UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Brittany Bolin |
|Patient Assessment Tool . |Assignment Date: 10/04/16 |
| ( 1 PATIENT INFORMATION |Agency: USF-CON |
|Patient Initials: S.H. |Age: 41 |Admission Date: 10/01/16 |
|Gender: Male |Marital Status: Single |Primary Medical Diagnosis with ICD-10 code: Occluded Brachial Artery |
| | |I74.2 |
|Primary Language: English | |
|Level of Education: High School Graduate |Other Medical Diagnoses: (new on this admission) |
| |Peripheral Artery Disease |
|Occupation (if retired, what from?): Pasco County Road and Bridge Worker | |
|Number/ages children/siblings: Daughter- 11, brother- 45, sister- 47 | |
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|Served/Veteran: No |Code Status: Full Code |
|Living Arrangements: Lives by self, one story house |Advanced Directives: No |
| |If no, do they want to fill them out? No |
| |Surgery Date: 10/01 Procedure: Embolectomy Thrombectomy|
| |Upper Extremity |
|Culture/ Ethnicity /Nationality: White/American | |
|Religion: Baptist |Type of Insurance: Blue Cross Blue Shield |
|( 1 CHIEF COMPLAINT: “Ongoing arm pain for the past 3 weeks radiating up arm to shoulder.” |
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|( 3 HISTORY OF PRESENT ILLNESS: |
|Patient is 41 year old male with a history of tobacco abuse who arrived in the ER on 10/01/16 complaining of arm pain. |
|Pain started 3 weeks ago located in the right wrist, and then radiated to forearm 2 weeks ago, pain is ongoing. |
|On 09/30/16 pain became severe and radiated to right upper arm, presenting with tingling sensation, parasthesia, and |
|coolness in the hand. Movement makes the pain worse, and elevation makes the pain better. Patient has taken Aleve and |
|Ibuprofen for the pain. Pain is currently a 9/10. In the ER they performed an Arterial Upper Extremity Ultrasound to |
|observe blood flow, ultrasound showed occlusive thrombus in distal brachial artery. Patient denies SOB or CP. Denies |
|fever, chills, nausea, vomiting, or trauma to the area. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
|Date |Operation or Illness |
|10/01/16 |Occluded Brachial Artery; Embolectomy Thrombectomy Right Upper Extremity; unresolved; arm elevation, Warfarin 5 mg PO x1 daily |
|10/02/16 |Occluded Brachial Artery; Embolectomy Thrombectomy Right Upper Extremity; unresolved; arm elevation, Warfarin 5 mg PO x1 daily |
|10/04/16 |Occluded Brachial Artery; Transesophageal Echocardiogram; unresolved; arm elevation, Warfarin 5 mg PO x1 daily |
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|( 2|Age (in years) |
|FAM| |
|ILY| |
|MED| |
|ICA| |
|L | |
|HIS| |
|TOR| |
|Y | |
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|( 1 immunization History |
| |Yes |No |
|Routine childhood vaccinations | | |
|Routine adult vaccinations for military or federal service | | |
|Adult Diphtheria (Date) U | | |
|Adult Tetanus (Date) | | |
|Influenza (flu) (Date) | | |
|Pneumococcal (pneumonia) (Date) | | |
|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 |NKA | |
|Food |NKA | |
|Environmental |NKA | |
|Other (latex, tape, ect.) |NKA | |
|( 5 PATHOPHYSIOLOGY: |
|Peripheral Artery Disease (PAD) is an atherosclerotic disease that affects the limbs. Atherosclerosis |
|is a thickening and hardening of the vessel wall, and is caused by plaque. When plaque forms on the vessel walls, the |
|vessels become occluded and this affects blood flow. If a thrombus forms, the vessels can become completely occluded. |
|Risk factors for PAD are smoking, hypertension, diabetes, increased levels of low-density lipoproteins (LDL), decreased |
|levels of high-density lipoproteins, and autoimmunity. PAD can be gradual or acute. PAD can be asymptomatic in early |
|stages, but can be identified early by conducting a history and physical examination. This can look for evidence of an |
|atherosclerotic disease, determining the ankle-brachial index, and measuring blood flow using the non invasive Doppler. |
|PAD is treated by lifestyle changes including cessation of smoking, diet, exercise, managing hypertension, ect. PAD can |
|also be treated by antiplatelet therapy. If PAD is symptomatic or an occlusion is evident, treatment should include |
|vasodialators, anti-platelet, anti-thrombotic drug therapy, and possibly surgical measures. If PAD is managed early, |
|symptoms can be avoided. If PAD is not managed early, this can lead to tissue death, decay, and sometimes amputation. |
|(Huether & McCance, 2012) |
( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]
|Name Acetaminophen (Tylenol) |Concentration (mg/ml) 650 mg |Dosage Amount (mg) 2 tabs |
|Route PO |Frequency q4hr |
|Pharmaceutical class: Antipyretic; Nonopoid Analgesic | Home Hospital or X Both |
