has been unable to clear or cough up any sputum) |

| |

| |

|Pulse: 71 |

|Blood Pressure: (include location) |

|139/68 taken on right arm |

| |

| |

| |

|Respirations: 16 |

| |

| |

| |

|Temperature: (route taken?) 96.9 degrees F, temporal |

|SpO2: 93% |

|Is the patient on Room Air or O2: |

|2 liters nasal cannula |

| |

| |

|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 access device Type: 20 gauge peripheral IV Location: left forearm Date inserted: 2/23/16 |

|Fluids infusing? no yes - what? NaCl 0.9% 1000mL @ 75mL/hr |

| |

|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 Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |

| Ears symmetric without lesions or discharge Whisper test heard: right ear- 12 inches & left ear- 12 inches |

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

|Dentition: patient had top and bottom dentures which were well cleaned |

|Comments: |

| |

|Pulmonary/Thorax: Respirations regular and unlabored* Transverse to AP ratio 2:1 Chest expansion symmetric *Patient occasionally experienced coughing|

|fits with labored breathing |

|Percussion resonant throughout all lung fields, dull towards posterior bases *percussion was dull in most fields due to mucus accumulation in the lungs |

|Sputum production: thick thin Amount: scant small moderate large *Pt was not able to cough up any sputum |

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

|Lung sounds: expiratory wheezing |

|RUL RH LUL RH |

|RML RH LLL RH, D |

|RLL RH. D |

| |

|CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent |

|Cardiovascular: No lifts, heaves, or thrills |

| |

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

| |

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

| |

|[pic] |

| |

|This is the patient’s ECG strip from 02/23/16, taken on admission. It shows sinus tachycardia and an incomplete right bundle branch block with a ventricular rate of |

|117 beats per minute. The patient does not normally have tachycardia and it was likely a result of the patient’s dyspnea at the time and the body overcompensating. |

|At the time of the current assessment the patient was back to normal sinus rhythm with a pulse rate of 71 beats per minute. |

| |

| |

| |

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

| |

|Apical pulse: 3 Carotid: 3 Radial: 3 PT: 2 |

| |

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

| |

|Location of edema: pitting non-pitting |

| |

|Extremities warm with capillary refill less than 3 seconds |

| |

| |

| |

|GI 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 |

| |

|Last BM: (date 2 / 24 / 16 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

| |

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

| |

|Nausea emesis Describe if present: |

| |

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

| |

|Other – Describe: |

| |

| |

| |

|GU Urine output: Clear Cloudy Color: yellow Previous 24 hour output: 800 mLs |

| |

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

| |

|CVA punch without rebound tenderness |

| |

| |

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

| |

|Strength bilaterally equal at 4 RUE 4 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 |

| |

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

| |

| |

| |

|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- patient uses a walker for ambulation assistance |

| |

|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: 2 Achilles: Ankle clonus: positive negative Babinski: |

|positive negative |

|*Altered sensation in feet due to peripheral neuropathy |

|*Only assessed the patellar and Babinski reflex since those are the main ones taught in Health Assessment lab |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|±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 |

| |

|13.4/mm3 *H |

| |

|11.6/mm3 *H |

| |

|10.6/mm3 |

| |

|10.7/mm3 |

| |

|Normal: 5,000-10,000mm3 |

| |

| |

|2/23/16 |

| |

|2/24/16 |

| |

|2/25/16 |

| |

|2/26/16 |

| |

|The patient’s white blood cell count was elevated at the time of admission, but then started on a downward trend and now has been constant for the last two days at |

|the high end of the normal range. |

|It is important to look at the patient’s white blood cell count in order to assess the presence of infection. A high count of over 10,000 would indicate that an |

|infection could be present. When the patient was first admitted, it was likely from her symptoms (fever, dyspnea, tachypnea, and tachycardia) that there was an |

|infection present. So she was started on broad spectrum antibiotics and once influenza A was confirmed she was started on antivirals. It is likely that the |

|combination of these medications helped to reduce the infection and bring her white count down. |

