UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Casey Stevens |

|Patient Assessment Tool . |Assignment Date: 09/06/13 |

| ( 1 PATIENT INFORMATION |Agency: Tampa General Hospital |

|Patient Initials: J, D |Age: 40 |Admission Date: 09/05/13 |

|Gender: Male |Marital Status: Single |Primary Medical Diagnosis with ICD-10 code: |

|Primary Language: English |Cellulitis 682.9 |

|Level of Education: Bachelors Degree |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): Disabled |Alcohol Abuse 305.00 |

|Number/ages children/siblings: No Children, No Siblings | |

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

|Living Arrangements: “I live at home with my parents.” |Advanced Directives: No |

| |If no, do they want to fill them out? “At some point” |

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

|Culture/ Ethnicity /Nationality: Caucasian | |

|Religion: No preference |Type of Insurance: Medicare |

|( 1 CHIEF COMPLAINT: “I came into the hospital because of pain and swelling to my left leg.” |

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

|O: The patient stated that his pain began on September 1st 2013. |

|L: The patient stated that the location of his pain was located on his left leg. |

|D: The patient stated that the pain is constant around the affected area. |

|C: The patient described his pain as a sharp, hot, pressure on and around the affected area. |

|A: The patient stated that walking and touching the left extremity makes his pain worse. |

|R: The patient stated that his pain does not radiate anywhere else and that his pain medications help relieve the pain. |

|T: The patient stated that his treatment to minimize his pain is to take his pain medication Oxycodone as ordered. |

|S: The patient stated that on a 0-10 scale is pain would be ranked at about a 7 with the use of pain medication. |

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|The patient is a 40- year-old male presenting to the hospital with left leg pain, redness and swelling. He has a history of alcohol abuse and is showing symptoms |

|of withdrawal including fever, night sweats, and chills. The patient stated that his pain began on September 1st 2013. When asked to describe his pain he stated, |

|“it is a constant sharp pain that hurts to touch.” The affected area is hot to touch but has no open wounds and is open to room air. The patient stated that when|

|administered the pain medication on time the pain is manageable. The pain medication that he has ordered is Oxycodone and is PRN every 4 hours. When asked to rank |

|his pain on a 0-10 scale the patients stated that his pain remains around a 7 all day long and his desired number would be 0. |

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

|Date |Operation or Illness |

|High School |Cirrhosis, alcoholic |

| |Bipolar disorder |

|05/10/11 |Colonization with VRE: Cleared 10/08/12 |

| |Obesity |

| |Gastric Ulcer |

| |Tonsillectomy |

|07/01/11 |MRI of Lumbar Spine |

|11/15/01 |MRI of Cervical Spine |

|04/16/12 |CT Myelogram Lumbar Spine |

|10/19/12 |Esophagogastroduodenoscopy |

| |Esophagogastroduodenoscopy with Banding |

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|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

| |Patient stated that he was adopted and knows nothing about his birth parents. |

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|( 1 immunization History |

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

|Routine childhood vaccinations | | |

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

|Adult Diphtheria (Date) Unknown | | |

|Adult Tetanus (Date): Unknown | | |

|Influenza (flu) (Date) October 2012 | | |

|Pneumococcal (pneumonia) (Date): Unknown | | |

|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 |Tylenol |“Makes me jaundice” |

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

| Cellulitis is an infection of the dermis and subcutaneous tissue usually caused by staphylococcus aureus. Cellulitis can occur as an extension of a skin |

|wound, as an ulcer, or from furuncles or carbuncles. The infected area is warm, erythematous, swollen, and painful. The infection is usually in the lower |

|extremities and responds to systemic antibiotics, as well as therapy to relieve pain. Cellulitis also can be associated with other diseases including chronic |

|venous insufficiency and stasis dermatitis. |

| Diagnostic blood studies reveal mild leukocytosis with a left shift or an elevation in neutrophils, and a wound culture will identify the causative organism.|

|Treatment involves resting the affected site with elevation if possible. Antibiotics sensitive for the causative organisms are indicated. Pain medication can help |

|relieve tension and pain. Without treatment, cellulitis may spread to the bloodstream-causing septicemia. |

