UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Marlee Griggs |

|Patient Assessment Tool . |Assignment Date: 1/22/14 |

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

|Patient Initials: M.D. |Age: 63 |Admission Date: 1/20/14 |

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

| | |J45.21 Mild intermittent asthma with (acute) exacerbation |

|Primary Language: English | |

|Level of Education: completed 2.5 years of college |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): switchboard operator at Bayfront | |

|Number/ages children/siblings: 32 yo son; 68 yo sister; 66 yo sister | |

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

|Living Arrangements: lives with a good friend that she refers to as her “brother”, they rent|Advanced Directives: No |

|a one story house that does not have any stairs. |If no, do they want to fill them out? No |

| |Surgery Date: NA Procedure: NA |

|Culture/ Ethnicity /Nationality: Caucasian/non-hispanic | |

|Religion: Methodist |Type of Insurance: BCBS |

|( 1 CHIEF COMPLAINT: |

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|“I came in because my asthma got worse on Monday.” |

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

|The patient is a 63 year old Caucasian female that was admitted into the emergency department on 1/20/2014 due to worsening asthma symptoms. The patient was |

|diagnosed with asthma in 1959 and reported that for the past several years she has had very good control over her asthma. On Sunday the patient reported she |

|noticed a cough and congestion that became increasingly worse. The patient went to a local walk-in clinic for her symptoms, but they continued to get worse. On |

|Monday, the 20th, she called 911 because her symptoms continued to get worse and she did not have a way to get to the hospital. The patient reported that it felt |

|as if she had “tightness” in her chest, was easily winded, and had shortness of breath. The patient stated that when her asthma symptoms worsen it causes her blood|

|pressure to increase which causes an increase in her anxiety. The patient typically manages her asthma symptoms by using Advair Diskus, a rescue inhaler, and a |

|nebulizer if needed. The patient was moved to 3N to receive albuterol and prednisone treatments in addition to her routine Advair Diskus. The patient has wheezing |

|throughout all lobes in the lung, and the doctor explained to the patient that it will take several days for the wheezing to subside completely. The plan of care |

|was for the patient to receive treatments through respiratory therapy and prednisone to help relax the constriction of the bronchioles. As of 1/22/14, the patient |

|began to deny her respiratory therapy treatments due to her increase in blood pressure after receiving the treatments. The patient will potentially be discharged |

|on 1/22/2014, but the doctor wanted to observe the patient and determine whether the wheezing continued to subside. |

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

|Date |Operation or Illness |

|1959 |Patient was diagnosed with asthma. |

|1982 |Patient had a C-section for the birth of her son. |

|1982-1983 |The patient was diagnosed with anxiety. disorder |

|1988 |Patient had a hysterectomy performed due to benign fibroid tumors. The patients vagina, cervix, and one ovary were removed. |

|2004 |The patient was diagnosed with HTN. |

|12/27/2013 |The patient was diagnosed with A-fib. |

|unknown |GERD |

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|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

| |The patient’s eldest sister did not have any of the above disease processes. |

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|( 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 (2004) | | |

|Influenza (flu) (9/2013) | | |

|Pneumococcal (pneumonia) (9/2013) | | |

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

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

|REACTIONS |Causative Agent | |

|Medications | | |

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| |NKA | |

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

|etc.) | | |

| |NKA | |

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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) |

|Asthma is a chronic disease that affects the bronchioles in the lungs. The bronchioles branch off from the bronchi and eventually lead to the alveoli. The |

|bronchioles are lined with smooth muscle and are able to constrict or dilate based on the needs of the body. This allows the body to control how much air is |

|delivered to the alveoli. Asthma causes the bronchioles of the lung to become inflamed which causes bronchoconstriction, or a narrowing of the passageway. This |

|leads to wheezing, shortness of breath, chest tightness, and coughing. When an asthma attack occurs, the inflammatory response in the bronchioles leads to swelling|

|and a tightening of the muscles that surround the bronchiole which drastically reduces the amount of air that is able to flow through the bronchioles and be |

|delivered to the alveoli. Asthma can often be triggered by breathing in allergens, being exposed to allergens, or changes in the environment. Common triggers for |

|asthma include pet hair or dander, dust mites, medications, changes in weather, chemicals in the air or in food, exercise, mold, pollen, strong emotions such as |

|stress, tobacco smoke, or respiratory infections such as a common cold. It is not clear as to why some people have asthma, and others do not, but it is believed to|

