UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Brooke Hyler |
|Patient Assessment TOOL. |Assignment Date: 10/15/14 |
| ( 1 PATIENT INFORMATION |Agency: TGH UD 2H |
|Patient Initials: J.A. |Age: 32 |Admission Date: 10/07/14 |
|Gender: Male |Marital Status: Married |Primary Medical Diagnosis with ICD-10 code: |
|Primary Language: Spanish |Hypertension—401.9 |
|Level of Education: 2 Years College |Other Medical Diagnoses: (new on this admission) |
|Occupation: Customer Service Representative |NONE |
|Number/ages children/siblings: 1 Brother (age 28); 2 Sisters (ages 25 and 20) | |
|1 Son (age 4) | |
|Served/Veteran: No |Code Status: Full Code |
|Living Arrangements: Patient lives in a rental apartment in the city with wife and son. |Advanced Directives: No |
| |If no, do they want to fill them out? No |
| |Surgery Date: 10/14/14 Procedure: Removal |
|Culture/ Ethnicity /Nationality: Spanish |of Silicone Oil Eye |
|Religion: Christian |Type of Insurance: Hillsborough Healthcare |
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|( 1 CHIEF COMPLAINT: “I could not see out of my left eye.” |
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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |
|A 32 year old male was admitted into the hospital on 10/07/14 for a scheduled procedure for the removal of the |
|silicone oil eye as a follow-up surgery proceeding a vitrectomy of the left eye on 07/08/14 for treatment of a retinal detachment associated with diabetic |
|retinopathy. However, the patient also presented to the hospital |
|with uncontrolled hypertension. Upon antihypertensive medication administration and physician consults, the |
|patient’s surgery was postponed to 10/14/14 until hypertension was managed. Patient denies any pain associated |
|with silicone oil eye removal surgery pre-operatively and post-operatively. However, the patient reports visual |
|impairment with accompanied feelings of anxiety related to the loss of vision localized to the left eye. Patient |
|explains that the onset of his visual impairment started in February 2014 with the diagnosis of diabetic |
|retinopathy. Patient reports visual impairment strictly localized to the left eye with no associated pain or other |
|symptoms. Patient expresses feelings eagerness for discharge post-operatively. Patient’s hypertension is |
|ongoing and being managed through scheduled antihypertensives. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation
|Date |Operation or Illness |
|2001 |Diabetes Mellitus (Type 2) |
|2001 |Hypertension |
|Feb. 2014 |Vision loss of left eye |
|Feb. 2014 |Retinal detachment of left eye |
|Feb. 2014 |Diabetic retinopathy |
|04/03/14 |Esophagogastroduodenoscopy |
|07/08/14 |Vitrectomy (Left eye) |
|07/08/14 |Eye surgery (Insertion of silicone eye)—Left Eye |
|Sept. 2014 |Lensectomy |
|10/14/14 |Removal of Silicone eye (Left eye) |
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|( 2|Age (in years) |
|FAM| |
|ILY| |
|MED| |
|ICA| |
|L | |
|HIS| |
|TOR| |
|Y | |
| |Maternal Grandfather died of stroke in 2013 |
| |Patient cannot recall any other family history onset dates for anything else listed above. |
|( 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 unknown) | | |
|Adult Tetanus (Date unknown) | | |
|Influenza (flu) (Every year) | | |
|Pneumococcal (pneumonia) (Date unknown) | | |
|Have you had any other vaccines given for international travel or occupational purposes? NONE | | |
|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |
|REACTIONS |Causative Agent | |
|Medications |Zofran |Stomach pain, nausea, vomiting, and discomfort. |
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|Other (food, tape, latex, dye, |NONE |NONE |
|etc.) | | |
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|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |
|genetic factors impacting the diagnosis, prognosis or treatment) |
|The patient was admitted to the hospital with visual impairment of the left eye associated with diabetic retinopathy. |
|Diabetic retinopathy is the leading cause of blindness in adults less than 60 years of age worldwide (Huether, pg. 467). |
|This disease results from relative hypoxemia, damage to retinal blood vessels, and RBC aggregation. A major risk factor |
|for diabetic retinopathy is the diagnosis of diabetes. In comparison to type 1 diabetes, retinopathy seems to develop more |
|rapidly in individuals with type 2 diabetes because of the likelihood of long-standing hyperglycemia before diagnosis |
|(Huether, pg. 467). General prevention of diabetic retinopathy includes frequent monitoring and control of blood glucose, |
|along with yearly ophthalmologic eye exams. This disease is usually diagnosed with the optical coherence tomography |
|which detects diabetic macular edema by measuring retinal thickness (Huether, pg. 467). Treatment of diabetic |
|retinopathy includes the use of angiotensin-receptor blocker candesartan. Surgical laser photocoagulation is also another |
|form of treatment (Huether, pg. 467). It is recommended that patient’s with this disease follow a prescribed diet for |
|patients with diabetes. A major complication associated with diabetic retinopathy is blindness if untreated or left without |
|care (Huether, pg. 467). |
( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]
|Name carvedilol (Coreg) |Concentration |Dosage Amount 25 mg |
|Route Oral |Frequency 2 times Daily with meals |
|Pharmaceutical class Beta blockers; antihypertensives |Home Hospital or Both |
|Indication Management of hypertension |
|Side effects/Nursing considerations Bradycardia, heart failure, pulmonary edema, Stevens-Johnson syndrome, toxic epidermal necrolysis, anaphylaxis, angioedema, |
|hyperglycemia; monitor blood pressure, and pulse before and after administration. |
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|Name hydrochlorothiazide (Microzide) |Concentration |Dosage Amount 25mg |
|Route Oral |Frequency Daily |
|Pharmaceutical class Thiazide diuretics |Home Hospital or Both |
|Indication Management of uncontrolled hypertension |
|Side effects/Nursing considerations Stevens Johnson syndrome, hypokalemia, dizziness, drowsiness; monitor for use with other antihypertensives. |
