UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Kristin McTaggart |
|MSI & MSII Patient Assessment Tool . |Assignment Date: 3/8/16 |
| ( 1 PATIENT INFORMATION |Agency: MCH |
|Patient Initials: S. G. |Age: 67 |Admission Date: 3/7/16 |
|Gender: female |Marital Status: widow |Primary Medical Diagnosis: Symptomatic paraesophageal hiatal hernia |
|Primary Language: English | |
|Level of Education: B.S. |Other Medical Diagnoses: No new diagnoses |
|Occupation: Retired mortgage broker | |
|Number/ages children/siblings: Daughter, 43 | |
|Son, 40 | |
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|Served/Veteran: No |Code Status: Full |
|Living Arrangements: Home with a caretaker |Advanced Directives: Yes |
| |If no, do they want to fill them out? |
| |Surgery Date: 3/7/16 Procedure: Laparoscopic paraesophageal |
| |hiatal hernia repair with anterior gastropexy |
|Culture/ Ethnicity /Nationality: Caucasian | |
|Religion: Methodist |Type of Insurance: Medicare |
|( 1 CHIEF COMPLAINT: |
|“Stomach pain and nausea” |
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|( 3 HISTORY OF PRESENT ILLNESS: |
|Pt has had a paraesophageal hiatal hernia diagnosed 10 years ago. The hernia has enlarged over the past year causing pain and is pressing against the stomach. The|
|pain feels like indigestion, burning, and sometimes hurts in her chest. The duration of the pain varies. The pain is worse when lying down after eating. Antacids|
|and Zofran help with the indigestion and nausea. Pt is scheduled to have surgery to repair the hiatal hernia. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
|Date |Operation or Illness |
|1958 |Appendectomy |
|11/1996 |Plantar fasciitis left foot |
|9/2001 |Breast reduction and tummy tuck |
|8/2013 |X-lift spinal fusion T11-S1 |
|5/2015 |Thyroid biopsy-results benign |
|12/2015 |Parathyroid removal |
|2/2014 |Diabetes mellitus type 2 |
|10/2012 |Hyperparathyroidism |
|1/2013 |Spinal stenosis |
|10/2012 |Adult onset scoliosis |
|12/2006 |Sleep apnea |
|9/2005 |Fibromyalgia |
|( 2 FAMILY MEDICAL HISTORY |
|( 1 immunization History |
| |Yes |No |
|Routine childhood vaccinations | | |
|Routine adult vaccinations for military or federal service | | |
|Adult Diphtheria 5/3/11 | | |
|Adult Tetanus 5/3/11 | | |
|Influenza (flu) 9/17/15 | | |
|Pneumococcal (pneumonia) 9/3/13 | | |
|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 |Oxycodone |Nausea |
| |Caduet |Liver enzymes elevated |
| |Topomax |Liver enzymes elevated |
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|Other (food, tape, latex, dye, |No known | |
|etc.) | | |
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|( 5 PATHOPHYSIOLOGY: |
|A hiatal hernia occurs in the upper area of the stomach that herniates into the thorax through the hiatal opening also known as the esophageal opening (Osborn, |
|Wraa, Watson, Holleran, 2014). There are two types of hiatal hernias. One is a sliding hernia and the other is a rolling paraesophageal hernia. This patient has|
|the second of the two in which the upper part of the stomach herniates next to the esophagus. The risk facts that contribute to developing a hiatal hernia are |
|age, obesity, pregnancy, and being a female (Huether & McCance, 2012). Some of the signs and symptoms that exist are reflux, heartburn, chest pain, and |
|indigestion. There are several ways to diagnose this abnormality. Upper endoscopy and barium swallow tests can be used to diagnose hiatal hernias (Osborn, Wraa, |
|Watson, Holleran, 2014). Treatment of hiatal hernias with mild symptoms is changes in diet such as elevating the head of the bed, eating small meals frequently, |
|avoid laying down after eating, no alcohol, smoking cessation, and losing weight (Osborn, Wraa, Watson, Holleran, 2014). Medical management may be appropriate with|
|H2 blockers, antacids, and proton pump inhibitors (Osborn, Wraa, Watson, Holleran, 2014). If symptoms become severe, surgery can be done to correct the |
|abnormality (Osborn, Wraa, Watson, Holleran, 2014). It is important to note that many patients are asymptomic with hiatal hernias ((Huether & McCance, 2012). |
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( 5 Medications:
|Name Zofran (ondanestron) |Concentration 8 mg |Dosage Amount 2 tabs |
|Route PO |Frequency PRN q 8 hr |