|be a combination of environmental and genetic factors. Some risk factors that increase a person’s likelihood of having asthma include having a first degree |

|relative with asthma, having another allergic condition such as hay fever, being overweight, being a smoker, exposure to second hand smoke, having a mother who |

|smoked while pregnant, exposure to exhaust fumes or other types of pollution, exposure to occupational triggers such as chemicals used in farming, hairdressing, or|

|manufacturing, and a low birth weight. There are several tests that may be used to diagnose asthma. The doctor will most likely complete a physical exam to rule |

|out chronic obstructive pulmonary disorder (COPD) or respiratory infection and will ask questions about symptoms that have been experienced and any other health |

|problems and the doctor will also observe for signs of what a patient is experiencing. Spirometry and peak flow meter tests may also be used to help aid in the |

|diagnosis of asthma. Spirometry measures how much air you can exhale after taking a deep breath and it also measures how fast you can breathe out. The spirometry |

|test is used to estimate how much the bronchioles have constricted and narrowed. The peak flow meter is a device that allows the practitioner to see how hard you |

|can exhale. If the peak flow meter reading is low it can be a signal to the healthcare provider that the patient’s lungs may not be working as well and that the |

|asthma is getting worse. The lung function tests are often conducted before and after a bronchodilator is given to determine if the function of the lungs improves |

|after receiving medication that opens the airways of the lungs. If lung function improves after receiving treatment with a bronchodilator then there is a high |

|probability that the diagnosis is asthma. A combination of treatments is usually necessary to help control asthma and prevent acute asthma attacks. It is important|

|for individuals to be aware of their triggers and the necessary steps to avoid the triggers. It is also recommended to track one’s breathing to ensure that the |

|current asthma medications are keeping the symptoms under control. Medications are an important aspect of controlling one’s asthma symptoms and the right |

|medications are dependent on one’s age, symptoms, individual triggers, and what combination works best to keep one’s asthma under control. The two main categories |

|of asthma medications include the long-term asthma control medications and quick-relief rescue medications. There are multiple types of medications that fall under|

|those two types of treatments, but the long-term asthma control medications are generally taken every day and help keep asthma symptoms at bay on a daily basis. |

|The quick-relief or rescue medications are taken on an as needed basis and are used for short-term, very quick symptom relief during an asthma attack. Some of the |

|medications in this category can also be used before exercise if it is recommended by the healthcare provider. Asthma is a chronic disease that cannot be cured, |

|but with proper treatment and a thorough understanding of triggers and how to prevent exposure to triggers, its symptoms can be managed and controlled. (Mayo |

|Clinic, 2012). Genetic factors contributing to the development of asthma in an individual is estimated between 30% and 50%. The research conducted thus far has |

|shown that asthma is autosomal dominant, meaning that only one parent needs to pass down the gene in order for the child to inherit the disease. There are several |

|candidate genes that are being studied with variations in PTGDR, GPRA, IRAK3, CHI3L1, HNMT, and ADRB2. There are several other loci that have been associated with |

|an increased susceptibility to asthma and include 1p31, 2p, and 17q21. The interplay of genetic and environmental factors is complex, but an increase in gene |

|variation and the strong percentage of the contribution of genetic factors can increase one’s chance of being diagnosed with asthma. (Nursing Central, 2013). |

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

|Name: amlodipine (Norvasc) |Concentration (mg/ml) |Dosage Amount: 5 mg |

|Route: PO |Frequency: BID |

|Pharmaceutical class: calcium channel blockers |Both |

|Indication: Used alone or with other agents in the management of hypertension, angina pectoris, and vasospastic angina. |

|Side effects: headache, dizziness, fatigue, peripheral edema, angina, bradycardia, palpitations, hypotension, ginigival hyperplasia, nausea, flushing. Nursing |

|considerations: Monitor BP and pulse before therapy, during dose titration, and periodically during therapy. Monitor ECG periodically during prolonged therapy. |

|Monitor intake and output ratios and daily weight. Assess for signs of HF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention). |

|Assess location, duration, intensity, and precipitating factors of patient's anginal pain. |