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|Name Insulin aspart (Novolog) lnPn |Concentration |Dosage Amount |
|4-16 units | |Blood sugar 150-199: 4 units |
| | |Blood sugar 200-249: 8 units |
| | |Blood sugar 250-299: 10 units |
| | |Blood sugar 300-349: 12 units |
| | |Blood sugar 350-399: 16 units |
| | | |
| | |Onset: within 15 minutes; peak: 1-2 hours; |
| | |duration: 3-4 hours |
|Route Subcutaneous |Frequency 3 times Daily with meals |
|Pharmaceutical class Pancreatics |Home Hospital or Both |
|Indication Control of hyperglycemia from type 2 DM |
|Side effects/Nursing considerations Hypoglycemia, anaphylaxis; monitor blood sugar with accu-checks. |
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|Name loratadine (Claritin) |Concentration |Dosage Amount 10mg |
|Route Oral |Frequency Daily |
|Pharmaceutical class Antihistamines |Home Hospital or Both |
|Indication Relief of symptoms of seasonal allergies |
|Side effects/Nursing considerations Blurred vision, photosensitivity; advise patient to avoid taking alcohol or other CNS depressants concurrently with this drug. |
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|Name lorazepam (Ativan) |Concentration |Dosage Amount 0.5mg |
|Route Oral |Frequency 2 times Daily |
|Pharmaceutical class Benzodiazepines |Home Hospital or Both |
|Indication Management of anxiety |
|Side effects/Nursing considerations Apnea, cardiac arrest, dizziness, drowsiness, lethargy, blurred vision; monitor when in use with other CNS depressants. |
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|Name losartan (Cozaar) |Concentration |Dosage Amount 100mg |
|Route Oral |Frequency Daily |
|Pharmaceutical class Angiotensin II receptor antagonists |Home Hospital or Both |
|Indication Management of hypertension |
|Side effects/Nursing considerations Angioedema, dizziness, fatigue, hypotension, diarrhea; monitor blood pressure and pulse before and after administration. |
|Monitor possible hypotension when in use with other antihypertensives. |
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|Name nifedipine (Procardia) |Concentration |Dosage Amount 60mg |
|Route Oral |Frequency 2 times Daily |
|Pharmaceutical class Calcium channel blockers |Home Hospital or Both |
|Indication Management of hypertension |
|Side effects/Nursing considerations Arrhythmias, heart failure, Stevens-Johnson syndrome, headache, flushing; monitor blood pressure and pulse before and after |
|administration. Monitor when in use with other antihypertensives. |
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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? Diabetic diet |Analysis of home diet (Compare to “My Plate” and |
|Diet pt. follows at home? Diabetic diet |Consider co-morbidities and cultural considerations): |
|24 HR average home diet: |In relation to “My Plate,” the patient follows a |
|Breakfast: Patient reports that he does not regularly |relatively healthy diet. However the patient’s diet is lacking |
|consume breakfast. |in certain areas related to the overall food pyramid. The |
|Lunch: Chicken salad wrap /Tuna salad /Chicken |patient’s diet is sufficient in protein. However, the patient is |
|Breast with Rice (2 cups) |lacking sufficient and healthy amounts of fruits and |
|Dinner: Hamburger/French fries (1-2 cups) /Subway |vegetables. According to “My Plate,” the patient is lacking |
|Cuban Sandwich (12 inches long) /Wendy’s Salad (3 cups) |in sufficient fruits, vegetables, grains, and dairy. Also, since the patient is a|
| |diabetic patient, he should be recommended |
|Snacks: Carrots (2 cups) with Ranch (3-4 oz.) |to eat less foods that are high in sugar and fats. Overall, |
| |according to “My Plate,” the patient is consuming a |
|Liquids (include alcohol): Water (2-2.5 liters) /Gatorade |relatively healthy diet with small insufficiencies related to |
|(8-16 oz.) / Tea (8-16 oz.) / Beer socially (8 oz.) |certain areas of the food pyramid. |
|[pic] |Use this link for the nutritional analysis by comparing the patients 24 HR |
| |average home diet to the recommended portions, and use “My Plate” as reference. |
|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |
|Who helps you when you are ill? |
|Patient states that his wife is his support when he is ill. (Wife is present at the bedside.) |
|How do you generally cope with stress? or What do you do when you are upset? |
|Patient states that he is moderate at coping with stress. He explained that he likes to drive around his |
|neighborhood when he is stressed or upset. Patient reports, “My son helps me cheer up.” |
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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |
|Patient denies any recent difficulties. |
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|+2 DOMESTIC VIOLENCE ASSESSMENT |
|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |
|am going to ask some questions that help me to make sure that you are safe.” |
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|Have you ever felt unsafe in a close relationship? No, never |
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|Have you ever been talked down to? No Have you ever been hit punched or slapped? No |
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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? |
|No If yes, have you sought help for this? NONE |
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|Are you currently in a safe relationship? Yes. Patient reports, “I am currently very happy with my wife.” |
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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 Intimacy vs. Isolation if the point in a person’s life where they have become adults and have developed feelings of love and have |
|developed relationships. Intimacy is a stage of love and compassion towards a significant other, influencing most of their decisions. Isolation is a stage of |
|loneliness from lack of love or relationships. These people generally isolate themselves from society due to deficient relationships related to intimacy and love. |
|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |
|The patient is in the stage Intimacy vs. Isolation, while showing signs of Intimacy. Upon interaction with the |