|Indication For Temp. > 100.4 degrees F or for mild pain if NSAID is not ordered |
|Side effects/Nursing considerations: Hepatotoxicity, do not take with alcohol. Administer with full glass of water. Assess pain prior to and following medication. |
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|Name Acetaminophen-Oxycodone (Percocet) |Concentration 10 mg |Dosage Amount 1 tab |
|Route PO |Frequency q4hr |
|Pharmaceutical class: Opoid Analgesic |Home Hospital or XBoth |
|Indication: PRN pain |
|Side effects/Nursing considerations: Monitor respiratory rate. Caution with MAO inhibitor. Do not take with alcohol, antihistamines, and other sedatives/hypnotics.|
|Administer with food/ milk to minimize GI irritation. |
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|Name Ducosate (Colace) |Concentration 100 mg |Dosage Amount 1 cap. |
|Route PO |Frequency: Twice Daily |
|Pharmaceutical class: Stool softener |Home X Hospital or Both |
|Indication PRN Constipation |
|Side effects/Nursing considerations: Assess bowel sounds, abdominal distention, amount/color of stool produced. Administer with full glass of water or juice. |
|Name Heparin |Concentration 2,500 units |Dosage Amount 0.5 ml |
|Route: IV Inj. |Frequency: PRN |
|Pharmaceutical class: Anticoagulant |Home X Hospital or Both |
|Indication: PRN aPTT ≤ 40 sec.; bolus dose for use during titration of Heparin drip |
|Side effects/Nursing considerations: Assess for signs of bleeding and hemmorrhage, Heparin Induced Thrombocytopenia. Monitor aPTT levels q4hr. Do not take with |
|NSAIDs, aspirin, or thrombolytics. |
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|Name Hydromorphone (Dilauded) |Concentration 0.5 mg |Dosage Amount 0.5 ml |
|Route IV Inj. |Frequency q3hr |
|Pharmaceutical class: Opioid Agonist |Home X Hospital or Both |
|Indication: PRN Pain, breakthrough |
|Side effects/Nursing considerations: Monitor respiratory rate and BB. Avoid MAO inhibitors, alcohol, antidepressants, sedatives/hypnotics |
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|Name Nitroglycerin |Concentration 0.4 mg |Dosage Amount 1 tab. |
|Route SL |Frequency q 5 minutes PRN CP |
|Pharmaceutical class: Nitrates |Home X Hospital or Both |
|Indication: PRN CP; hold systolic < 100 mmHG |
|Side effects/Nursing considerations: Monitor BP, HR. Caution with antihypertensives, alcohol, BBs, Calcium channel blockers, and phenothiazines, Assess pain |
|location, duration, and intensity. Hold under tongue until dissolved. Administer 3 tablets every 5 minutes for 15 minutes until pain goes away. If pain does not go|
|away after third tab, call provider. |
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|Name Heparin drip additive +.45% NaCl |Concentration 25,000 units |Dosage Amount 250 ml |
|Route IV drip |Frequency13 ml/hr infuse over 19.2 hr |
|Pharmaceutical class: Anticoagulant |Home X Hospital or Both |
|Indication: PRN aPTT ≤ 40 sec.; bolus dose for use during titration of Heparin drip |
|Side effects/Nursing considerations: Assess for signs of bleeding and hemmorrhage, Heparin Induced Thrombocytopenia. Monitor aPTT levels q4hr. Do not take with |
|NSAIDs, aspirin, or thrombolytics. |
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|Name Lactated Ringers |Concentration 1,000 ml |Dosage Amount 1,000 ml |
|Route IV Inj. |Frequency20 ml/hr over 50 hrs. |
|Pharmaceutical class: Mineral and electrolyte |Home X Hospital or Both |
|Indication: Replace fluid and electrolytes |
|Side effects/Nursing considerations: Monitor for HF, pulmonary edema, hyponatremia, fluid balance, and IV patency. |
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|Name Sodium Chloride 0.9% |Concentration 1,000 ml |Dosage Amount 1,000 ml |
|Route IV Inj. |Frequency 20 ml/hr over 50 hrs. |
|Pharmaceutical class: Mineral and electrolyte replacement/supplement |Home X Hospital or Both |
|Indication: Reconstitute or dilute other medications |
|Side effects/Nursing considerations: Monitor for HF, pulmonary edema, hyponatremia, fluid balance, and IV patency. |
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|Name Warfarin |Concentration 5 mg |Dosage Amount 1 tab |
|Route PO |Frequency 1xdaily |
|Pharmaceutical class: Anticoagulant |Home Hospital or X Both |
|Indication: Treatment of venous thrombosis, prevention of thrombus formation. |
|Side effects/Nursing considerations: Assess for bleeding, avoid alcohol, assess for severe kidney and liver disease. Caution with Aspirin and other anticoagulants.|
|Monitor PT and INR. PT ranges from 1.3-1.5 and INR 2.5-3.5. |
|( 5 NUTRITION: |
|Diet ordered in hospital? Regular | |
|Diet pt follows at home? Regular |The patient is consuming the correct amount vegetables, not enough whole grains, |
