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_______________________________________________________________________________________________

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|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? 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. |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|+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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