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|Name: PARoxetine (Paxil) |Concentration |Dosage Amount: 20 mg |

|Route: PO |Frequency: 1x/day |

|Pharmaceutical class: selective serotonin reuptake inhibitors |Both |

|Indication: Paxil is used to treat generalized anxiety disorder. |

|Side effects: : NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS, anxiety, dizziness, drowsiness, headache, insomnia, weakness, agitation, amnesia, confusion, |

|emotional lability, hangover, impaired concentration, malaise, mental depression, syncope blurred vision, rhinitis cough, pharyngitis, respiratory disorders, |

|yawning chest pain, edema, hypertension, palpitations, postural hypotension, tachycardia, vasodilation constipation, diarrhea, dry mouth, nausea, abdominal pain, |

|↓/↑ appetite, dyspepsia, flatulence, taste disturbances, vomiting, ejaculatory disturbance, ↓ libido, genital disorders, infertility, urinary disorders, urinary |

|frequency, sweating, photosensitivity, pruritus, rash, weight gain/loss, back pain, bone fracture, myalgia, myopathy paresthesia, tremor, SEROTONIN SYNDROME, |

|chills, fever |

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|Nursing considerations: Monitor appetite and nutritional intake. Weigh weekly. Notify health care professional of continued weight loss. Adjust diet as tolerated |

|to support nutritional status. Monitor mental status (orientation, mood, behavior). Inform health care professional if patient demonstrates significant increase in|

|anxiety, nervousness, or insomnia. Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, |

|hyperthermia], neuromuscular aberations [hyper reflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]), especially in patients taking other |

|serotonergic drugs (SSRIs, SNRIs, triptans). Assess frequency and severity of episodes of anxiety and assess the level of anxiety before/after taking the drug. |

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|Name: prednisone |Concentration |Dosage Amount: 40 mg |

|Route: PO |Frequency: 1x/day |

|Pharmaceutical class: corticosteroid | Hospital |

|Indication: Used systemically and locally in a wide variety of chronic diseases including: Inflammatory, Allergic, Hematologic, Neoplastic, and Autoimmune |

|disorders. |

|Side effects: depression, euphoria, headache, ↑ intracranial pressure (children only), personality changes, psychoses, restlessness, cataracts, ↑ intraocular |

|pressure, hypertension, PEPTIC ULCERATION, anorexia, nausea, vomiting acne, ↓ wound healing, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression, |

|hyperglycemia fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis, THROMBOEMBOLISM, thrombophlebitisweight gain, weight loss, muscle |

|wasting, osteoporosis, avascular necrosis of joints, muscle pain cushingoid appearance (moon face, buffalo hump), ↑ susceptibility to infection |

|Nursing considerations:. Assess involved systems (respiratory) before and periodically during therapy. Assess patient for signs of adrenal insufficiency |

|(hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness) before and periodically during therapy. |

|Monitor intake and output ratios and daily weights. Observe patient for peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify health care |

|professional if these occur. Assess the patient before beginning therapy to ensure there are no signs of infection as corticosteroids can mask s/s of infection. |

|Educate the patient on the importance of slowly discontinuing the medication as sudden disuse can lead to adrenal insufficiency. |

|Name: alprazolam (Xanax) |Concentration |Dosage Amount: 0.25 mg |

|Route: PO |Frequency: TID |

|Pharmaceutical class: benzodiazapenes |Both |

|Indication: The medication is used for generalized anxiety disorder, panic disorder, and anxiety associated with depression. |

|Side effects:  dizziness, drowsiness, lethargy, confusion, hangover, headache, mental depression, paradoxical excitation, blurred vision, constipation, diarrhea, |

|nausea, vomiting, weight gain, rash, physical dependence, psychological dependence, tolerance |

|Nursing considerations: Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically during therapy. |

|Assess patient for drowsiness, light-headedness, and dizziness. These symptoms usually disappear as therapy progresses but dose should be reduced if these symptoms|

|persist. Instruct pt’s to not drink grapefruit juice while taking Xanax, alcohol and CNS depressants should not be used concurrently with Xanax. Discuss with pt |

|other non-pharmacological techniques to decrease anxiety, such as exercise, support group, relaxation techniques. |

