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 |

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|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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