| |

|Hemoglobin |

| |

|12. 7 g/dL |

| |

|12.4 g/dL |

| |

|11.7 g/dL *L |

| |

|12.3 g/dL |

| |

|Normal: 12-16 g/dL |

| |

| |

|2/23/16 |

| |

|2/24/16 |

| |

|2/25/16 |

| |

|2/26/16 |

|The trend of the patient’s hemoglobin remains fairly consistent at the low end of the normal values with one instance of it dropping to below normal range. |

|Hemoglobin is a good indicator of the presence of oxygen in red blood cells. It is the iron containing pigment of RBCs that carries oxygen from the lungs to tissues.|

|These lab values are to be expected for the patient. When she came into the ED she was in a state of hypoxemia, her respirations were fast and elevated and she was |

|not getting an adequate supply of oxygen. Therefore, there was less oxygen in the lungs for the red blood cells to carry and hemoglobin levels dropped. As treatment |

|for the patient’s underlying condition continues and respirations and oxygenation improve, it is expected for the hemoglobin levels to increase. However, since the |

|patient does have a history of asthma and COPD, it is possible that the hemoglobin levels may always be on the low side. |

| |

|Carbon Dioxide |

| |

|34 mEq/L *H |

| |

|30 mEq/L |

| |

|30 mEq/L |

| |

|29 mEq/L |

| |

|Normal: 23-30 mEq/L |

| |

| |

|2/23/16 |

| |

|2/24/16 |

| |

|2/25/16 |

| |

|2/26/16 |

|The patient’s carbon dioxide levels start off above normal values at the time of admission, and then decrease and remain fairly consistent over the next few days. |

|It would be expected that the patient’s carbon dioxide levels were elevated at the time of admission. The patient was having trouble breathing due to hypoxemia and |

|all of the congestion and coughing due to the influenza. Her respirations were elevated and when this happens, it becomes harder to adequately and fully exhale to |

|release carbon dioxide, and so the patient was retaining carbon dioxide which was not fully being filtered out in the lungs. This likely decreased once the patient |

|was started on oxygen therapy and was able to slow down her respirations. |

| |

|Glucose |

| |

|120 mg/dL *H |

| |

|140 mg/dL *H |

| |

|137 mg/dL *H |

| |

|138 mg/dL *H |

| |

|Normal: 65-99 mg/dL |

| |

| |

|2/23/16 |

| |

|2/24/16 |

| |

|2/25/16 |

| |

|2/26/16 |

|The trend of glucose levels remains elevated from normal range for all of the blood draws and even shows a slight trend upward. |

|It is unusual for a non-diabetic patient to have such consistent levels of elevated glucose, although after looking at her medical history, a hypothesis can be made |

|regarding her glucose levels. Even though the patient has never been diagnosed with diabetes she has conditions associated with diabetes such as hypertension, |

|peripheral neuropathy, glaucoma, and now elevated glucose levels. It could be possible that the patient is experiencing effects of un-medicated diabetes mellitus. |

|This possibly should be brought to the provider’s attention to see if he wants to further investigate the possibility of diabetes in the patient. |

| |

|Calcium |

| |

|8.2 mg/dL *L |

| |

|7.7 mg/dL *L |

| |

|7.8 mg/dL *L |

| |

|7.8 mg/dL *L |

| |

|Normal: 9-11 mg/dL |

| |

| |

|2/23/16 |

| |

|2/24/16 |

| |

|2/25/16 |

| |

|2/26/16 |

|The trend of the patient’s calcium levels remains consistently below the normal range. |

|According to the patient’s 24 hour diet recall, it can be expected that her calcium levels would be decreased. The patient was deficient in dairy intake, and since |

|dairy is a primary source of calcium, it makes sense that her calcium levels would also be deficient. This is important to address with the patient for modification,|

|because she already has several risk factors for osteoporosis. She is an elderly, white, postmenopausal woman who smoked for a good majority of her life. And an |

|inadequate intake of calcium is just another risk factor to add to the patient developing fragile bones that are at risk for fracture. |