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

|Name: Amiloride (Midamor) |Concentration (mg/ml): 1 x 5mg tablet |Dosage Amount (mg): 5 mg |

|Route: Oral |Frequency: Daily |

|Pharmaceutical class: Diuretic |Home Hospital or Both |

|Indication: Used with other agents to treat edema; Counteracts potassium loss caused by other diuretics. |

|Side effects/Nursing considerations: Dizziness, headache, arrhythmias, constipation, nausea, vomiting, hyperkalemia, hypernatremia, muscle cramps, and allergic |

|reactions. |

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|Name: Chlordiazepoxide (Librium) |Concentration: 2 x 25 mg capsule |Dosage Amount: 50 mg |

|Route: Oral |Frequency: Every 6 hours |

|Pharmaceutical class: Benzodiazepines |Home Hospital or Both |

|Indication: Treatment of alcohol withdrawal |

|Side effects/Nursing considerations: Dizziness, drowsiness, hangover, headache, mental depression, paradoxical excitation, sedation, blurred vision, constipation, |

|diarrhea, nausea, vomiting, weight gain, rashes, physical dependence, psychological dependence, and tolerance. |

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|Name: Famotidine (Pepcid) |Concentration: 1 x 20mg tablet |Dosage Amount: 20 mg |

|Route: Oral |Frequency: Two times daily |

|Pharmaceutical class: Histamine h2 antagonist |Home Hospital or Both |

|Indication: Treatment of heartburn, acid indigestion , and sour stomach. |

|Side effects/Nursing considerations: Confusion, dizziness, drowsiness, hallucinations, headache, arrhythmias, constipation, diarrhea, nausea, erectile dysfunction,|

|gynecomastia, agranulocytosis, aplastic anemia, anemia, neutropenia, thrombocytopenia, pain at IM site, and hypersensitivity reactions. |

|Name: Folic acid (Folvite) |Concentration: 1 x 20 mg |Dosage Amount: 1 mg |

|Route: Oral |Frequency: Daily |

|Pharmaceutical class: Water Soluble Vitamins |Home Hospital or Both |

|Indication: Prevention and treatment of megaloblastic and macrocytic anemia’s |

|Side effects/Nursing considerations: Rash, irritability, difficulty sleeping, malaise, confusion, and fever. |

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|Name: Furosemide (Lasix) |Concentration: 0.5 x 40 mg |Dosage Amount: 20 mg |

|Route: Oral |Frequency: Daily |

|Pharmaceutical class: Loop diuretics |Home Hospital or Both |

|Indication: Edema due to heart failure, hepatic impairment or renal disease |

|Side effects/Nursing considerations: Blurred vision, dizziness, headache, vertigo, hearing loss, tinnitus, hypotension, anorexia, constipation, diarrhea, dry |

|mouth, dyspepsia, nausea, vomiting, excessive urination, Stevens Johnson syndrome, toxic epidermal necrolysis, photosensitivity, pruritus, rash, dehydration, |

|hypocalcemia, hypokalemia, hypomagnesaemia, hypernatremia, hypovalemia, metabolic alkalosis, aplastic anemia, angranulocytosis, leukopenia, muscle cramps, and |

|fever. |

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|Name: Hydroxyzine (Atarax) |Concentration: 1 x 25 mg |Dosage Amount: 25mg |

|Route: Oral |Frequency: 4 times daily |

|Pharmaceutical class: Antianxiety agent |Home Hospital or Both |

|Indication: Treatment of anxiety |

|Side effects/Nursing considerations: Drowsiness, agitation, ataxia, dizziness, headache, weakness, wheezing, dry mouth, bitter taste, constipation, nausea, urinary|

|retention, flushing, pain at IM site, and chest tightness. |

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|Name: Ibuprofen (Advil, Motrin) |Concentration: 1 x 400 mg |Dosage Amount: 400 mg |

|Route: Oral |Frequency: Every 6 hours PRN |

|Pharmaceutical class: Nonopioid analgesics |Home Hospital or Both |

|Indication: Mild to moderate pain |

|Side effects/Nursing considerations: Headache, dizziness, drowsiness, psychic disturbances, blurred vision, tinnitus, arrhythmias, edema, GI bleeding, hepatitis, |

|constipation, dyspepsia, nausea, vomiting, abdominal discomfort, exfoliative dermatitis, Stevens Johnson Syndrome, Toxic epidermal necrolysis, allergic reactions. |