|Pharmaceutical class antiemetic |Home Hospital or Both X |
|Indication nausea |
|Adverse/ Side effects: headache, constipation, diarrhea, malaise/fatigue, blurred vision, temporary vision loss, slow heart rate, decrease in urination, anxiety |
|Nursing considerations/ Patient Teaching: Watch for signs of an allergic reaction such as swelling of the face, lips or mouth, hives and difficulty breathing, |
|watch out for patients with liver disease, can impair thinking ability. |
|Name Norvasc (amlodipine besylate) |Concentration 5 mg |Dosage Amount 1 tab |
|Route PO |Frequency 1 x daily |
|Pharmaceutical class: Calcium channel blocker |Home Hospital or Both X |
|Indication Hypertension |
|Adverse/ Side effects: Headache, dizziness, drowsiness, tired feeling, nausea, stomach pain, flushing, fainting, swelling in hands, feet, or ankles, fluttering in |
|your chest, chest pain spreading down the arm or shoulder. |
|Nursing considerations/ Patient Teaching: need to make sure patient does not have a heart valve problem, CHF, or liver disease. If taking a beta-blocker, do not |
|stop using the beta-blocker without notifying the doctor. Stopping beta-blocker suddenly can cause serious heart problems that will not be prevented by |
|amlodipine. Continue to follow your diet, medication, and exercise routines closely. Keep using the medication even if you feel well. You may need to use blood |
|pressure medication for the rest of your life. Avoid alcohol. Avoid standing up too quickly to prevent a fall. |
|Name Cozaar (losartan) |Concentration 100 mg |Dosage Amount 1 tab |
|Route PO |Frequency 1 x daily |
|Pharmaceutical class: Angiotensin II receptor antagonist |Home Hospital or Both X |
|Indication: hypertension |
|Adverse/ Side effects: cold or flu like symptoms, dry cough, muscle cramps, pain in legs or back, diarrhea, headache, dizziness, insomnia, fainting, wheezing, |
|chest pain, pale skin, confusion, weight gain, swelling, high potassium, pain during urination, nausea, vomiting |
|Nursing considerations/ Patient Teaching: Monitor blood pressure before. You may take with or without food. Call your doctor if you have ongoing vomiting or |
|diarrhea, or sweating more than usual. You may become dehydrated while taking this medication, which can severely lower blood pressure. Have your blood pressure |
|checked regularly. Keep using this medication even if you feel well. You may need to be on the medication for the rest of your life. It may take 3 to 6 weeks |
|for the medication to work. Avoid alcohol because it can further lower your blood pressure and increase the medication side effect. Avoid potassium supplements |
|and salt substitutes. Avoid standing up too fast. |
|Name Lyrica (pregablin) |Concentration 150 mg |Dosage Amount 1 tab |
|Route PO |Frequency tid |
|Pharmaceutical class anticonvulsant |Home Hospital or Both X |
|Indication fibromyalgia |
|Adverse/ Side effects weight gain, chest pain, shortness of breath, blurred vision, difficulty in concentration. Watch for allergic reaction such as fever, chills,|
|hives, and rash. |
|Nursing considerations/ Patient Teaching: Pt should not stop medication abruptly. Avoid driving until there is an understanding of how the medication affects the |
|pt. Watch for suicidal ideation. |
|Name: Glucophage(metformin) |Concentration 1000mg |Dosage Amount 1 tab |
|Route PO |Frequency bid |
|Pharmaceutical class Oral diabetic/Biguanide |Home Hospital or Both X |
|Indication DM type 2 |
|Adverse/ Side effects: Abdominal pain, cough, diarrhea, fever, chills, painful urination, malaise, low back pain, nausea, vomiting, metallic taste in mouth, joint|
|pain, abnormal stools. |
|Nursing considerations/ Patient Teaching: Medication should be stopped before any general anesthesia at least two days before. Pt should refrain from taking if |
|having IV contrast procedure at least 48 hours after. Use with caution in pt with renal impairment. |
|Name Toujeo Solostar (insulin glargine) |Concentration 300 units/mL |Dosage Amount 50 units |
|Route Subcutaneous injection |Frequency 1 x daily in a.m. |
|Pharmaceutical class insulin |Home Hospital or Both X |
|Indication DM type 2 |
|Adverse/ Side effects: Swelling, pain, changes in the feel of skin, weight gain, cough, hives, itching, rash, abnormal heartbeat, muscle cramps, hoarseness, |