|patient, he had consistent positive remarks and comments regarding his wife and their happy marriage. He would |
|continually state “She’s such a good wife.” Every time I would walk into the patient’s room, him and his wife |
|would be nestled up in his bed together watching movies. This patient truly expressed signs of intimacy throughout |
|my interaction with him. |
|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |
|This patient’s hospitalization did not have any impact on his developmental stage of life due to the consistent |
|positive remarks and comfort that his wife gave him throughout his stay during my shift. |
|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” |
|Patient reports, “I believe that the cause of my illness is due to my diabetes.” “My grandfather had diabetes and I |
|believe that I inherited it from him.” |
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|What does your illness mean to you? |
|Patient reports that his illness “doesn’t mean anything.” He expresses eagerness for discharge. |
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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? Women |
|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? Yes (wife has). |
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|Are you currently sexually active? Yes |
|When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? Usage of condoms. |
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|How long have you been with your current partner? 6 years. |
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|Have any medical or surgical conditions changed your ability to have sexual activity? No |
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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |
|No, none. |
±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Patient reports, “I am not extremely religious, but we are Christian and sometimes go to church.”
Do your religious beliefs influence your current condition?
Patient does not believe that religious belies influence his current 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 |
| If so, what? |How much?(specify daily amount) |For how many years? N/A years |
|N/A |N/A |(age thru ) |
| | |N/A |
|Pack Years: N/A | |If applicable, when did the patient quit? |
| | |N/A |
|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? NO|Has the patient ever tried to quit? N/A |
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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |
| What? |How much? (give specific volume) |For how many years? |
|Beer, socially |8-16 oz. |(age 21 thru 32 ) |
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| If applicable, when did the patient quit? | | |
|Never. Patient has not quit. |
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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |
| If so, what? |
|None |How much? |For how many years? |
| |None |(age thru ) |
| | |N/A |
| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |
| |N/A | |
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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |
|No, none. |
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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 |
| 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: 30 | Diverticulitis | Life threatening allergic reaction |
|Bathing routine: Every Night |Appendicitis | Enlarged lymph nodes |
|Other: | Abdominal Abscess |Other: |
| | Last colonoscopy? April 2014 | |
|HEENT |Other: |Hematologic/Oncologic |
| Difficulty seeing Left Eye |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: A- |
| Post-nasal drip |Normal frequency of urination: 6x/day |Other: |
| Oral/pharyngeal infection | Bladder or kidney infections | |
| Dental problems | |Metabolic/Endocrine |
| Routine brushing of teeth 2x/day | | Diabetes Type: 2 |
| Routine dentist visits 2x/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 (DOES NOT APPLY) | CVA |
| Asthma | Infection of the female genitalia | Dizziness |
| Bronchitis | Monthly self breast exam | Severe Headaches |
| Emphysema | Frequency of pap/pelvic exam | Migraines |
| Pneumonia | Date of last gyn exam? | Seizures |
| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |
| Environmental allergies | menarche age? | Encephalitis |
|last CXR? January 2014 | menopause age? | Meningitis |
|Other: |Date of last Mammogram &Result: |Other: |
| |Date of DEXA Bone Density & Result: | |
|Cardiovascular |Men Only |Mental Illness |
|Hypertension Onset: 2001 | Infection of male genitalia/prostate? | Depression |
| Hyperlipidemia | Frequency of prostate exam? NEVER | Schizophrenia |
| Chest pain / Angina | Date of last prostate exam? NEVER | Anxiety Usage of Ativan |
|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? January 2014 |Arthritis | Chicken Pox |
|Other: |Other: |Other: |
|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |
|Patient has not mentioned or sought out any other medical attention for anything else other than what is listed |
|above. |
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|Any other questions or comments that your patient would like you to know? |
|Patient expresses that he has no other questions or concerns. |
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|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |
|General Survey: A&O x4 |Height: 5’9” |Weight”225lbs. BMI: 33.2 |Pain: 0/10 |
| |Pulse: 97 |Blood | |
| | |Pressure: 144/96 (Right arm) | |
|Temperature: 97.6 F (Oral) |Respirations: 16 | | |
| |SpO2: 93% |Is the patient on Room Air or O2: Room Air |
|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |
| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |
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|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |
| awake, calm, relaxed, interacts well with others, judgment intact |
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|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |
| 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 | |
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|NO IV SITES |
|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 Slight redness present in the left eye. |