| |fruits, and dairy, and too much protein foods. The patient is also consuming too |
| |much saturated fats and sodium. Due to the patient’s sensitive condition, I |
| |recommend he needs to change his diet drastically to help reduce the risk factors|
| |of another arterial occlusion. The patient needs to watch his daily intake of |
| |saturated fats and sodium because this can contribute to the formation of plaque,|
| |and eventually lead to another occluded artery. I would recommend the patient |
| |follow the DASH diet to reduce overall sodium and saturated fat intake, and to |
| |limit consumption of alcohol. I would recommend the patient eating more |
| |unsaturated fats such as fish, nuts, and seeds, and less saturated fats. I would |
| |also recommend reducing sodium intake to no more that 1.5 to 2 grams/day. The |
| |patient also needs to consume the daily recommendation of fruits which is 2 |
| |cups/day. He can do this by packing a cup of grapes, berries, or apple slices in |
| |his lunch, and starting the day off with fruit and whole grain toast for |
| |breakfast. He is consuming too much caffeine daily, so I would recommend the |
| |patient to limit himself to two cups of coffee a day to start, and eventually |
| |only drink one cup/day. |
|24 HR average home diet: Regular | |
|Breakfast: Pot of black coffee | |
|Lunch: White bread, turkey, cheese, pickle slice, 8 oz. water | |
|Dinner: 9 oz. steak, salad with ranch, one potato with butter and sour cream | |
|Snacks: Buttered popcorm | |
|Liquids (include alcohol): Coffee, water, alcohol, soda | |
|[pic] |[pic] |
|(1 COPING ASSESSMENT/SUPPORT SYSTEM: |
|Who helps you when you are ill? Female friend. |
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|How do you generally cope with stress or what do you do when you are upset? Drink alcohol, up to 8 drinks. |
|No exercise, reading, or other outlets. |
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|Recent difficulties? |
|Stress from current condition/hospitalization and anxiety from work and relationships. |
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|+2 DOMESTIC VIOLENCE ASSESSMENT |
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|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |
|am going to ask some questions that help me to make sure that you are safe.” |
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|Have you ever felt unsafe in a close relationship? _____No__________________________________________________ |
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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? ______________________ |
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|Are you currently in a safe relationship? Yes |
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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 |
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|My patient is currently in the Generativity vs. Stagnation stage of development. Generativity vs. Stagnation stage |
|is when we establish our careers, settle down within a relationship, begin our own families and develop a sense of being a |
|part of the bigger picture. We give back to society through raising our children, being productive at work, and |
|becoming involved in community activities and organizations. By failing to achieve these objectives, we become stagnant |
|and feel unproductive. Success in this stage will lead to the virtue of care. Mcleod (2013) |
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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |
|Due to the fact my patient is in the Generativity vs. Stagnation stage, his condition has had a huge impact on his life. His condition |
|has caused him to miss work, and progressively led to hospitalization. Because he is not able to work or actively participate in the |
|generativity part of this stage, he has developed fear and anxiety. Mcleod (2013) The patient stated, “I do not like being in the hospital |
|because it has caused me to miss work, and I need to work. |
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|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” |
|No idea, doctors don’t even know. |
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|What does your illness mean to you? |
|My illness causes stress because I have had to miss work for almost a week now. |
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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?__Yes, partner has HPV_________________________________ Have you or your partner received the Gardasil (HPV) |
|vaccination? ___No______________________________________ |
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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? ____________No_____________ |