|shortness of breath, difficulty breathing. |
|Nursing considerations/ Patient Teaching: Make sure the patient is educated on how to give self a subq injection. Educate the patient on the signs and symptoms of|
|hypoglycemia. Store away from sunlight. Dispose after 28 days of use. Avoid skipping or delaying meals. |
|Name Rocephin (ceftriazone) |Concentration 1 g/50 mL |Dosage Amount 1 g |
|Route IV |Frequency 1 time daily |
|Pharmaceutical class cephalosporin antibiotic |Home Hospital X or Both |
|Indication Prophylactic treatment of infection from surgery |
|Adverse/ Side effects: Nausea, vomiting, upset stomach, headache, dizziness, overactive reflexes, pain or swelling of the tongue, vaginal itching or discharge, |
|bloody or watery diarrhea, fever, chills, joint pain, rash, white patches or sores of the mouth or lips, unusual bleeding, purple or red spots under skin, |
|bruising, severe tingling, dark colored urine, pale or yellowed skin, confusion, weakness, seizure, decrease in urination, chalky-colored stools, sever skin |
|reaction |
|Nursing considerations/ Patient Teaching: Watch for signs of an allergic reaction, such as hives, difficulty breathing, swelling of face, lips, or tongue. |
|Name Ultram/tramadol |Concentration 50 mg/tab |Dosage Amount 1 tab |
|Route PO |Frequency PRN/q6hr |
|Pharmaceutical class central acting analgesic |Home Hospital X or Both |
|Indication moderate to severe pain |
|Adverse/ Side effects seizures, dizziness, headache, somnolence, constipation, nausea, dry mouth, serotonin syndrome, physical dependence |
|Nursing considerations/ Patient Teaching Assess pain level, type, and location before and after taking the medication, assess bowel function, prevent constipation |
|by taking a laxative, increasing fluid and fiber intake, monitor patient for seizures, patient should not drink alcohol, avoid driving because of drowsiness, |
|change positions slowly, patient should turn cough and deep breathe every two hours to prevent atelectasis |
|Name Prilosec (omeprazole) |Concentration 40 mg/cap |Dosage Amount 1 cap |
|Route PO |Frequency bid |
|Pharmaceutical class proton pump inhibitor |Home Hospital or Both X |
|Indication Decrease stomach acid |
|Adverse/ Side effects: nausea, vomiting, diarrhea, weakness, rash, headache, dizziness, |
|Nursing considerations/ Patient Teaching: Long-term use may mask gastric cancer. Assess for abdominal pain or bleeding, Caps should not be crushed. Do not |
|double dose. Avoid alcohol. Teach pt to report dark tarry stools. |
|( 5 NUTRITION: |
|Diet ordered in hospital? Clear liquid |Analysis of home diet: |
|Diet patient follows at home? Low sugar | |
|24 HR average home diet: | |
|Breakfast: 1 cup oatmeal with whole milk, 3 tablespoons raisins, 3 tablespoons |[pic] |
|walnuts | |
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|Lunch: salad with fried chicken, 2 T. balsamic dressing | |
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|Dinner: 6 oz. baked salmon, sweet potato, ½ c. squash, ½ c. pinto beans, 2 T. | |
|butter | |
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|Snacks: chocolate chip cookie, apple, 3 T. hummus and 4 small stalks celery | |
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|Liquids: 3 12 oz. bottles of water, 1 c. coffee with 2 T. creamer | |
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|[pic] |According to (2016), my patient exceeds her calorie intake by 205 |
| |calories. It is recommended that 20 to 35% of calories come from fat, and she is|
| |eating 47% from fat. By switching to grilled chicken from fried and limiting |
| |the amount of butter she used for cooking, she can decrease her total fat intake.|
| |She could also use fat free milk in her oatmeal. Being a diabetic, she should |
| |make sure she limits the amount of fat to help with weight loss. Her sodium |
| |intake is 3,501 milligrams, and the limit is 2,300 milligrams. She should look |
| |for low sodium or no sodium labels on foods. The fried chicken is full of |
| |sodium, and by switching to grilled chicken she will decrease her sodium intake. |
| |She should try and stay away from canned vegetables because these items are high |
| |in sodium as well. |