| PERRLA pupil size 3/3 mm Peripheral vision intact Decreased Peripheral vision in the left eye EOM intact through 6 cardinal fields without nystagmus |
| Ears symmetric without lesions or discharge Whisper test heard: right ear- 12 inches & left ear- 12 inches |
| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |
|Dentition: No present problems with Dentition. |
|Comments: |
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|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 |
| |CL – Clear |Percussion resonant throughout all lung fields, dull towards posterior bases |
| |WH – Wheezes |Sputum production: thick thin Amount: scant small moderate large |
| |CR - Crackles | Color: white pale yellow yellow dark yellow green gray light tan brown red |
| |RH – Rhonchi | No sputum production. |
| |D – Diminished | |
| |S – Stridor | |
| |Ab - Absent | |
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|Cardiovascular: No lifts, heaves, or thrills PMI felt at: 5th intercostal space on the left midclavicular line. |
|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) |
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|Patient not on telemetry. No ECG tracing present. |
| 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: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3 |
|No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |
|Location of edema: pitting non-pitting NO EDEMA |
|Extremities warm with capillary refill less than 3 seconds |
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|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: Light Yellow Previous 24 hour output: 670 mLs |
|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |
|CVA punch without rebound tenderness |
|Last BM: (date 10 / 14 / 14 ) 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) NOT DONE |
|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |
| Other – Describe: |
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|Musculoskeletal: ( Full ROM intact in all extremities without crepitus |
|Strength bilaterally equal at ___5/5____ RUE ____5/5___ LUE ___5/5____ RLE & ___5/5____ 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 |
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|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |
|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |
|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride |
|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |
|Triceps: 2 Biceps: 2 Brachioradial: 2 Patellar: 2 Achilles: 2 Ankle clonus: positive negative Babinski: |
|positive negative |
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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |
|diagnostic tests): |
|Lab |
|Dates |
|Trend |
|Analysis |
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|CBC |
|WBC |
|Normal (4.6-10.2 k/ul) |
|Pre-Op: 6.15 |
|Post-Op: 8.32 |
|RBC |
|Normal (4.69-6.13 m/ul) |
|Pre-Op: 3.62 (LOW) |
|Post-Op: 3.96 (LOW) |
|Hemoglobin |
|Normal (14.1-18.1 g/dl) |
|Pre-Op: 10.4 (LOW) |
|Post-Op: 11.5 (LOW) |
|Hematocrit |
|Normal (43.5-53.7%) |
|Pre-Op: 29.7 (LOW) |
|Post-Op: 32.7 (LOW) |
|Platelet Count |
|Normal (142-424 k/ul) |
|Pre-Op: 241 |
|Pot-Op: 275 |
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|(10/14/14) |
|(10/15/14) |
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|(10/14/14) |
|(10/15/14) |
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|(10/14/14) |
|(10/15/14) |
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|(10/14/14) |
|(10/15/14) |
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|(10/14/14) |
|(10/15/14) |
|Upon reviewing the results of the patient’s lab values, the WBC was within normal limits both pre-operatively and post-operatively. However, although still within |
|normal limits, the WBC minimally increased possibly signifying the beginning of an infection or inflammatory process. The patient’s RBC, hemoglobin, and hematocrit |
|were all lower than the normal range both pre-operatively and post-operatively, showing no real trend. The platelet count is also within normal limits both |
|pre-operatively and post-operatively, again showing no real trend in this lab value. |
|Patient’s WBC, both pre-operatively and post-operatively, were within normal limits. However, since there was a slight increase in his WBC post-operatively, it is |
|crucial to look for signs and symptoms of an infection or an inflammatory process. An increased WBC is indicative of a possible infection, so it would be important |
|for the nurse to take precautious measures and frequently assess this patient post-operatively. The patient’s lab values show that the patient’s RBC, hemoglobin, and|
|hematocrit are all lower than normal limits both pre-operatively and post-operatively. Usually patient’s undergoing surgeries are at a high risk for blood loss, |
|which is a cardinal reason behind a decreased RBC, hemoglobin, and hematocrit level. However, this patient received a vitrectomy of the left eye along with the |
|removal of the silicone eye, which is a “blood-less” surgery. This means that the patient’s vitreous humor was removed aiding in the recovery of the patient’s |
|retina, causing no external blood loss. Because surgical blood loss would not be the main concern or reason behind this patient’s low RBC, hemoglobin, and |
|hematocrit, nutrition deficiency or anemia could be indicative of why these levels may be low. This patient attempts to follow a diabetic diet, which could be the |
|causative agent of certain nutrient-deficits. The patient’s platelet count is within normal range indicating that he has sufficient clotting factors both |
|pre-operatively and post-operatively. Although this was a “blood-less” surgery, it is still important to check the platelet count to ensure there are sufficient |
|clotting factors if the patient does sustain any possible blood loss during surgery. |
| |
|Metabolic Panel |
|Sodium |
|Normal (135-145 meq/L) |
|Pre-Op: 138 |
|Post-Op: 135 |
|Potassium |
|Normal (3.5-5.3 mmol/L) |
|Pre-Op: 4.1 |
|Post-Op: 4.9 |
|Chloride |
|Normal (98-107 meq/L) |
|Pre-Op: 108 |
|Post-Op: 106 |
|BUN |
|Normal (6.0-20 mg/dl) |
|Pre-Op: 30 (HIGH) |
|Post-Op: 32 (HIGH) |
|Creatinine |