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|Name: Lactulose (Enulose) |Concentration: 20g/30ml |Dosage Amount: 20 g |

|Route: Oral |Frequency: 2 time daily |

|Pharmaceutical class: Osmotic |Home Hospital or Both |

|Indication: Treatment of chronic constipation |

|Side effects/Nursing considerations: Belching, cramps, distention, flatulence, diarrhea, hyperglycemia |

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|Name: Lorazepam (Ativan) |Concentration0.25 ml= 0.5mg of 2 mg/ml |Dosage Amount: 0.5 mg |

|Route: Intravenous |Frequency: Every 4 hours PRN |

|Pharmaceutical class: Benzodiazepine |Home Hospital or Both |

|Indication: Anxiety disorder |

|Side effects/Nursing considerations: Dizziness, drowsiness, lethargy, headache, ataxia, slurred speech, confusion, blurred vision, respiratory depression, apnea |

|cardiac arrest, bradycardia, hypotension, constipation diarrhea, nausea, vomiting, weight gain, rashes, physical dependence, tolerance |

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|Name: Magnesium Sulfate |Concentration: 4g/100ml |Dosage Amount: 4 g |

|Route: Intravenous |Frequency: Once |

|Pharmaceutical class: Minerals Electrolytes |Home Hospital or Both |

|Indication: Treatment. Prevention of hypomagnesaemia |

|Side effects/Nursing considerations: Drowsiness, arrhythmias, bradycardia, hypotension, diarrhea, muscle weakness, flushing, sweating, hypothermia |

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|Name: Oxycodone (Roxicodone) |Concentration: 2x 5 mg |Dosage Amount: 10 mg |

|Route: Oral |Frequency: Every four hours PRN |

|Pharmaceutical class: Opioid agonist |Home Hospital or Both |

|Indication: Moderate to severe pain |

|Side effects/Nursing considerations: Confusion, sedation, dizziness, dysphoria, euphoria, blurred vision, respiratory depression, orthostatic hypotension, |

|constipation, dry mouth, nausea, vomiting, urinary retention, flushing sweating, physical dependence, psychological dependence, and tolerance. |

|Name: Piperacillin/Tazobactam (Zosyn) |Concentration: 3.375 g/ 50 ml |Dosage Amount: 3.375 g |

|Route: Intravenous |Frequency: Every 6 hours |

|Pharmaceutical class: Extended spectrum penicillin |Home Hospital or Both |

|Indication: Skin and skin structure infections |

|Side effects/Nursing considerations: Seizures, confusion, dizziness, headache, insomnia, diarrhea, constipation, nausea, vomiting, bleeding, leukopenia, |

|neutropenia, pain, hypersensitivity reactions, fever |

|Name: Propranolol (Inderal) |Concentration:1 x 10 mg |Dosage Amount: 10 mg |

|Route: Oral |Frequency: 2 times daily |

|Pharmaceutical class: Beta Blocker |Home Hospital or Both |

|Indication: Used to manage alcohol withdrawal |

|Side effects/Nursing considerations: Fatigue, weaknes, anxiety, dizziness, drowsiness, blurred vision, dry eyes, arrhythmias, bradycardia, HF, Pulmonary edema, |

|orthostatic hypotension, constipation, diarrhea, nausea, Stevens Johnson syndrome, muscle cramps, anaphylaxis |

|Name: Rifaximin (Xifaxan) |Concentration: 1 x 550 mg |Dosage Amount: 550 mg |

|Route: Oral |Frequency: 2 times daily |

|Pharmaceutical class: Rifamycins |Home Hospital or Both |

|Indication: Reducation in risk of overt hepatic encephalopathy recurrence |

|Side effects/Nursing considerations: Dizziness, peripheral edema, and pseudomembranous colitis. |

|Name: Vancomycin (Vancocin) |Concentration: 2,00mg/ 500ml |Dosage Amount: 2,000 mg |

|Route: Intravenous |Frequency: Every 12 hours |

|Pharmaceutical class: Anti-infective |Home Hospital or Both |

|Indication: Treatment of potentially life- threatening infections when less toxic anti-invectives are contraindicated. |

|Side effects/Nursing considerations: Hypotension, Nausea, vomiting, nephrotoxicity, rashes, eosinophilia, leukopenia, phlebitis, back and neck pain. |