|(1 COPING ASSESSMENT/SUPPORT SYSTEM: |
|Who helps you when you are ill? “My caretaker or my daughter” |
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|How do you generally cope with stress? or What do you do when you are upset? |
|“I go into my room and do meditation or take a nap.” |
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|Recent difficulties : “I really haven’t had any recent difficulties.” |
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|+2 DOMESTIC VIOLENCE ASSESSMENT |
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|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |
|am going to ask some questions that help me to make sure that you are safe.” |
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|Have you ever felt unsafe in a close relationship? ______No__________________________ |
|Have you ever been talked down to?____Yes___________ Have you ever been hit punched or slapped? _______No__ |
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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? |
|_____No_______________________________ If yes, have you sought help for this? ______________________ |
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|Are you currently in a safe relationship? No |
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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 of both parts of Erickson’s developmental stage for your |
|patient’s age group: My patient falls into Erikson’s ego integrity versus despair in terms of psychosocial development. This is the last stage of life where a |
|person comes into acceptance with their life, worth, and eventual death. Ego integrity is being happy with one’s life from the past up to the present. Despair is|
|feeling a sense of loss and feelings of sadness associated with aging (Treas & Wilkinson, 2014). |
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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: |
|My patient is a 67 year old female. She feels happy with where she is in her life. She is not afraid of death and feels like she has led a happy, meaningful, and|
|satisfying life. |
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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |
|My patient just feelings like she is experiencing a normal part of aging. She does not feel like having health complications with her thyroid will take over her |
|life. |
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|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” |
|“My genes and my diet” |
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|What does your illness mean to you? “I don’t really have an opinion. I just think it is a normal part of aging.” |
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|+3 SEXUALITY ASSESSMENT: |
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|Have you ever been sexually active?____Yes___________________________________________________________ |
|Do you prefer women, men or both genders? __men _______________________________________________ |
|Are you aware of ever having a sexually transmitted infection? _____No_____________________________________ |
|Have you or a partner ever had an abnormal pap smear?___________No_____________________________________ Have you or your partner received the Gardasil (HPV) |
|vaccination? ______No ________________________________ |
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|Are you currently sexually active? _______No ____________________ If yes, are you in a monogamous relationship? ____________________ When sexually active, what |
|measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? _________”I have not been sexually active since my husband |
|passed away.”_____ |
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|How long have you been with your current partner?_____NA___________________________________________________ |
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|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:
What importance does religion or spirituality have in your life?
____”It is extremely important and I could not survive without it.”___________________________ _
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Do your religious beliefs influence your current condition?