|Normal (0.72-1.25) |
|Pre-Op: 1.3 (HIGH) |
|Post-Op: 1.7 (HIGH) |
| |
| |
| |
|(10/14/14) |
|(10/15/14) |
| |
| |
|(10/14/14) |
|(10/15/14) |
| |
| |
|(10/14/14) |
|(10/15/14) |
| |
| |
|(10/14/14) |
|(10/15/14) |
| |
| |
|(10/14/14) |
|(10/15/14) |
|There is no relevant trend among the patient’s sodium, potassium, or chloride levels. Both pre-operatively and post-operatively, these lab values were within normal |
|limits. However, the patient’s BUN and creatinine levels were higher than normal limits both pre-operatively and post-operatively, so again there is no real trend. |
|However, although within defined limits, both the BUN and creatinine both slightly increased post-surgery. |
|The patient has normal levels of sodium, chloride, and potassium, indicating that this patient has balanced electrolytes with no identifiable insufficiencies. |
|However, this patient has elevated BUN and creatinine levels both pre-operatively and post-operatively indicating that his kidneys are compensating for his illness. |
|This patient has type 2 diabetes and uncontrolled hypertension. With consistent elevated blood glucose and hypertension, the kidneys are compensating for these harsh|
|conditions and aren’t properly filtering and functioning efficiently. Elevated BUN and creatinine levels are cardinal signs for insufficient kidney functioning. |
| |
|Blood Glucose |
|Normal (70-100) |
|Pre-Op: 213 (HIGH) |
|Post-Op: 169 (HIGH) |
| |
| |
|(10/14/14) |
|(10/15/14) |
|This patient’s blood glucose level had been fluctuating up and down throughout my shift due to his type 2 diabetes mellitus. On his pre-operative date, he had a |
|higher blood glucose level than that of his post-operative date. There was no true consistent trend. |
|This patient’s pre-operative blood glucose level was higher than that of his post-operative level. This patient has type 2 diabetes mellitus, which causes the spikes|
|in his blood glucose. However, this patient has regularly scheduled Novolog that he takes after his meals. This insulin enables his cells to become more |
|insulin-sensitive, causing a decreased blood glucose level. Throughout my shift, the patient’s glucose was reportedly decreased after his insulin administration and |
|would begin to increase again once the drug’s duration period ended. According to his pre-operative levels and post-operative levels, it looks as though he received |
|his insulin after his surgery date on 10/15/14. |
| |
| |
|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and |
|frequency if applicable.) |
|Patient is currently on a Diabetic Diet. A consult has been made with the physician to speak about patient’s uncontrolled hypertension. Current scheduled consult |
|with ophthalmology to assess the progress of the patient’s left eye. Accu-checks ordered routinely to assess blood glucose in the management of patient’s type 2 DM. |
|Vitals are stable: Blood pressure: 144/96, Pulse: 97, Respirations: 16, Temperature: 97.6 F (oral), and current pain level is 0/10. |
| |
|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
|1. Ineffective self-health management related to uncontrolled hypertension as evidenced by consistent |
|increased blood pressure unaccompanied by medications prior to hospitalization. |
| |
|2. Risk for infection related to invasive vitrectomy associated with the removal of the silicone eye. |
| |
| |
|3. Anxiety related to vision impairment as evidenced by patient’s reported level of anxiousness associated |
|with the return of vision. |
| |
± 15 CARE PLAN
Nursing Diagnosis: Ineffective self-health management related to uncontrolled hypertension as evidenced by consistent increased blood pressure unaccompanied by medications prior to hospitalization.
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is |
| | |Provide References |Provided |
|Stabilize and maintain a safe and |Throughout entire shift (0645-1400), |Patient’s who suffer from uncontrolled |During my shift (0645-1400), the patient|
|controlled blood pressure both in the |administer antihypertensive medications |hypertension are at a greater risk for |was administered all scheduled |
|hospital and at home, when discharged. |as ordered and scheduled by the |developing many harsh life-threatening |antihypertensive medications that were |
| |patient’s physician. Continually educate|conditions. Among these conditions |ordered by his physician. The nurse and |
| |the patient why it is important to take |include stroke, heart attacks, coronary |I educated the patient on how this |
| |these medications and what they do and |artery disease, heart failure, organ |medication affected his health and his |
| |how they function in promoting a safe |system failure, and many other |uncontrolled hypertension. Patient was |
| |and stable blood pressure. |debilitating factors. For those with |compliant in receiving all medication |
| | |uncontrolled hypertension, it is highly |during my shift. The patient’s blood |
| | |recommended to get started on, or alter |pressure remained within safe limits |
| | |a scheduled antihypertensive medication |throughout my shift and did not |
| | |regimen. These medications can decrease |fluctuate into dangerous hypertensive or|
| | |the workload on the heart or can dilate |hypotensive levels. This goal is will be|
| | |the vessels in a person’s body. By |ongoing until the date of discharge and |
| | |decreasing the workload of the heart and|until the patient’s physician has |
| | |dilating vessels, a person’s blood |decided that this medication regimen has|
| | |pressure can decrease and not work as |positively affected and controlled his |
| | |hard to promote blood flow to the rest |hypertension. |
| | |of the body. It is crucial to administer| |
| | |antihypertensive medications to a | |
| | |patient with uncontrolled hypertension | |
| | |and to educate that patient on how it is| |
| | |affecting his/her body. Educating a | |
| | |patient about their medications allows | |
| | |more room for administration compliance.| |
| | |If the patient is aware of how these | |
| | |medications are positively impacting his| |
| | |uncontrolled hypertension, they are more| |
| | |likely to be compliant and | |
| | |understanding. | |