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

|Diet ordered in hospital? Regular Diet |Analysis of home diet (Compare to “My Plate” and |

|Diet pt follows at home? Regular Diet |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: Regular |Recommended amount for a 40 year old male |

|Breakfast: eggs and toast or cereal |Fruit: 2 cups |

| |Vegetable: 3 cups |

|Lunch: Left over foods, fast food, sandwich, frozen meals, cereal. |Grains: 7 ounces equivalent |

| |Protein food: 6 ounces equivalent |

|Dinner: “Whatever my mother makes to eat.” Vegetables, meat, bread. |Dairy: 3 cups |

| |Oils: 6 teaspoons |

|Snacks: Potato Chips, ice-cream, popcorn, crackers, candy | |

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|Liquids (include alcohol): Soda, juice, and beer. | |

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|[pic] |Use this link for the nutritional analysis by comparing the patients 24 HR |

| |average home diet to the recommended portions, and use “My Plate” as reference. |

| |My patients diet at home needs to improve nutritionally. He is not getting all |

| |the required amounts from the food pyramid to get all the nutrients recommended |

| |for him. The patient stated that he mostly only eat carbohydrates and junk food. |

| |He does not have a balanced diet at all. He needs to improve his diet |

| |nutritionally or he will continue to be eating unhealthy. |

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

|Who helps you when you are ill? “My family helps me when I am ill.” |

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

|“I like to be alone; So I will isolate myself from others.” |

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

|“I have been feeling very anxious while in the hospital.” |

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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.” |

|Have you ever felt unsafe in a close relationship? “No” |

|Have you ever been talked down to? “No” |

|Have you ever been hit punched or slapped?  “No” |

|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? “No” |

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|Are you currently in a safe relationship? “Currently not in a relationship” |

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|( 4 DEVELOPMENTAL CONSIDERATIONS: |

|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |

|Role Confusion/Diffusion Intimacy vs. /Stagnation Isolation Generativity vs. Self absorption 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: |

|Generativity means transmitting something positive to the next generation. This can be done through roles of parenting, teaching, or through social activism. |

|Generativity is about leaving a legacy to the next generation. Stagnation is the feeling of having done nothing to help the next generation or failure to leave a |

|legacy. |

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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 in the stagnation stage because he does not seem happy with where he is at in his life. He told me he hates not being able to have a job and still |

|lives with his parents. He stated that he has had times in his life where he was depressed and he was diagnosed with bipolar disorder. The patient said that he |

|copes with his stress and the “bad days” by drinking alcohol but wants to quit. My patient was cooperative during his interview but seemed agitated at times. |

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

|The reason my patient was admitted to the hospital was because of cellulitis to his left lower extremity. However, he also suffers from alcohol abuse. This |

|diagnosis definitely has an impact on my patient’s developmental stage of life. He is not happy about how his life is going and turns to alcohol to comfort him. My|

|patient did state that he is willing to change and will turn to healthy coping mechanisms from now on. |

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|+3 CULTURAL ASSESSMENT: |

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

|“Infection to my leg.” |

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|What does your illness mean to you? |

|“It means being stuck inside this hospital.” |

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|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |

|Consider beginning with:  “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |

|usually related to either infection, changes with aging and/or quality of life.  All of these questions are confidential and protected in your medical record” |

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|Have you ever been sexually active? “Yes” |

|Do you prefer women, men or both genders? “Men” |

|Are you aware of ever having a sexually transmitted infection? “No” |

|Have you or a partner ever had an abnormal pap smear? “No” |

|Have you or your partner received the Gardasil (HPV) vaccination? “No” |

|Are you currently sexually active? “No”  |

|When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? “Use protection” |

|How long have you been with your current partner? “Currently single” |

|Have any medical or surgical conditions changed your ability to have sexual activity? “No” |

|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? “No” |

±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?

“Not much”

Do your religious beliefs influence your current condition?