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|How long have you been with your current partner?_Two 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 |
±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
_____I believe in God but I don’t go to church. ________________________________________________________________
______________________________________________________________________________________________________
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? X Yes No |
| If so, what? |How much?(specify daily amount) |For how many years? 1years |
|Cigarettes |8-10/day |(age 40 thru 41 ) |
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|Pack Years: 0.5 pack years | |If applicable, when did the patient quit? |
| | |Currently |
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|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? Yes, currently |
|No |
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|2. Does the patient drink alcohol or has he/she ever drank alcohol? X Yes No |
| What? |How much? (give specific volume) |For how many years? |
|Beer/liquor |4-5 12 oz. drinks/day |(age 16 thru 41 ) |
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| If applicable, when did the patient quit? | | |
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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? X Yes No |
| If so, what? Marijuana |
| |How much? |For how many years? |
| |7 oz./day |(age 15 thru 21 ) |
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| Is the patient currently using these drugs? Yes X No|If not, when did he/she quit? | |
| |Age 21 | |
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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks? |
|Construction hazard at work. Wears protection including hard hat, closed toed boot, protective glasses, uniform. Does not |
|wear sunscreen. |
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( 10 Review of Systems
|General Constitution |Gastrointestinal |Immunologic |
| Recent weight loss | 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: | Diverticulitis | Life threatening allergic reaction |
|Bathing routine: Daily |Appendicitis | Enlarged lymph nodes |
|Other: | Abdominal Abscess |Other: |
| | Last colonoscopy? Never | |
|HEENT |Other: |Hematologic/Oncologic |
| Difficulty seeing |Genitourinary | Anemia |
| Cataracts or Glaucoma | nocturia | Bleeds easily |
| Difficulty hearing | dysuria | Bruises easily |
| Ear infections | hematuria | Cancer |
| Sinus pain or infections | polyuria | Blood Transfusions |
|Nose bleeds | kidney stones |Blood type if known: |
| Post-nasal drip |Normal frequency of urination: 2 x/day |Other: |
| Oral/pharyngeal infection | Bladder or kidney infections | |
| Dental problems | |Metabolic/Endocrine |
| Routine brushing of teeth 1 x/day | | Diabetes Type: |
| Routine dentist visits x/year | | Hypothyroid /Hyperthyroid |
|Vision screening May 2016 | | 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? Never | Schizophrenia |
| Chest pain / Angina | Date of last prostate exam? Never | Anxiety |
|Myocardial Infarction | BPH | Bipolar |
| CAD/PVD |Urinary Retention |Other: |
|CHF |Musculoskeletal | |
|Murmur | Injuries or Fractures |Childhood Diseases |
| Thrombus | Weakness | Measles |
|Rheumatic Fever | Pain Currently 9/10 | Mumps |
| Myocarditis | Gout | Polio |
| Arrhythmias | Osteomyelitis | Scarlet Fever |
| Last EKG screening, when? Currently |Arthritis | Chicken Pox |
|Other: |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? |
|No |
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|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |
|General Survey: |Height: 190.5 cm |Weight: 88.2 kg BMI: 24 |Pain: (include rating & location) |
| | | |9/10 Right hand radiating up to shoulder |
| |Pulse: 51 |Blood 127/71 | |
| | |Pressure: Brachial | |
| | |(include location) | |
|Temperature: 97.5 F |Respirations: 16 | | |
|Oral Route | | | |
| |SpO2 97% |Is the patient on Room Air or O2: Room air |
|Overall Appearance: |
| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |
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|Overall Behavior: |
| awake, calm, relaxed, interacts well with others, judgment intact |
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|Speech: |
| clear, crisp diction |
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|Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat |
| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |
|Other: |
|Integumentary | |
| Skin is warm, dry, and intact | |
| Skin turgor elastic | |
| No rashes, lesions, or deformities | |
| Nails without clubbing | |
| Capillary refill < 3 seconds | |
| Hair evenly distributed, clean, without vermin | |