| |

|Albumin |

| |

|3.8 g/dL *L |

| |

|3.4 g/dL *L |

| |

|3.1 g/dL *L |

| |

|3.2 g/dL *L |

| |

|Normal: 4-6 g/dL |

| |

| |

|2/23/16 |

| |

|2/24/16 |

| |

|2/25/16 |

| |

|2/26/16 |

|The patient’s albumin levels were low to begin with and displayed a downward trend over the next few days. |

|Albumin is a good indicator of a patient’s nutritional status. If it is decreased like with this patient, it indicates insufficient intake and malnutrition. When |

|questioned about her recent eating habits, the patient admits to not eating much in the hospital due to the unfamiliar environment and food. She also states that in |

|the week leading up to her hospital admission she did not eat very much because she wasn’t feeling well. It would be expected that once the patient has recovered and|

|is back in her home environment eating normally again, that her albumin levels would begin trending upward. |

| |

|Procalcitonin |

| |

|0.05 ng/mL |

| |

|Normal: less than 0.1 ng/mL |

| |

| |

|2/23/16 |

|The patient’s procalcintonin levels were within normal limits on the day they were tested. Only one lab result was available at the time of assessment. |

|Procalcitonin is monitored in a patient to assess the presence of bacterial infection as well as the risk for developing sepsis. If the value is less than 0.1 ng/mL |

|than a bacterial infection is either absent or very unlikely and there is no risk for sepsis. The more this value increases, the higher the chance of bacterial |

|infection is and the more likely the risk of sepsis becomes. What this means for the patient is that is it unlikely that she has a bacterial infection. This test was|

|done because on admission the patient was suspected to have sepsis from some sort of infection. However, this was quickly ruled out as the patient did not meet the |

|criteria for sepsis. The possibility of infection was still high though and it was unsure at the time whether it was viral, bacterial, or fungal and so the patient |

|was started on a broad spectrum antibiotic and kept on it to prevent the risk of further infection after influenza was confirmed. |

| |

|*All normal lab values and rationales were obtained from (Unbound Medicine, Inc., 2016) |

| |

|Diagnostic Procedures: |

|The patient had a diagnostic 12 lead ECG done on admission on 2/23/16 to check for possible cardiac problems that could have resulted secondary to the hypoxemia the |

|patient was currently experiencing. An ECG or electrocardiogram is a noninvasive study that “measures the electrical currents or impulses that the heart generates |

|during a cardiac cycle” (Unbound Medicine, Inc., 2016). The results showed an incomplete right bundle branch block that was consistent with prior ECGs done on the |

|patient. What was not consistent was the showing of sinus tachycardia with a ventricular rate of 117 beats per minute. This was likely due to the state of stress and|

|dyspnea the patient was in at the time. She was started on supplemental oxygen and subsequent vital signs revealed a decrease in pulse rate and the patient returned |

|to normal sinus rhythm. |

|The patient also had a diagnostic Chest X-Ray done at the time of admission to get a better view of what was going on inside the thoracic cavity. A chest x-ray is |

|one of the most common radiological diagnostic tests where the lungs and heart are “easily penetrated by x-rays and appear on chest images” (Unbound Medicine, Inc., |

|2016). The CXR findings showed no acute cardiopulmonary abnormalities, but did show mild interstitial of each lung base which is most likely a result of the |

|patient’s prior smoking history, which could add to the complications of a respiratory infection. |

|On 2/23/16 at the time of admission the patient’s blood samples were sent for Microbiology Rapid Testing which came back positive for the influenza A antigen and |

|negative for the influenza B antigen, and so the patient was started on antiviral therapy. Since sepsis was suspected at this time, the patient’s blood sample was |

|also sent for Microbiology Blood Culture, and on 2/25/16 results showed that there was no preliminary growth on day two. |

|The current orders for the patient are to obtain a Sputum Culture for microbiology testing, once the patient is able to clear and cough up any mucus secretions. It |

|is likely that they will want to test for the presence of pneumonia since it is a common complication of influenza, especially for older patients with a history of |

|respiratory problems. |

|+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.) |

|The patient is ordered a regular diet while in the hospital since she is not on any cardiac, diabetic, or renal restrictions. |

|A sputum culture sample is needed from the patient once she is able to cough up any mucus secretions. This will be tested for further infection such as pneumonia. |