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|Name: panteprazole (Protonix) |Concentration |Dosage Amount: 40 mg |

|Route: PO |Frequency: 1x/day |

|Pharmaceutical class: proton-pump inhibitors |Both |

|Indication: Used for the following conditions: Erosive esophagitis associated with GERD, decrease relapse rates of daytime and nighttime heartburn symptoms on |

|patients with GERD, and pathologic gastric hypersecretory conditions. |

|Side effects: headache, abdominal pain, diarrhea, eructation, flatulence, hyperglycemia, hypomagnesemia (especially if treatment duration ≥3 mo), bone fracture. |

|Nursing considerations: Assess patient routinely for epigastric or abdominal pain and for frank or occult blood in stool, emesis, or gastric aspirate, May cause |

|hypomagnesemia. Monitor serum magnesium prior to and periodically during therapy. Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods|

|that may cause an increase in GI irritation. Advise patient to report onset of black, tarry stools; diarrhea; or abdominal pain to health care professional |

|promptly. |

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|Name: fluticasone-salmeterol, Advair Diskus 250/50 |Concentration |Dosage Amount: fluticasone 250 mcg; salmeterol 50 |

| | |mcg |

|Route: PO inhalation |Frequency: 1 puff BID |

|Pharmaceutical class: fluticasone: corticosteroids; salmeterol: |Both |

|adrenergics | |

|Indication: fluticasone: maintenance and prophylactic treatment of asthma. Salmeterol: as concomitant therapy for the treatment of asthma and the prevention of |

|bronchospasm in patients who are currently taking but are inadequately controlled on a long-term asthma-control medication (e.g. inhaled corticosteroid). |

|Side effects (fluticasone): headache, dizziness, dysphonia, hoarseness, oropharyngeal fungal infections, nasal stuffiness, rhinorrhea, sinusitis, bronchospasm, |

|cough, upper respiratory tract infection, wheezing, diarrhea, adrenal suppression, decreased bone mineral density, decreased growth in children, Cushing’s |

|syndrome., muscle pain, HYPERSENSITIVITY REACTION INCLUDING ANAPHYLAXIS, LARYNGEAL EDEMA, URTICARIA, AND BRONCHOSPASM, CHURG-STRAUSS SYNDROME, fever. Nursing |

|considerations: Monitor respiratory status and lung sounds. Monitor for signs and symptoms of hypersensitivity reactions periodically during therapy. Advise |

|patient to stop using medication and notify health care professional immediately if signs and symptoms of hypersensitivity reactions occur. Instruct patient in the|

|proper use of the metered-dose inhaler. Instruct patient when using inhalation corticosteroids and bronchodilator to use bronchodilator first and to allow 5 min to|

|elapse before administering the corticosteroid. Side effects (salmeterol): headache, nervousness, palpitations, tachycardia, abdominal pain, diarrhea, nausea, |

|muscle cramps/soreness, trembling, ASTHMA-RELATED DEATH, paradoxical bronchospasm, cough. Nursing considerations: Assess lung sounds, pulse, and BP before |

|administration and periodically during therapy. Observe for paradoxical bronchospasm and hypersensitivity reaction |

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|Name: rivaroxaban (Xarelto) |Concentration |Dosage Amount: 20 mg |

|Route: PO |Frequency: QPM |

|Pharmaceutical class: antithrombotic, factor xa inhibitors |Both |

|Indication: Prevention of deep vein thrombosis that may lead to pulmonary embolism following knee or hip replacement therapy. (This is the indication listed in |

|Davis Drug Guide, although she did not have knee or hip replacement surgery) |

|Side effects: : syncope, blister, prutitus, BLEEDING, wound secretion, extremity pain, muscle spasm |

|Nursing considerations: Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry stools; hematuria; fall in hematocrit|

|or BP; guaiac-positive stools); bleeding from surgical site. Notify health care professional if these occur. |

|Instruct patient not to drink alcohol or take other Rx, OTC, or herbal products, especially those containing aspirin or NSAIDs, or to start or stop any new |

|medications during therapy without advice of health care professional. |

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|Name: zolpidem (Ambien) |Concentration |Dosage Amount: 5 mg |

|Route: PO |Frequency: HS |

|Pharmaceutical class: nonbenzodiazepene GABAa receptor agonist |Hospital |

|Indication: Used for insomnia |

|Side effects:  daytime drowsiness, dizziness, abnormal thinking, amnesia, behavior changes, "drugged" feeling, hallucinations, sleep-driving, diarrhea, nausea, |

|vomiting, ANAPHYLACTIC REACTIONS, hypersensitivity reactions, physical dependence, psychological dependence, tolerance |

|Nursing considerations: Assess mental status, sleep patterns, and potential for abuse prior to administration. Prolonged use of >7–10 days may lead to physical and|

|psychological dependence. Limit amount of drug available to the patient .Assess alertness at time of peak effect. Notify health care professional if desired |

|sedation does not occur. Assess patient for pain. Medicate as needed. Untreated pain decreases sedative effects. Instruct pt to not drive or partake in other |

|activities that require alertness until the response to the medication is known. |