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| Peripheral IV site Type: Peripheral Location: L forearm Date inserted: 10/01/16 |
| no redness, edema, or discharge |
| Fluids infusing? no yes - what? NaCl 0.9%, lactated ringers, Heparin drip |
| 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 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |
| Ears symmetric without lesions or discharge Whisper test heard: right ear- 2 inches & left ear- 2 inches |
| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |
|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 | |
| |D – Diminished |Clear bilaterally to bases. No adventitious sounds. |
| |S – Stridor | |
| |Ab - Absent | |
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|Cardiovascular: No lifts, heaves, or thrills PMI felt at: Apex |
|Heart sounds: S1 S2 X Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |
|Rhythm |
|[pic] |
| Calf pain bilaterally negative Pulses bilaterally equal +3 |
|Apical pulse: +3 Carotid: +3 Brachial: +3 Radial:R +3; L+1 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 |
|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: Yellow Previous 24 hour output: X N/A |
|Foley Catheter Urinal or Bedpan Bathroom Privileges X without assistance or with assistance |
|CVA punch without rebound tenderness |
|Last BM: (date 10 / 01 / 16 ) X Formed Semi-formed Unformed Soft X Hard Liquid Watery |
|Color: Light brown X Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |
|Hemoccult positive / negative |
|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___ RUE ___3___ LUE ___5___ RLE & __5____ in LLE |
|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: +2 |
|Triceps: +2 Biceps: +2 Brachioradial: +2 Patellar: +2 Achilles: +2 Ankle clonus: negative Babinski: |
|negative |
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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS |
|Lab |
|Dates |
|Trend |
|Analysis |
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|INR |
|1.2 |
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|1.2 |
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|1.3 |
|Normal: 2-3 |
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|10/01/16 |
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|10/02/16 |
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|10/03/16 |
|The patient has maintained a steady INR for the past three days. However, for therapeutic effects, his INR should be around 2.5-3.5 while taking Warfarin to prevent |
|additional thrombus. |
|Monitoring the patients INR is routine when taking Warfarin. The patient should have increasing INR while taking Warfain to achieve therapeutic effects. |
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|aPTT |
|35.5/45.5 |
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|88.9/178.7/35.5 |
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|47.7/42.8 |
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|Normal: 1.5-2.5x mean normal or |
|45-75 seconds |
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|10/01/16 |
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|10/02/16 |
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|10/03/16 |
|The patients levels were low upon admission, and elevated when Heparin was administered. The patient’s aPTT levels drastically increased to a high level, and when |
|the Heparin amount was adjusted, they returned to normal. |
|aPTT is monitored in patients who are taking Heparin. The patients levels were low upon admission, and elevated when Heparin was administered. This indicated the |
|Heparin was working. |
| |
|PT |
|13.3/13.4 |
| |
|13.9 |
| |
|14.2 |
|Normal: 10-13.5 seconds |
| |
|10/01/16 |
| |
|10/02/16 |
| |
|10/03/16 |
|The patients PT was within normal range, and steadily increased when Warfarin was administered. |
|PT is monitored for patients on Warfarin. A prolonged PT time indicated blood is taking longer to clot, and is therapeutic for those with a blood clot. |
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|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: |
|Regular diet |
|Braden assessment for falls |
|12 lead EKG stat for CP |
|SCD’s |
|aPTT 6 hours after Heparin infusion |
|TEE |
|Up ad lib |
|Echo |
| |
| |
| |
|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
|Fear R/T unknown etiology of condition AEB increased alertness, attack behaviors, and verbalizing fear. |
| |
| |
|Knowledge deficit R/T risks of smoking AEB patient verbalizing they smoke daily. |
| |
| |
|Risk for Impaired Skin Integrity related to ischemic tissues of arms and hands. |
| |
± 15 CARE PLAN
Nursing Diagnosis: Fear R/T unknown etiology of condition AEB increased alertness, attack behaviors, and verbalizing fear.