|A daily CBC and CMP is ordered for the patient to continue monitoring the effects of treatment in the hospital. An increase of white blood cells could indicate a new|

|or worsening infection. A decrease in hemoglobin could suggest worsening hypoxemia. And the metabolic profile also should be monitored to make sure the patient is |

|getting adequate nutrients, although the decrease in albumin suggests that she is not getting adequate nutritional intake. |

|There is a standing order to notify the physician of glucose 150 mg/dL. Looking at the patient’s current values and past medical history, it is likely |

|that she is pre-diabetic and should probably have her glucose levels monitored on a more frequent basis to prevent further complications. |

|Obtain and order a 12 lead ECG for any onset of chest pain. The patient has denied any chest pain up to this point, but it is possible that prolonged hypoxemia could|

|lead to cardiac complications that would need to be evaluated at the first sign of onset. |

|The patient is on droplet precautions while in the hospital, and a face mask is required before entering her room. Since influenza is spread by droplets, it could |

|easily be transmitted to any persons in her room by her coughing or sneezing. The mask must be removed upon leaving the room, and hands must be washed to get any |

|droplets off of the skin. |

|SCDs are ordered for when the patient is lying in bed as a DVT prophylaxis along with daily Lovenox shots. |

|Vitals are ordered q8 hours. Since the patient is not considered a critical care patient, vitals can be more spread out but still need to be done every shift to |

|evaluate any changes or trends. |

|There is a standing order to elevate the head of the bed and move the patient to the chair for meals. The more elevated the patient is, the better quality of lung |

|expansion she will have and the easier it will be for her to clear sputum so that it will not remain in the lung bases and become infected. |

|An educational video was ordered for the patient to watch entitled “Falls: Walking Safely in the Hospital,” since the patient is elderly with a history of |

|complications including glaucoma and peripheral neuropathy, she is considered a fall risk in the hospital. The patient is also very independent and likes to do |

|things for herself, so it is important that she is reminded to call and ask for help getting up and moving about to prevent falls. |

|There is a standing order to continue supplemental oxygen therapy at 2 liters nasal cannula and to titrate as needed to maintain SpO2 between 88-92% since the |

|patient has COPD. An overflow of oxygen for this patient could decrease the respiratory drive to take a breath, so it is normal for her to have a lower O2 saturation|

|than patients without COPD. |

| |

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

| |

|1. Ineffective airway clearance related to mucus secretions in the chest, as evidenced by audible coughing, wheezing, and rhonchi. |

| |

| |

| |

|2. Imbalanced nutrition: less than body requirements related to the patient’s decreased appetite due to illness, as evidenced by decreased albumin levels and the |

|patient stating that she has not been eating much recently. |

| |

| |

| |

|3. Risk for falls related to weakness from hypoxemia, difficulty seeing, and numbness in feet from peripheral neuropathy. |

| |

| |

| |

|4. Risk for infection related to inadequate vaccinations and hospitalization with respiratory complications. |

| |

| |

| |

|5. Activity intolerance related to imbalance between oxygen supply and demand and generalized weakness, as evidenced by the patient’s report of weakness and fatigue |

|and exertional dyspnea. |

| |

| |

| |

| |

| |

± 15 CARE PLAN

Nursing Diagnosis: Ineffective airway clearance related to mucus secretions in the chest, as evidenced by audible coughing, wheezing, and rhonchi.

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

| | |Provide References | |

|Short Term: |* Help the patient to deep breathe and perform |* It is important to teach the patient the most |This goal was met. By the end of shift, the patient |

|The patient will demonstrate effective coughing |controlled coughing. Instruct them to inhale deeply, |effective ways of coughing so that they don’t have to|was able to demonstrate proper coughing techniques |

|techniques and will explain methods useful to enhance|hold breath for several seconds, and cough two or |cough as often and cause exhaustion. Controlled |and explain ways to help mobilize secretions. |

|secretion removal by the end of shift. |three times with the mouth open while tightening the |coughing utilizes the muscles of the diaphragm and | |

| |upper abdominal muscles. |helps to make the cough more forceful and effective | |