| |Continually monitor the patient’s blood |Monitoring the patient’s blood pressure |Throughout my entire shift (0645-1400), |
| |pressure and heart rate to aid in |and heart rate is crucial in the |the patient technician and I continually|
| |identifying the trends and maintenance |maintenance of his uncontrolled |assessed and monitored the patient’s |
| |of the patient’s hypertension. Ensure |hypertension. By taking and documenting |vital signs, including the blood |
| |that the patient’s blood pressure is |the patient’s blood pressure both before|pressure and heart rate. We ensured that|
| |remaining within safe limits, without |medication administration and after |the patient’s blood pressure remained |
| |uncontrolled fluctuation. |medication administration allows health |within safe limits throughout my shift, |
| | |care providers to develop a trend in |both before and after antihypertensive |
| | |blood pressure levels and what impact |medication administration. At the |
| | |the medication may have on the patient’s|beginning of my shift, upon assessing |
| | |blood pressure. It helps the physician |his vital signs, the patient’s blood |
| | |figure out a helpful and safe |pressure decreased from 169/95 to 144/96|
| | |prescription and it helps the patient |after administration of antihypertensive|
| | |remain safe. In regards to blood |medication. At the end of my shift the |
| | |pressure, safety takes priority. |patient’s blood pressure decreased from |
| | |Monitoring the blood pressure before |157/95 to 142/93. Throughout my shift, |
| | |medication allows the nurse to see if it|the patient’s blood pressure was being |
| | |is safe to administer the |controlled while remaining within safe |
| | |antihypertensive. If the patient’s blood|limits with the help of antihypertensive|
| | |pressure is dangerously low prior to |medication administration. Goal was met |
| | |administration, the nurse can know to |during my shift and will continue to be |
| | |hold the medication and not cause the |ongoing until hypertension is fully |
| | |patient to bottom out with hypotension. |controlled. |
| | |Monitoring the blood pressure after | |
| | |medication administration is crucial to | |
| | |see how the medication is affecting the | |
| | |patient and whether or not it is | |
| | |controlling and stabilizing his | |
| | |uncontrolled hypertension. | |
| |Encourage the patient to exercise and |Although antihypertensive medications |The patient received education from the |
| |promote a healthy diet low in fats to |aid in the stabilization and control of |physician, nurse, and the dietary team |
| |decrease the build up of plaque and |hypertension, they do not cure |about conscious eating and healthy |
| |residual in the patient’s arteries, |hypertension by any means. Since they do|living during my shift (0645-1400). The |
| |allowing the patient’s blood pressure |not cure hypertension, it is crucial for|patient was compliant with the |
| |and blood flow to remain within safe |the nurse and other health care |promotional education. He relayed back |
| |limits. * |providers to promote healthy eating and |to nurse on what foods he should eat |
| | |exercise to patients with hypertension. |instead of eating high-fatty foods. |
| | |Exercise and eating a low-fat diet can |Patient reported understanding of the |
| | |implement healthy living and maintenance|importance of exercise in the assistance|
| | |of hypertension. Exercise can stimulate |of controlling his hypertension. Patient|
| | |a healthy heart, while a low-fat diet |understands that antihypertensive |
| | |can reduce the risk of plaque and |medications do not cure hypertension, |
| | |residual build-up in the patient’s |showing that the implementation of |
| | |arteries. Decreasing the risk for plaque|healthy eating and healthy living is |
| | |build-up in a person’s arteries |crucial. |
| | |decreases the amount of pressure and | |
| | |force of the blood that the heart has to| |
| | |pump to the rest of the body. A | |
| | |combination of healthy eating and living| |
| | |along with antihypertensive medication | |
| | |allows the body’s blood pressure to | |
| | |stabilize and promote safe and | |
| | |controlled levels. | |
|Promote home health and home safety in |Teach safety in taking medications once |Safety is the number one priority when |During my shift, the patient was |
|accordance with diagnosed hypertension. |patient is discharged from the hospital |referencing medications and medication |continually receiving education |
| |to ensure that his hypertension remains |administration. Each and every |regarding his multiple antihypertensive |
| |controlled and within safe limits. * |medication has numerous side effects, |medications. The patient showed |
| | |adverse effects, and possible |compliance and understanding as to what |
| | |life-threatening symptoms. In order to |each medication did and how it affected |
| | |avoid most of these dangerous factors, |his hypertension. He acknowledged the |
| | |it is crucial for the patient to fully |numerous safety measures that were shown|
| | |understand what he/she is taking, |to him regarding medication |
| | |especially when they are at home without|administration. This goal is ongoing |
| | |the supervision of a health care |however, because the patient was not |
| | |provider. Patient education related to |planned for discharge during my shift |
| | |medication safety is a huge priority in |(0645-1400). |
| | |discharge planning. Patient education | |
| | |can ensure that the patient will be | |
| | |knowledgeable about what medication he | |
| | |is taking, how many he is taking, how | |
| | |often he is taking them, and why it is | |
| | |important that he is compliant with the | |
| | |scheduling of the medication. The nurse | |
| | |and other health care providers should | |
| | |ensure that the patient feels | |
| | |comfortable and safe with medication | |
| | |administration at home before he is | |
| | |discharged. | |
| |Assist patient with scheduling and |Assisting the patient in incorporating |During my shift (0645-1400), the patient|
| |incorporating medication regimen into |medication administration into his daily|reported that he understood that he |