______”Yes”________________________________________________________________________________________________
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|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |
|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? No |
| If so, what? NA |How much? NA |For how many years? NA |
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|Pack Years: NA | |If applicable, when did the patient quit? NA |
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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? NA |
| |If yes, what did they use to try to quit? NA |
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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes |
| What? Red wine |How much? 2 x week |For how many years? 40 years |
| |Volume: 6 oz. |(age 25 thru 65 ) |
| |Frequency: 2 x week | |
| If applicable, when did the patient quit? 2014 | | |
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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No |
| If so, what? NA |
| |How much? NA |For how many years? NA |
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| Is the patient currently using these drugs? NA |If not, when did he/she quit? NA | |
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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |
|No |
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|5. For Veterans: Have you had any kind of service related exposure? NA |
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( 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 SPF: 15 | Diverticulitis | Life threatening allergic reaction |
|Bathing routine: 2x daily |Appendicitis | Enlarged lymph nodes |
|Other: | Abdominal Abscess |Other: |
| | Last colonoscopy? 6/13/14 | |
|HEENT |Other: |Hematologic/Oncologic |
| Difficulty seeing |Genitourinary | Anemia |
| Cataracts or Glaucoma | nocturia | Bleeds easily |
| Difficulty hearing | dysuria | Bruises easily |
| Ear infections | hematuria | Cancer |
| Sinus pain or infections | polyuria | Blood Transfusions |
|Nose bleeds | kidney stones |Blood type if known: |
| Post-nasal drip |Normal frequency of urination: x/day |Other: |
| Oral/pharyngeal infection | Bladder or kidney infections | |
| Dental problems | |Metabolic/Endocrine |
| Routine brushing of teeth 2 x/day | | Diabetes Type: 2 |
| Routine dentist visits 2 x/year | | Hypothyroid /Hyperthyroid |
|Vision screening 1x year | | 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? 2/18/14 | Seizures |
| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |
| Environmental allergies | menarche age? 14 | Encephalitis |
|last CXR? 2/23/16 | menopause age? 50 | Meningitis |
|Other: |Date of last Mammogram &Result: 8/15 negative |Other: |
| |Date of DEXA Bone Density & Result:3/14/osteopenia | |
|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: |
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|General Constitution |
|Recent weight loss or gain |
|How many lbs? |
|Time frame? |
|Intentional? |
|How do you view your overall health? “ok” |
|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |
|No |
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|Any other questions or comments that your patient would like you to know? |
|No |
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|±10 PHYSICAL EXAMINATION: |
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|General Survey: 67 year old Caucasian female, cooperative, alert and oriented x 3. |
|Height 67 inches |
|Weight 230 lb |
|BMI 36% |
|Pain: O: after surgery L:Abdomen D:1 day C:Aching A:moving/walking R: laying down T:tramadol S:2/10 |
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|Pulse 86 |
|Blood Pressure: Brachial 153/89 |
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|Respirations 17 |
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|Temperature: oral 97.4 F |
|SpO 95% |
|Is the patient on Room Air |
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|Overall Appearance: |
| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |
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|Overall Behavior: |
| awake, calm, relaxed, interacts well with others, judgment intact |
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|Speech: |
| clear, crisp diction |
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|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 |
| 2 surgical puncture wounds clean, dry and covered with band-aid |
| Central access device Type: Peripheral IV Location: Right hand Date inserted: 3/7/16 |
|Fluids infusing? no yes - what? 0.9% NS |
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|HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline |
| Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge |
| Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |
| PERRLA pupil size 3 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |
| Ears symmetric without lesions or discharge |
| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |
|Dentition: NA |
|Comments: |
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|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |
|Percussion resonant throughout all lung fields, dull towards posterior bases |
|Sputum production: NA Amount: NA |
|Color: NA |
|Lung sounds: Clear to bases |
|RUL CL LUL CL |
|RML CL LLL CL |
|RLL CL |
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|CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent |
|Cardiovascular: No lifts, heaves, or thrills |
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|Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |