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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? Regular diet |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: | |

|Breakfast: one banana | |

|Lunch: banana, sandwich made of 2-3 ounces of rotisserie chicken, 1 tsp. of |According to MyPlate there are a lot of important nutrients that the patient is |

|mustard, and 2 slices of whole wheat bread, and 2 ounces of cut up cheese |not consuming in her diet. The patient is not consuming enough whole grains, |

| |vegetables, whole fruit, or dairy. The patient could increase her whole grains by|

| |eating cereal or whole wheat toast for breakfast, and could increase her whole |

| |fruit intake by adding in another small serving of fruit as a snack in the |

| |morning or afternoon. The patient could incorporate some of her favorite |

| |vegetables into her dinner or snack on raw ones throughout the day. Eating foods |

| |like yogurt or drinking milk will also help increase the amount of dairy the |

| |patient is consuming. |

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|Dinner: 6 ounce sirloin, baked potato with 1-2 tsp of butter | |

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|Snacks: 2-3 dark chocolate candies | |

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|Liquids (include alcohol): The patient only drinks water and stated she consumes | |

|about 24 ounces/day. | |

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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. |

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| |[pic] |

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

|Who helps you when you are ill? “My ‘brother’ and my son.” |

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

|The patient reported that she used to have better coping skills when she was seeing a counselor, but now she relies a lot on her anxiety medications. |

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

|The patient stated that her recent illnesses have caused a lot of anxiety for her. The patient works for Bayfront and is nervous that she could potentially lose |

|her job because of all the time she has had to take off of work. The patient stated that she was very anxious over her high blood pressure and she also did not |

|like the fact that they were not giving her the “same” medications that she took at home. The patient reported that she feels as if her inability to sleep has also|

|made her feel more anxious. |

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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? “Yes, many years ago.” |

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|Have you ever been talked down to? “Yes.” Have you ever been hit punched or slapped?  “Yes, my fiancé punched me in the face, but I ended up not marrying him.” |

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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? “I’m not currently 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. Self absorption/Stagnation Ego Integrity vs. Despair |

|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |

|patient’s age group: The stage of “Generativity vs. Self-absorption/Stagnation” is for individuals that are in their 40’s-60’s. Janet Belsky (2007) defines |

|Erikson’s stage of generativity as the phase in which individuals find meaning in their life through the care and enrichment of others. This can be through |

|fostering the next generation, taking care of others, or helping others through one’s job. When someone has not achieved generativity, it causes feelings of |

|stagnation, and a loss of a sense of purpose in one’s life. |

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

|I believe the patient is in the stage of generativity. The patient told me several times about how she worked for Bayfront and that she really enjoys her job. The |

|patient was hopeful that this year would be a better year and that she wouldn’t have to be in and out of the hospital as much. The patient seems to take pride in |

|her work, her appearance, and in her son. She spent a lot of time telling me about her son and that she was going to have a grandson soon. There was nothing that |

|the patient said that made it seem as if she felt like she had lost a sense of purpose in her life. |

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

|The patient has a diagnosis of anxiety, so I think her being in the hospital and not sleeping well has caused her to feel more anxious, but I don’t believe that |

|has changed her developmental stage to self-absorption/stagnation. The patient said several times that she knows if she could get home and get some sleep that she |

|would feel a lot better. |

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

|“My asthma is not psychosomatic, I don’t believe it’s r/t my anxiety.” |

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|What does your illness mean to you? |

|“It’s a pain in the ass. When I got used to taking Advair, my asthma was pretty well managed, but it’s been getting worse.” |

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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, only men.” |

|Are you aware of ever having a sexually transmitted infection? “Yes, but I was dating a doctor at the time and had it taken care of.” |

|Have you or a partner ever had an abnormal pap smear? “No.” Have you or your partner received the Gardasil (HPV) vaccination? N/A |

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|Are you currently sexually active?   “No, but not necessarily by choice.” When sexually active, what measures do you take to prevent acquiring a sexually |

|transmitted disease or an unintended pregnancy?  “I usually know the person very well before I am with them in that way.” |

|How long have you been with your current partner? N/A |

|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?

“My religion has become really important to me, especially the older I get. I’ve always grown up going to church, and it is a source of comfort.”

Do your religious beliefs influence your current condition?