| | |(Gosselink et al., 2008, as cited in Ackley & Ladwig,| |

| | |2014a). | |

| | | | |

| | |* This particular technique is used in patients with | |

| |* If the patient has obstructive lung disease such as|chronic obstructive lung complications to prevent the| |

| |COPD, it may be helpful to teach them to use the |glottis from closing during the cough and to | |

| |forced expiratory technique known as the “huff cough”|effectively clear mucus secretions (Bhowmik et al., | |

| |in which the patient does a serious of coughs while |2009, as cited in Ackley & Ladwig, 2014a). | |

| |saying the word “huff.” | | |

| | |* Incentive spirometers are useful for patients who | |

| | |are sedentary in hospital beds with risks for | |

| |* Encourage the patient to use the incentive |pulmonary complications. It helps to expand the | |

| |spirometer as ordered (usually at least once an |alveoli and prevent them from collapsing which could | |

| |hour). Make sure the patient knows how to correctly |result in pneumonia for the patient (Ackley & Ladwig,| |

| |use this instrument and have them demonstrate return |2014a). | |

| |teaching. | | |

| | |* Not only does body movement help to mobilize | |

| | |secretions, but immobility can be seriously | |

| |* Encourage the client to participate in activity and|contraindicated in the elderly because it can | |

| |ambulation as much as tolerated without exhaustion. |decrease ventilation and increase the stasis of | |

| | |secretions which can lead to pneumonia (Ackley & | |

| | |Ladwig, 2014a). | |

| | | | |

| | |* Not only does an increase in fluid help to increase| |

| | |ciliary action to move secretions, but elderly | |

| |* Educate the patient on the importance of increasing|patients are also prone to dehydration from | |

| |fluid intake up to 2500 mL/day. |forgetting to drink enough fluids which can create | |

| | |more viscous secretions that are harder to move | |

| | |(Ackley & Ladwig, 2014a). | |

|Long Term: |* Auscultate breath sounds every four hours. |* The quality of breath sounds will give you an |This goal was not met at the time of assessment. It |

|The patient will be able to cough up and clear mucus | |indication of the patient’s respiratory status. |is recommended that the patient be re-assessed at the|

|from the chest and have clear breath sounds by the | |Normal breath sounds should be clear to the bases, |time of discharge. |

|time of discharge. | |but the presence of crackles or wheezing suggests | |

| | |fluid or obstruction in the airway (Jarvis, 2012, as | |

| | |cited in Ackley & Ladwig, 2014a). | |

| | | | |

| | |* Supplemental oxygen can help to correct hypoxemia | |

| | |which can allow the patient to breathe more | |

| |* Administer oxygen via nasal cannula as ordered. |effectively (Wong & Elliott, 2009, as cited in Ackley| |

| | |& Ladwig, 2014a). | |

| | | | |

| | |* An upright position helps to increase lung | |

| | |expansion which allows patients to breathe more | |

| | |easily and effortlessly and also helps to prevent the| |

| |* Position the patient to at least 30 degrees if not |patient acquiring pneumonia (Siela, 2010, as cited in| |

| |more in bed, and help to reposition them at least |Ackley & Ladwig, 2014a). | |

| |every 2 hours. | | |

| | |* Medications like bronchodilators help to open up | |

| | |the airway, decrease resistance, and improve the | |

| | |efficiency of respirations which will allow for | |

| | |easier expulsion of secretions (Barnett, 2008, as | |

| | |cited in Ackley & Ladwig, 2014a). | |

| |* Administer respiratory therapy medications such as | | |

| |bronchodilators or inhaled steroids as ordered by the|* The proper use of percussion on the back near the | |

| |provider. |base of the lungs can help to break up mucus | |

| | |secretions and make them more mobile to help be | |

| | |excreted by the patient’s coughing (Ackley & Ladwig, | |

| | |2014a). | |

| | | | |

| |* Provide percussion and vibration as needed and/or | | |

| |as ordered by the provider or respiratory therapy. | | |

|±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 *Social services should be consulted as the patient receives social security benefits and Medicare, and will likely need the help of social work to help figure out the finances of the current |