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|Rhythm: No ECG on file for this patient |
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|Calf pain bilaterally negative Pulses bilaterally equal |
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|Apical pulse: 2+ Carotid: 2+ Brachial: 2+ Radial: 2+ Femoral: not assessed Popliteal: not assesed DP: 2+ |
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|No temporal or carotid bruits Edema: No |
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|Location of edema: NA |
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|Extremities warm with capillary refill less than 3 seconds |
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|GI Bowel sounds hypoactive x 4 quadrants; no bruits auscultated No organomegaly |
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|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen tender to palpation |
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|Last BM: 3 / 7 / 16 Formed X Semi-formed Unformed Soft Hard Liquid Watery |
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|Color: Medium Brown |
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|Nausea emesis Describe if present: Not present |
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|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |
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|Other – Describe: |
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|GU Urine output: Clear Cloudy Color: yellow Previous 24 hour output: N/A |
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|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance |
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|CVA punch without rebound tenderness : Not assessed |
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|Musculoskeletal: X Full ROM intact in all extremities without crepitus |
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|Strength bilaterally equal at ___5/5____ RUE ____5/5___ LUE __5/5_____ RLE & __5/5_____ in LLE |
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|vertebral column without kyphosis or scoliosis |
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|Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis |
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|parasthesias in feet |
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|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused |
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|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |
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|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride |
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|DTR: not assessed |
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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS |
|Lab |
|Dates |
|Trend |
|Analysis |
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|CXR |
|2/23/16 |
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|negative |
|No abnormalities present |
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|Hemoglobin A1C |
|3/7/16 |
|9.8 |
|This is a high finding. It is a measure of how her red blood cells use glucose over the past three months. It shows that she is not controlling her diabetes. The |
|range should be between 4-6.5. |
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|EGD |
|1/13/16 |
|Paraesophageal hernia |
|Finding is a portion of the stomach is herniating upward through the diaphragm. |
| |
|Hemoglobin |
|3/7/16 |
|12 g/dL |
|This is within the normal range for hemoglobin. |
| |
|Platelets |
|3/7/16 |
|288,000 |
|This is within the normal range for platelets. |
| |
|Hematocrit |
|3/7/16 |
|38.2% |
|This is within the normal range for hematocrit. |
| |
|White blood cells |
|3/7/16 |
|10.2 |
|This is within the normal range for WBC. |
| |
|Sodium |
|3/7/16 |
|139 mEq/L |
|This is within the normal range for sodium. |
| |
|Potassium |
|3/7/16 |
|4.9 mEq/L |
|This is within the normal range for potassium. |
| |
|BUN |
|3/7/16 |
|15 mg/dL |
|This is within the normal range for BUN. |
| |
|Creatinine |
|3/7/16 |
|0.813 mg/dL |
|This is within the normal range for creatinine. |
| |
|Glucose |
|3/7/16 |
|3/9/16 |
|167 mg/dL |
|171 mg/dL |
|Both of these blood glucose levels are above the normal range. |
| |
| |
| |
| |
| |
| |
| |
|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: |
|Accucheks ACHS, Fall risk scale q 12 hr, IS q 1 hr, vitals q 6 hr, ambulate 3 x daily, CPAP q 12 hr, maintain 02 saturation >92%, up and independent, activity as |
|tolerated, clear liquid diet, Zofran for nausea q8hr PRN |
| |
| |
|( 8 NURSING DIAGNOSES (Ackley & Ladwig, 2014). |
| |
|1. Altered nutrition related to preoperational procedure and surgical procedure as evidenced by diet ordered (NPO since last Saturday & post surgery diet of clear |
|liquids) and patient stating “feeling weak.” |
| |
| |
| |
|2. At risk for infection related to the surgical procedure. |
| |
| |
| |
|3. At risk for falls related to the side effects from the pain medication. |
| |
| |
| |
|4. Imbalanced nutrition related to home diet of excessive intake in relation to metabolic need as evidenced by BMI and weight. |
| |
| |
| |
|5. Pain related to the incision sites as evidenced by patient having abdominal pain of 6 out of ten on a zero to ten pain scale. |
| |
| |
| |
| |
| |
± 15 CARE PLAN
Nursing Diagnosis: Imbalanced nutrition related to home diet of excessive intake in relation to metabolic need as evidenced by BMI and weight.