“No, I would never refuse help for my medical condition.”

|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No X |

| If so, what? |How much?(specify daily amount) |For how many years? X years |

| | |(age thru ) |

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

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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? |

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

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

|White zinfandel |16 ounces/day, everyday |(age 20 thru present ) |

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

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

| 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 |

|The patient reported that she worked for St. Pete Times and people used to smoke in the office and she was exposed to a lot of second hand smoke. |

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( 10 Review of Systems

|General Constitution |Gastrointestinal |Immunologic |

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

|Integumentary | Constipation Irritable Bowel | Night sweats (after hysterectomy) |

| 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 (benign fibroid tumors) |

| Use of sunscreen no SPF: | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: shower everyday |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? 2010 | |

|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: O+ |

| Post-nasal drip |Normal frequency of urination: 5 x/day |Other: |

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

| Dental problems (teeth extracted) | |Metabolic/Endocrine |

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

| Routine dentist visits 1x/year | | 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? 2 years ago | Seizures |

| Tuberculosis | menstrual cycle regular irregular | Tremors (right hand) |

| Environmental allergies | menarche age? 12 | Encephalitis |

|last CXR? 1/20/2014 | menopause age? NA (partial hysterectomy) | Meningitis |

|Other: |Date of last Mammogram &Result: 2013, negative |Other: |

| |Date of DEXA Bone Density & Result: 2010, no | |

| |osteoporosis | |

|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? 1/21/2014 |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

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

| |

|“No.” |

| |

| |

| |

| |

| |

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

| |

|“No.” |

| |

| |

| |

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

|General Survey: The patient is a 63 year |Height: 5’5” |Weight: 214 BMI: 35.6 |Pain: (include rating & location) |

|old woman that is clean and dressed | | | |

|appropriately. She is very concerned | | |0/10 |

|about her appearance and made several | | | |

|remarks in regards to not being able to | | | |

|take care of herself the past several | | | |

|days and apologizing for her appearance. | | | |

| |Pulse: 60 |Blood | |

| | |Pressure: 182/80 Left forearm | |

| | |(include location) | |

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

|97.7, oral | | | |

| |SpO2; 93 |Is the patient on Room Air or O2: RA |

|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 |

|The patient interacted well, but she was anxious throughout the interview process. The patient often complained of being tired, but did not want me to leave so that |

|she could rest. She also repeated herself several times in regards to feeling anxious and wanting her medications. |

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

| clear, crisp diction |

| |

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

| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |

|Other: |

|Integumentary | |

| Skin is warm, dry, and intact | |

| Skin turgor elastic | |

| No rashes, lesions, or deformities | |

| Nails without clubbing | |

| Capillary refill < 3 seconds | |

| Hair evenly distributed, clean, without vermin | |

| | |

| | |

| | |

| | |

| Peripheral IV site Type: 22 gauge Location: R wrist Date inserted: 1/20/14 |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

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

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

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

|Fluids infusing? no yes - what? |

| |

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

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

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

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

| Ears symmetric without lesions or discharge Whisper test heard: right ear- 6 inches & left ear- 6 inches |

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

|Dentition: The patient has several teeth that are missing due to extraction. Otherwise, dentition is intact. |

|Comments: |

| |

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

| | | Lungs clear to auscultation in all fields without adventitious sounds; WH in all lobes |

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

| |WH – Wheezes | |

| |CR - Crackles |Sputum production: thick thin Amount: scant small moderate large |

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

| |D – Diminished | |

| |S – Stridor | |

| |Ab - Absent | |

| | | |

| | | |

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

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

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

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

|Apical pulse: 3 Carotid: 3 Brachial: 2 Radial: 3 Femoral: Popliteal: 2 DP: 2 PT: 2 |

|No temporal or carotid bruits Edema: [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/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |

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

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

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

|CVA punch without rebound tenderness |

|Last BM: (date 01 / 20 /2014 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

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

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

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

| Other – Describe: |

| |

| |

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

|Strength bilaterally equal at ____4___ RUE _____4__ LUE ____5___ RLE & ____5___ in LLE |

|[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] |

|vertebral column without kyphosis or scoliosis |

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

| |

| |

| |

|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-unable to assess, patient didn’t feel comfortable |

|standing up |

|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride- didn’t assess, patient didn’t want to stand up) |

|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 |

|-didn’t have reflex hammer to test DTR |

| |

| |

| |

|±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 |

| |

|Glucose |

|136 mg/dL |

|177 mg/dL |

|Normal Random glucose test ................
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