“No”

|+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? X years |

|-Cigarettes |0.2 packs a day |(age thru ) |

| | |“Started in high school” |

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

| | |01/01/07 |

|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? No|Has the patient ever tried to quit? |

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

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

|-Beer |6 cans of beer per day |(age thru ) |

| | |“Since High School” |

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

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

| If so, what? |

| |How much? |For how many years? |

| | |(age thru ) |

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

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

|The patient stated never being exposed to any occupational or environmental hazards or risks. |

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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: Once a day |Appendicitis | Enlarged lymph nodes |

|Other: Jaundice and Cellulitis | Abdominal Abscess |Other: |

| | Last colonoscopy? | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing- Use of Contacts |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: 6x/day |Other: |

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

| Dental problems | |Metabolic/Endocrine |

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

| Routine dentist visits 1x/year | | Hypothyroid /Hyperthyroid |

|Vision screening | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

| | |Other: |

|Pulmonary | | |

| Difficulty Breathing | |Central Nervous System |

| Cough - dry or productive |Women Only | CVA |

| Asthma | Infection of the female genitalia | Dizziness |

| Bronchitis | Monthly self breast exam | Severe Headaches |

| Emphysema | Frequency of pap/pelvic exam | Migraines |

| Pneumonia | Date of last gyn exam? | Seizures |

| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |

| Environmental allergies | menarche age? | Encephalitis |

|last CXR? | menopause age? | Meningitis |

|Other: |Date of last Mammogram &Result: |Other: |

| |Date of DEXA Bone Density & Result: | |

|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? Unknown | 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? |Arthritis | Chicken Pox |

|Other: Patient stated occasional angina |Other: |Other: |

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|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? |

|The patient did not have anything else he would like me to know about him. |

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

|General Survey: Patient was awake and |Height: 6’3 |Weight: 360 BMI: 45 |Pain: (include rating & location) |

|pleasant | | |7 on a 0-10 scale |

| |Pulse: 99 |Blood | |

| | |Pressure: 116/62 | |

| | |(include location) Right Arm | |

|Temperature: (route taken?) |Respirations: 17 | | |

|99.9- Oral | | | |

| |SpO2: 99% |Is the patient on Room Air or O2: |

|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 | |

|- Patient had cellulitis of the left lower extremity | |

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| Peripheral IV site Type: 18 gage Location: Lateral Right arm/ Basilic vein Date inserted: 09/05/13 |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? Vancomycin |

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

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

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

|Fluids infusing? no yes - what? |

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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 Whisper test heard: right ear- inches & left ear- inches |

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

|Dentition: |

|Comments: Patients sclera was white with a tint of yellow. |

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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 | |

| |D – Diminished | |

| |S – Stridor | |

| |Ab - Absent | |

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|Cardiovascular: No lifts, heaves, or thrills PMI felt at: 5th intercostal space 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) |

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

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

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

|Location of edema: LLE pitting non-pitting |

|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: Previous 24 hour output: mLs N/A |

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

|CVA punch without rebound tenderness |

|Last BM: (date 09 / 05 / 13 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

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

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

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

| Other – Describe: |

| |

| |

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

|Strength bilaterally equal at 5 RUE, 5 LUE, 5 RLE, & 5 in LLE |

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

|vertebral column without kyphosis or scoliosis |

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

| |

| |

| |

|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |

|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |

|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: Biceps: Brachioradial: Patellar: Achilles: 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 |

| |

|Sodium: 132- Low |

|Normal values: 135-145 |

|09/06/13 |

| |

|Patient was admitted 09/05/13. Lab results only for that day at this time. |

|Patient has been vomiting due to alcohol withdrawal. |

| |

|Calcium: 8.2- Low |

|Normal values: 8.8-10.4 |

|09/06/13 |

|Patient was admitted 09/05/13. Lab results only for that day at this time. |

|Because the patient drinks alcohol chronically his vitamin D metabolism is obstructed. This causes your body to not absorb the calcium you get from your diet. |