| |his home schedule, ensuring that his |life at home is crucial is making the |would have to incorporate |
| |medication is being properly |patient comfortable with home medication|antihypertensive medications into his |
| |administered at planned times. * |administration. Many patients are not |home-health schedule. However, this goal|
| | |used to having to take prescribed |is ongoing because the patient has not |
| | |scheduled medications at home under |been set for discharge and has not been |
| | |their own discretion. For this reason, |shown effective home medication |
| | |it is important for the nurse to |scheduling techniques. This goal |
| | |understand that assistance and |however, it presumed to be met before |
| | |home-health planning is crucial in the |discharge. |
| | |compliance and safety of home | |
| | |medications for the patient. The patient| |
| | |should be shown when good times to take | |
| | |the scheduled medications would be and | |
| | |how they should easily be reminded to | |
| | |take them. Use of planners, calendars, | |
| | |and alarms can be a good resource in | |
| | |reminding a patient to take his | |
| | |medications at home without having to | |
| | |stress about them or forget to take | |
| | |them. The patient should demonstrate | |
| | |comfort and understanding on promotional| |
| | |ways to remember to incorporate | |
| | |medications into their daily home living| |
| | |before discharged. | |
|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
|Consider the following needs: |
|□SS Consult |
|□Dietary Consult * |
|□PT/ OT |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appts |
|□Med Instruction/Prescription * |
|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
± 15 CARE PLAN
Nursing Diagnosis: Risk for infection related to invasive vitrectomy associated with the removal of the silicone eye.
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care |
| | |Provide References |is Provided |
|Remain free of infection as a |Continually observe and report signs of|Redness, warmth, discharge, and elevated |During my shift (0645-1400), the nurse |
|post-operative complication associated |infection such as redness, warmth, |body temperature are all cardinal signs |and I continually monitored for signs |
|with surgery while hospitalized. |discharge, and increased body |and symptoms of an infection. Patients |and symptoms of an infection. We checked|
| |temperature. |recovering from any type of surgery are |his temperate twice throughout my shift,|
| | |put at a high risk for developing an |both of which were 97.6 and 97.9, |
| | |infection. Surgery is a risk factor for |indicating no sign of infection. We |
| | |an infection due to the invasive touch of|frequently assessed his surgical site |
| | |possibly contaminated instruments, tools,|(left eye) for any drainage, redness, or|
| | |surgeons’ hands, etc. Monitoring for |swelling. The patient’s remained free |
| | |these cardinal signs of infection |from these symptoms, again indicating no|
| | |implements the patient’s safety and |infection. The goal was met throughout |
| | |allows the nurse and other health care |my shift, in that the patient remained |
| | |professionals to promote the recovery of |free of an infection while hospitalized,|
| | |the patient. If the patient is free of |however the goal will continue to be |
| | |these cardinal signs and symptoms, then |ongoing until his date of discharge. |
| | |it can be presumed that the patient is | |
| | |post-operatively recovering well with | |
| | |minimal to absent complications. If the | |
| | |patient presents with these cardinal | |
| | |signs and symptoms, then the patient’s | |
| | |recovery plan will have to be altered to | |
| | |incorporate treatment of a possible | |
| | |infection. It is crucial to spot the | |
| | |signs and symptoms of a possible | |
| | |infection to allow the patient to move | |
| | |forward in recovery as opposed to moving | |
| | |backwards with infections that possibly | |
| | |could have been prevented. | |
| |Note and report laboratory values |An elevated white blood cell count is |During my shift (0645-1400), the nurse |
| |including a pre-operative and |highly indicative of the presence of a |and I checked the white blood cell count|
| |post-operative white blood cell count. |possible infection. It is crucial for a |of the patient. His pre-operative white |
| | |CBC lab, including the white blood count,|blood cell count was 6.15 and his |
| | |to be drawn both pre-operatively and |post-operative white blood cell count |
| | |post-operatively. Receiving both pre-op |was 8.32. Both of these values are |
| | |and post-op white blood cell count allows|within normal range, indicating that no |
| | |the nurse and other health care providers|infection is likely present. However, |
| | |to note any possible trends. If the |due to the fact that the patient’s white|
| | |patient’s white blood cell count has |blood cell count minimally increased |
| | |trended upwards post-operatively, it is |post-operatively, the goal is ongoing |
| | |very likely that an infection or |until the patient is free of infection |
| | |inflammatory process is present or has |upon the date of discharge. |
| | |developed. White blood cells are an | |
| | |important part of the immune system. | |
| | |These cells help fight infections by | |
| | |attacking any bacteria or germs that may | |
| | |invade the body. If there is an | |
| | |increasing number of white blood cells, | |
| | |then that means that there is a possible | |
| | |infection present that they are trying to| |
| | |attack and fight off. It is crucial for | |
| | |the nurse to check the WBC of a patient | |
| | |out of surgery due to its high risk | |
| | |factor and possible causations. | |
| |Use standard precautions and wear |Standard precautions, including hand |All throughout my shift, from |
| |gloves upon contact with the |washing and wearing gloves are two of the|(0645-1400), the nurse and I continually|
| |post-surgical site (left eye). |most important factors contributing the |followed standard precautions by washing|
| | |safety of the patient. These precautions |our hands before entering the room and |