|hospitalization. |

|□Dietary Consult *Dietary services should be consulted regarding the patients recent decrease in appetite, to discuss with her options of increasing her dietary intake, especially when she is ill. |

|□PT/ OT *Physical therapy is consulted to come and walk with the patient daily in the hall to keep her mobile while she is hospitalized. |

|□Pastoral Care |

|□Durable Medical Needs |

|□F/U appointments *The patient is aware that she will have follow-up appointments and states that her daughter will be driving her to these. |

|□Med Instruction/Prescription *The patient was started on Cardizem during this hospitalization, so if the doctors decide to continue this for her hypertension, she will need a prescription and medication teaching on |

|the side effects and dosing |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No *If the patient is discharged home on an antibiotic, most antibiotics can be obtained for free at Publix Supermarkets |

|□Rehab/ HH *It is possible that the patient could need home health if she is discharged home on supplemental oxygen. Home health will need to come to her house to set this up. |

|□Palliative Care |

Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to the patient’s decreased appetite due to illness, as evidenced by decreased albumin levels and the patient stating that she has not been eating much recently.

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

| | |Provide References | |

|Short Term: |* Teach the patient how to use a food diary to |* The use of the food diary is helpful to both the |The goal was met. The patient was able to identify |

|The patient will be able to identify nutritional |monitor both food intake and the percentage of served|patient and the provider to examine what types of |ways to consume the proper amount of calories and |

|requirements and explain how to adequately consume |food that is eaten (25%, 50%, 75%, or 100%). |foods were eaten, the patterns of eating, and |nutrients daily by the end of the shift. |

|the correct amount of calories for her height and | |deficiencies in the diet, and helps to evaluate what | |

|weight by the end of shift. | |changes need to be made (Shay et al., 2009, as cited | |

| | |in Ackley & Ladwig, 2014b). | |

| | | | |

| | |*Often patients who are ill or malnourished tire | |

| |* Help the patient to pick out small quantities of |easily and aren’t able to finish a meal. However, if | |

| |energy-dense and protein rich foods and serve them at|the meal is small and packed with energy, they should| |

| |frequent intervals. |be able to finish it and still get all the nutrients | |

| | |they need from it (Ackley & Ladwig, 2014b). | |

| | | | |

| | |* A lot of times, patients will just eat the foods | |

| | |they like on the tray and not the foods they need. By| |

| | |utilizing a color-coding system and assigning each | |

| |* Use colored plates or trays that help identify |food group a color on the tray it helps the patient | |

| |which food belongs to which food groups, and go over |to recognize if they are eating foods from all of the| |

| |it again with a patient each time a meal is brought. |food groups and not just one or two (Ackley & Ladwig,| |

| | |2014b). | |

| | | | |

| | |* Often, providers will prescribe nutritional | |

| | |supplement drinks for patients in the hospital that a| |

| | |lot of patients don’t like and don’t want to drink. | |

| | |So it is important to offer them other healthy | |

| |* Educate the patient on alternatives to nutritional |options that they are more likely to eat, so they are| |

| |supplement drinks such as small healthy snacks |still getting the extra calories and nutrients that | |

| |throughout the day. |they need (Simmons, Zhuo, & Keeler, 2010, as cited in| |

| | |Ackley & Ladwig, 2014b). | |

|Long Term: |* Monitor the patient’s serum albumin levels daily |* Serum albumin levels are good indicators of |This goal was not met. It is suggested to re-evaluate|

|The patient will maintain her current weight and show|after blood draws. |nutritional status and a serum albumin level of less |the patient at the time of discharge. |

|an increase in albumin levels by the time of | |than 3.5 is considered an indicator of risk of poor | |

|discharge. | |nutritional status (Dwyer, 2011, as cited in Ackley &| |

| | |Ladwig, 2014b). | |

| | | | |

| | |* This is important to mark and monitor the trend of | |

| |* Make sure to weigh the patient daily (preferably in|the patient’s weight. Research has shown that the | |

| |the morning wearing the same clothing). |presence of malnutrition in a decrease of 10 pounds | |