| |

|AST: 213- High |

|Normal values: 5-40 |

|09/06/13 |

|Patient was admitted 09/05/13. Lab results only for that day at this time. |

|The increased level of AST’s indicates liver damage. |

| |

|ALT: 76- High |

|Normal values: 7-56 |

|09/06/13 |

|Patient was admitted 09/05/13. Lab results only for that day at this time. |

|The increased level of ALT’s indicates liver damage. |

| |

|Alkaline Phosphate: 133- High |

|Normal values: 30-20 |

|09/06/13 |

|Patient was admitted 09/05/13. Lab results only for that day at this time. |

|Increased alkaline phosphate can indicate liver disease. |

| |

| |

| |

|Total Bilirubin: 7.5- High |

|Normal Values: 0.2-1.2 |

|09/06/13 |

|Patient was admitted 09/05/13. Lab results only for that day at this time. |

|Increased total bilirubin can indicate different types of liver problems. Patient was also very jaundice. |

| |

| |

| |

| |

| |

| |

| |

| |

|RBC: 3.62- Low |

|Normal Values: 4.32-5.72 |

|09/06/13 |

|Patient was admitted 09/05/13. Lab results only for that day at this time. |

|Demonstrates anemia due to bleeding. |

| |

|Hemoglobin: 11.4- Low |

|Normal Values: 13.5-17.5 |

|09/06/13 |

|Patient was admitted 09/05/13. Lab results only for that day at this time. |

|Demonstrates anemia due to bleeding. |

| |

|Hematocrit: 33.8-Low |

|Normal Values: 38.8-50.0 |

|09/06/13 |

|Patient was admitted 09/05/13. Lab results only for that day at this time. |

|Demonstrates anemia due to bleeding. |

| |

|Platelet count: 25- Low |

|Normal Values: 150-450 |

|09/06/13 |

|Patient was admitted 09/05/13. Lab results only for that day at this time. |

|A low platelet count can indicate an immune system problem. |

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|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and |

|frequency if applicable.) |

|Regular diet |

|Intake and output- Routine every 8 hours |

|Notify physician if patient has seizure activity, hallucinations, respiratory rate < 10, SBP less than 90 mmHg |

|Early and persistent ambulation and education |

|Pain assessment every 8 hours |

|Patient needs to be up as tolerated |

|Vitals every 4 hours |

|Withdrawal checks every 4 hours |

|Full code |

|CBC and CMP |

|Notify physician for pulse less than 60 or greater than 120, respiratory rate less than 12 or greater than 25, systolic BP less than 90 greater than 140, diastolic |

|less than 60 greater than 90. |

| |

| |

| |

| |

| |

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

|1.Acute pain related to irritation of the skin, impaired skin integrity, ischemic tissue. |

| |

| |

|2. Impaired skin integrity related to inflammatory response, secondary to cellulitis as evidence by patient stating tenderness to the left lower leg, redness, and |

|warm to touch. |

| |

| |

|3. Ineffective coping related to alcohol abuse |

| |

| |

|4. Knowledge deficient related to the prevention of symptoms and treatment of conditions related to inadequate information. |

| |

| |

± 15 CARE PLAN

Nursing Diagnosis: Impaired skin integrity related to inflammatory response, secondary to cellulitis as evidence by patient stating tenderness to the left lower leg, redness, and warm to touch.

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

| | |Provide References | |

|No signs of infection or worsening of infection. |Assess skin for drainage, warmth, and redness. |Indicates presence of infection. |Affected area was red and very warm to touch. |

| | | | |

| |Assess skin lesions for change. |Indicates progression or healing of skin disorder. |The affected area of the left lower extremity |

| | | |remained the same during my shift. |

| | | | |

| |Implement an individual treatment plan for site of |Treatment should be implemented according to patient |The treatment ordered for the patients affected area |

| |skin impairment. |needs and to prevent infection. |was to leave it open to room air. |

| | | | |

| |Remove or control impediments to wound healing. |Wound healing can be delayed if impediments are not |Patient repositioned himself throughout the day. |

| |Reposition every 2 hours, and assess for signs of |relieved. | |

| |skin breakdown. | | |

| | | | |

| |Teach patient care of skin wounds. |It is important for the patient to understand and |The nurse and doctor talked to the patient about |

| | |comply with care. |understanding and complying with his care. |

| | | | |

| |Patient should be placed in a private room with |To decrease the chance of infection. |Patient’s affected area did not have open wounds. He |

| |contact isolation. | |was placed in a private room without isolation |

| | | |procedures. |

| | | | |

± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)

Evaluate for signs of infection such as increased redness, drainage, fever, or foul odor.