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is |
| | |Provide References |Provided |
|Client will state pertinent factors |Have the client write down a few days of|By writing down an example of a typical |Goal partially met- client recognizes |
|contributing to weight gain by discharge. |what she eats to help identify areas of |few days diet, one can help point out |some of the factors contributing to |
| |concern. |the areas that are contributing to |weight gain. |
| | |weight gain. This also helps to show | |
| | |the client how many calories they are | |
| | |consuming in a day. | |
|Design dietary modifications to meet |Ask for an order to consult the |A registered dietician has been |Goal met- patient met with dietician |
|individual long-term goal of weight |registered dietician to help client |specifically educated to design and |and designed a diet plan to help with |
|control by discharge. |design a program. |analyze diets for specific diseases and |weight loss and control. |
| | |weight loss. | |
|Lose weight in a reasonable time period 1 |Ask the client to keep a food diary of |This will help the patient to |Goal not met- this is a long term goal|
|to 2 pounds per week. |everything eaten or drunk so that it is |self-monitor food intake and is helpful |and will need to be addressed at her |
| |recorded. |to analyze to make sure she stays on |follow-up appointment to see if she |
| |Ask the client to measure food |track to lose weight. |has met the stated goal. |
| |periodically to help with learning the |To lose weight, a person must balance | |
| |usual portion sizes. |energy intake and output. | |
| |Recommend the client utilize the U.S. |Slower weight loss is more likely to be | |
| |Dietary Guidelines to determine foods to|a lasting weight loss. | |
| |eat, which is available at | | |
| | | | |
| | | | |
| | | | |
± 15 CARE PLAN
Nursing Diagnosis: Pain related to the incision sites as evidenced by patient having abdominal pain of 6 out of ten on a 0-10 pain scale.
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is |
| | |Provide References |Provided |
|Client will use a self-report pain tool to|Assess pain level using a reliable |This is the first step in pain |Goal met. |
|identify current pain intensity level and |self-report pain tool, such as the 0-10 |assessment. This is an acceptable and | |
|establish a comfort-function goal by end |numerical pain rating scale. |reliable measurement of pain intensity | |
|of shift. | |level. | |
|Client will describe non-pharmacological |Teach the client about |Cognitive behavioral strategies can help|Goal met. |
|methods that can be used to help achieve |nonpharmacological interventions for |with pain, self-control, personal | |
|comfort-function goal by end of shift. |pain. |efficacy, and actively participate in | |
| |Support the client’s use of |reducing pain. | |
| |nonpharmacological methods to control | | |
| |pain such as distraction, imagery, | | |
| |relaxation, application of heat or cold,| | |
| |and positioning. | | |
|Client will become pain free by the |Teach the client about |Teaching clients to stay on top of pain |Goal not met this is long-term goal to|
|follow-up appointment. |nonpharmacological methods for pain. |and prevent it from getting out of |be pain free by her f/u appointment in|
| |Continue to reinforce using pain scale |control will allow them to recover and |two weeks. |
| |to help identify pain. Reingorce the |complete ADLs. | |
| |importance of taking pain medications to| | |
| |help relieve pain and explain that using| | |
| |pain medication to help with pain will | | |
| |not result in addiction. | | |
|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
|Consider the following needs: |
|□SS Consult |
|□Dietary Consult |
|□PT/ OT |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appointments |
|□Med Instruction/Prescription |
|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
References
Huether, S. E.; & McCance, K.L. (2012). Understanding pathophysiology (5th ed.). St. Louis, MO: Mosby
Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2014). Pharmacology: A nursing process approach (10th
ed.). St. Louis, MO: Elsevier Saunders
Osborn, K. S., Wraa, C. E., Watson, A. B., Holleran, R. (2014). Medical-surgical nursing: Preparation for
practice (2nd Ed.). Upper Saddle River, NJ: Pearson
Treas, L.S. & Wilkinson, J.M. (2014). Basic Nursing: Concepts, skills, & reasoning. Philadelphia, PA: F.A.
Davis Company
United States Department of Agriculture. (2016). . Retrieved from
. Accessed April 6th , 2016
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