| | |are important in the prevention of |before coming in contact with the |
| | |contracting an infection. It is |patient. We also applied gloves each and|
| | |appropriate for the nurse to wash hands |every time we came in contact with the |
| | |prior to entering the room and prior to |patient’s surgical site (left eye). Each|
| | |contact with the patient. It is also |time we assessed the patient’s left eye |
| | |important for the nurse to wear gloves at|for progression or any signs of an |
| | |all times when contacting the patient, |infection, we had washed our hand prior |
| | |especially when associated with the |and had administered gloves. This goal |
| | |surgical site. It is crucial to implement|was met throughout my shift. |
| | |this rule into patient care, because it | |
| | |can be the number one way to prevent | |
| | |nurse-to-patient infection. | |
|Patient will demonstrate home health |Teach the patient to thoroughly wash |Teaching the patient standard precautions|During my shift (0645-1400), the patient|
|precautions in regards to remaining free |his hands before each and every time he|and how to thoroughly wash his hands |expressed understanding of the |
|of an infection at home associated with |comes in contact with his left eye.* |before coming in contact with his |importance of hand washing and how it is|
|his post-operative site and condition. | |surgical site (left eye), is one of the |crucial is maintaining free of an |
| | |most important educational measures in |infection. However, the patient has not |
| | |preventing an infection. If the patient |been able to demonstrate for the nurse |
| | |shows compliance and understanding on the|and ask any questions he might have |
| | |precautionary rule of washing his hands |because his discharge date has not yet |
| | |before touching his surgical site, the |been planned. Therefore, this goal is |
| | |patient has a greater chance of not |ongoing. |
| | |contracting an infection. It is crucial | |
| | |for the nurse to have the patient | |
| | |demonstrate how to thoroughly wash his | |
| | |hands properly before coming in contact | |
| | |with his surgical site, in order to show | |
| | |the nurse that he is competent in | |
| | |maintaining a clean and safe home-health | |
| | |approach to taking care of his surgical | |
| | |site. | |
| |Instruct patient to store and |Should the patient have to administer any|This goal is ongoing because the |
| |administer any possible scheduled eye |possible future eye medications, he |patient’s discharge date has not yet |
| |medications in a clean environment out |should be instructed by the nurse and |been set and the patient has not |
| |of reach of any possible contaminants. |other health care providers how to store |received any education associated with |
| |* |them in is house and how to administer |eye medications during my shift. Consult|
| | |them properly without posing any risk for|with ophthalmologist has informed the |
| | |infection. It is important for the |patient of future eye drop medications |
| | |patient to understand that the eye |soon to be scheduled for him. This goal |
| | |medications should be administered after |is ongoing and had not been met during |
| | |proper hand hygiene has been implemented.|my shift (0645-1400). |
| | |The patient should also be instructed to | |
| | |demonstrate for the nurse the proper way | |
| | |to administer the medication so that the | |
| | |nurse can see if the patient is | |
| | |competent, clean, and compliant. It is | |
| | |also important for the nurse to teach the| |
| | |patient a clean and safe way to store the| |
| | |medication at home. The patient should | |
| | |understand that the medication should | |
| | |remain in a clean and protected | |
| | |environment, away from any possible | |
| | |contaminants around his home. | |
| |Encourage patient to contact the |Teaching the patient the cardinal signs |During my shift (0645-1400), the patient|
| |provider if any possible signs or |and symptoms of an infection is very |was instructed on what the cardinal |
| |symptoms of an infection occur. * |important for home-health education. If |signs of an infection are in association|
| | |the patient is aware and understands how |with his left eye. This goal however is |
| | |an infection can be assessed, then the |ongoing because, again, his discharge |
| | |safety of the patient has been promoted. |date has not yet been met and the |
| | |The nurse should include patient |patient has not received information |
| | |education about how to properly take his |about contacting the provider while at |
| | |own temperature and how to effectively |home about possible signs of an |
| | |assess his surgical site to make the |infection. This goal is therefore still |
| | |patient feel comfortable with addressing |ongoing and is presumed to be met by his|
| | |any possible sign of infection. If the |discharge date. |
| | |patient is able to spot the cardinal | |
| | |signs of an infection, then the | |
| | |probability of the infection becoming | |
| | |worse or life-threatening can be | |
| | |decreased as long as the patient knows to| |
| | |contact his physician as soon as these | |
| | |cardinal signs appear. Demonstration and | |
| | |acknowledgment of this information is | |
| | |crucial prior to the discharge of this | |
| | |patient. | |
|± DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
| |
|Consider the following needs: |
|□SS Consult |
|□Dietary Consult |
|□PT/ OT |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appts |
|□Med Instruction/Prescription |
|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
References
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software].
Davis’s Laboratory and Diagnostic Tests (Ativan, Claritin, Coreg, Cozaar, Microzide, Nifedipine). Nursing Central
Huether, S. (1996) Understanding Pathophysiology. Chapter 18, Page 467. St. Louis, Missouri: Wilson
"Erikson's Psychosocial Development in Psychology 101." Erikson's Psychosocial Development in Psychology
101 at AllPsych Online. Web. 18 October 2014.
"." . Web. 18 October 2014
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