Perform cleaning of wounds and dressing changes as ordered by the health care provider.

Perform hand hygiene and wear gloves while performing dressing changes.

Avoid scratching healed areas.

Keep unaffected skin clean and well hydrated.

Avoid exposure to the sun.

Wear loose fitting, soft clothing.

Teach actions to decrease risk of infection.

Teach signs and symptoms that should be reported to the health car provider.

Assess effectiveness of available support systems.

Assess home environment for need for assistive devices and safety.

Assess need for professional home health needs.

Assess abilities to obtain food, medications, and supplies.

Include vitamin C, iron, and zinc in the diet.

Assess appetite and weight loss.

Avoid foods that cause hypersensitivity reactions.

Teach foods to include and avoid in the diet.

Assess financial resources.

Encourage verbalization of feelings and fears.

Encourage positive reinforcement rather than rejection from the family.

Avoid things that are irritating or intensify itching such as excessive bathing.

Application of lotion to rehydrate the skin.

Recommend baths with cornstarch or oatmeal.

Proper application and use of prescribed medications.

Assess temperature and humidity.

Assess pain level and report increases in pain.

Assess effectiveness of pain medications.

Assess patient/family knowledge of pain medication and side effects.

± 15 CARE PLAN

Nursing Diagnosis: Ineffective coping related to alcohol abuse

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

| | |Provide References | |

|Reduction of ineffective and self-destructive coping |Identify two effective coping mechanisms. |Patients need to have ready choices on how to cope |Patient stated that his ways of coping are to isolate|

|through alcohol abuse and regular use of more | |with stress without their addictive substance. |himself from others and to listen to music. |

|effective coping styles. | | | |

| | | | |

| |Inventory those situations that challenge the |This prepares the patient for difficulties so |The patient stated that he would drink because that |

| |patient’s abilities to cope. |rehearsal and skill building can take place. |was his beverage of choice and because he could not |

| | | |work. |

| | | | |

| |Rehearse various coping strategies to prepare and |Rehearsal allows the patient to get familiar with the|The patient stated that he did need to quit drinking.|

| |select two for regular use. |skill and learn how to use it. |He stated he needed to find a hobby. |

| | | | |

| |Teach alternative, healthy coping mechanisms. |Revision of coping styles requires identification n |Patient agreed to try healthy coping mechanisms. |

| | |of the situations placing the patient at risk, | |

| | |typical problematic responses, and acknowledgment of | |

| | |a need to learn. | |

| | | | |

| |Asses for cirrhosis of the liver. |Years of substance abuse may result in cirrhosis. |Patient does have cirrhosis. |

| | | | |

| |Asses for depression and feelings of self-reproach |Alcohol is a depressant and contributes to deepening |Patient stated that he does have a history of |

| |and guilt for years of drinking and the effect on |existing depressions. |depression and bipolar disorder. |

| |others. | | |

| | | | |

| |Consider AA groups, psychiatric treatment, |These specialized interventions may be necessary to |Patient stated that since he was going through |

| |hospitalization, and 28-day alcohol treatment |treat the acute problem. |alcohol withdrawal in the hospital he will continue |

| |programs. | |to not drink once back in his home setting. |

|± DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

|Needs: |

|Stabilization of physiological condition. |

|Involvement in substance abuse treatment. |

|Awareness of the substance abuse problem and the necessary treatment. |

|Contact and linkage with the treatment venue associated with he substance abuse. |

|Teaching: |

|Patient will be able to demonstrate the need for attention to the physiological demands placed on him as a result of substance abuse. |

|Patient will initiate and continue involvement with substance abuse treatment framework. |

|Family members are able to list the signs of substance abuse evident in their relative and the appropriate interventions applicable to the situation. |

|The setting of the substance abuse treatment varies depending on the drug of abuse. Alcoholism can be treated via inpatient programs such as a detoxification unit, in a 28-day program, in a halfway house, through |

|self-help such as AA, or as an outpatient. |

| |

|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

Osborne, K.S., Wraa, C.E. &Watson, A.B. (2010). Medical –Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson.

Huether, S.E., & McCance, K.L. (2012). Understand Pathophysiology (5th ed.).

St. Louis, MO: Mosby.

Nursing, C (2013, August 28). Cellulitis. Retrieved from

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