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |
| | |Provide References | |
|Client will identify and verbalize known fears within|1. Assess source of fear with the patient. |1. The capacity to experience is adaptive, enabling |1. Goal was met |
|the next hour. |2. Assess for a history of anxiety. |rapid and energetic response to imminent threat or | |
| |3. Distinguish between real and imagined threats to |danger. | |
| |well-being. |2. Individuals with anxiety were found to have a | |
| |4. Encourage the client to explore underlying |higher level of fear of pain. | |
| |feelings that may contribute to the fear. |3. Fear activation occurs before conscious | |
| |(Ackley & Ladwig, 2014) |cognitive analysis of the stimulus can occur. | |
| | |4. Exploring underlying feelings may help the client | |
| | |to confront unresolved conflicts and develop coping | |
| | |abilities. (Ackley & Ladwig, 2014) | |
|Client will identify, verbalize, and demonstrate |1. Sit with client while they are demonstrating |1. Healing touch may reduce stress, anxiety, and |1. Goal was met |
|coping behaviors that reduce own fear before lunch |coping behaviors and offer support and comfort. |pain, and provide a greater sense of well being. | |
|time. |2. Explore past coping skills used by patient and |2. College students who expressed fear were assisted | |
| |other new outlets. |in fear reduction through strong cohesive | |
| |3. Educate patient about breathing and meditation and|relationships with others in similar situations. | |
| |demonstrate various breathing/meditation techniques. |3. Therapeutic touch, quiet time, or relaxing | |
| |4. Provide a quiet room environment by turning down |music/dialogue when feelings of calmness or | |
| |the lights, and putting on music. (Ackley & Ladwig, |relaxation are desired. | |
| |2014) |4. Nurses may offer therapeutic touch, quiet time, or| |
| | |relaxing music/dialogue when feelings of calmness or | |
| | |relaxation are desired. (Ackley & Ladwig, 2014) | |
| | | | |
|±2 DISCHARGE PLANNING: |
|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: Knowledge deficit R/T risks of smoking AEB patient verbalizing they smoke daily.
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |
| | |Provide References | |
|1. Patient will describe the rationale for cessation |1. Offer anticipatory educational interventions that |1. Patients who received anticipatory educational |1. Goal was met |
|of smoking. |support self-regulation and self-management. |interventions focused on self-care knowledge and the | |
| |2. Monitor how patients process information over |use of coping methods including stress-reduction and | |
| |time. |breathing exercises experienced increased | |
| |3. Engage client as a partner in the educational |self-efficacy and decreased anxiety. | |
| |decision process. (Ackley & Ladwig, 2014) |2. Patients are unique in how they process | |
| | |information. Some will be more uncertain and may need| |
| | |more educational intervention over time. | |
| | |3. A nursing approach that is collaborative and that | |
| | |uses encouragement and support to increase | |
| | |self-efficacy resulted in client satisfaction, | |
| | |empowerment, and confidence. (Ackley & Ladwig, 2014) | |
|2. Patient will identify resources that can be used |1. Help the patient locate appropriate follow-up |1. Advocating for patients participation using a |1. Goal was met |
|for more information or support after discharge. |resources for continuing information and support. |community-based case management program has | |
| |2. Use computer and web-based methods as appropriate.|demonstrated improved clinical and financial outcomes| |
| | |for clients with complex chronic conditions. | |
| |3. Use outreach and community educational |2. Computers and technology are proving effective | |
| |intervention as appropriate. (Ackley & Ladwig, 2014) |educational tools. | |
| | |3. Advocating for patients participation using a | |
| | |community-based case management program has | |
| | |demonstrated improved clinical and financial outcomes| |
| | |for clients with complex chronic conditions. (Ackley | |
| | |& Ladwig, 2014) | |
|± DISCHARGE PLANNING: |
| |
|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 |
Reference
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care. Maryland Heights, MO: Elsevier.
USDHHS. Retreived July 26, 2016, from
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St.Louis,MO:Mosby/Elsevier.
McLeod, S. (n.d.). Erik Erikson. Retrieved July 31, 2016, from
Erikson.htm
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