| | |since the start of admission can increase the length | |

| | |of hospital stays as it contributes to complications | |

| | |(Gout, Barker, & Crowe, 2009, as cited in Ackley & | |

| | |Ladwig, 2014b). | |

| | | | |

| | |* Being in a hospital is a strange and often scary | |

| | |experience for patients, and many things could deter | |

| | |them from being able to order the food they want, | |

| |* Go over the menu with the patient and help them to |such as not knowing how to order on the phone or even| |

| |pick out the foods that they are most familiar with |not being able to read the menu. Often times, a | |

| |and would be most likely to eat. |generic tray is brought to their rooms that they | |

| | |don’t like. It is important for the nurse to address | |

| | |these issues as patients may not be willing to openly| |

| | |admitting it (Ackley & Ladwig, 2014b). | |

| | | | |

| | |* In some cultures, mealtime is usually a social | |

| | |interaction, and often these patients are likely to | |

| | |eat more if other people are present at meal times | |

| | |(Ackley & Ladwig, 2014b). | |

| | | | |

| | |* Dysphagia is sometimes a common reason for elderly | |

| |* Assess the patient’s cultural needs, and if called |patients not to eat as much because they are having | |

| |for, provide company at meal time to encourage |difficulty swallowing food, and can be seen for | |

| |nutritional intake. |multiple reasons, even with the onset of pneumonia. | |

| | |Screening is important to make sure that this is not | |

| | |the reason patients are having trouble eating | |

| | |(Serra-Prat et al., 2012, as cited in Ackley & | |

| |* Screen for dysphagia in all elderly patients. |Ladwig, 2014b). | |

|±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 *Social services should be consulted as the patient receives social security benefits and Medicare, and will likely need the help of social work to help figure out the finances of the current |

|hospitalization. |

|□Dietary Consult *Dietary services should be consulted regarding the patients recent decrease in appetite, to discuss with her options of increasing her dietary intake, especially when she is ill. |

|□PT/ OT *Physical therapy is consulted to come and walk with the patient daily in the hall to keep her mobile while she is hospitalized. |

|□Pastoral Care |

|□Durable Medical Needs |

|□F/U appointments *The patient is aware that she will have follow-up appointments and states that her daughter will be driving her to these. |

|□Med Instruction/Prescription *The patient was started on Cardizem during this hospitalization, so if the doctors decide to continue this for her hypertension, she will need a prescription and medication teaching on |

|the side effects and dosing |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No *If the patient is discharged home on an antibiotic, most antibiotics can be obtained for free at Publix Supermarkets |

|□Rehab/ HH *It is possible that the patient could need home health if she is discharged home on supplemental oxygen. Home health will need to come to her house to set this up. |

|□Palliative Care |

References

Ackley, Betty J. & Ladwig, Gail B. (2014a). Ineffective airway clearance. In Nursing diagnosis handbook: an

evidence-based guide to planning care (pp. 129-133). St. Louis, MO: Mosby Elsevier.

Ackley, Betty J. & Ladwig, Gail B. (2014b). Imbalanced nutrition: less than body requirements. In Nursing

diagnosis handbook: an evidence-based guide to planning care (pp. 558-564). St. Louis, MO: Mosby

Elsevier.

. (2015). Adult BMI calculator. Retrieved 03 April 2016, from

ml

. (2015). Daily food plans. Retrieved 02 April 2016, from



Osborn, K., Wraa, C., Watson, A., Holleran, R. (Eds.). (2014). Chapter 27: Caring for the patient with

lower airway disorders. In Medical-surgical nursing: Preparation for practice (2nd ed.) (pp. 739-

740). Upper Saddle River, New Jersey: Pearson.

Supertracker.. (2015). SuperTracker: My Foods. My Fitness. My Health.. Retrieved 03 April

2016, from

Treas, L., & Wilkinson, J. (2014). Development: infancy through middle age. In Basic nursing: concepts,

skills, & reasoning (pp. 164). Philadelphia, PA: F.A. Davis Company.

Unbound Medicine, Inc. (2016). Nursing Central (1.27.) [Mobile application software]. Retrieved from



................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download