UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Allison Gosney |
|MSI & MSII Patient Assessment Tool . |Assignment Date: 3/24/2015 |
| ( 1 PATIENT INFORMATION |Agency: SJH |
|Patient Initials: H.A. |Age: 54 |Admission Date: 3/21/2015 |
|Gender: Female |Marital Status: Single |Primary Medical Diagnosis: Syncope secondary to hypotension. ICD 10: |
| | |G90.01 |
|Primary Language: English | |
|Level of Education: 10th grade. |Other Medical Diagnoses: (new on this admission): |
| |DVT in left leg. |
|Occupation (if retired, what from?): Unemployed | |
|Number/ages children/siblings: Three children. Has one son who is 35 years old. Two | |
|daughters that are 33 and 29. | |
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|Served/Veteran: |Code Status: Full |
|If yes: Ever deployed? No | |
|Living Arrangements: The patient lives at home with her oldest daughter who takes care of |Advanced Directives: |
|her when she is sick. There are no stairs in the home. |If no, do they want to fill them out? No. |
| |Surgery Date: None Procedure: |
|Culture/ Ethnicity /Nationality: African-American | |
|Religion: Baptist |Type of Insurance: Medicare |
|( 1 CHIEF COMPLAINT: “I had a stroke recently and while I was at home on my front porch I got dizzy and |
|almost fainted.” |
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|( 3 HISTORY OF PRESENT ILLNESS: |
|This patient is a 54 year old African-American female who was admitted to the emergency department three days ago |
|for syncope secondary to hypotension. The patient was standing on her front porch when she began to feel dizzy and light |
|headed, she did not lose consciousness. Upon arrival, the patient’s blood pressure was 80 over 50 and was vomiting. The |
|patient was started on fluids and was brought up to the floor for observation. The patient was recently hospitalized in |
|February for a right cerebrovascular accident due to uncontrolled hypertension. The patients antihypertensive medication |
|doses have been adjusted; Norvasc to five milligrams and Lisinopril to twenty milligrams. There are also plans to add a |
|beta blocker to the patient’s home medications. A chest x-ray was done and showed no acute cardio-pulmonary processes. |
|A CT of the head without contrast was also done and showed generalized atrophy with areas of chronic ischemic |
|demyelination from the previous stroke. An ultra-sound of the left lower extremity was also done and showed a DVT in |
|the left popliteal vein demonstrating normal patency. Neurology and cardiology were both consulted. The patient will |
|need an electroencephalogram (EEG). The patient will also be started on a three month treatment of anticoagulation of |
|warfarin or Xarelto but is currently receiving Plavix and Lovenox. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of disease
|Date |Operation or Illness |
|1974 |Appendix was removed. |
|2009 |Elbow surgery. |
|2012 |Diagnosed with asthma. Managed with albuterol. |
|February 2015 |Cerebrovascular accident. Manages hypertension with Norvasc and Lisinopril. |
|February 2015 |Diagnosed with diabetes. Managed with insulin aspart. |
|February 2015 |Hyperlipidemia managed with Lipitor. |
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|( 2 FAMILY MEDICAL HISTORY |
|( 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) Is within 10 years? 2014 | | |
|Influenza (flu) (Date) Is within 1 years? 2015 | | |
|Pneumococcal (pneumonia) (Date) Is within 5 years? | | |
|Have you had any other vaccines given for international travel or occupational purposes? Please List | | |
If yes: give date, can state “U” for the patient not knowing date received
|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |
|REACTIONS |Causative Agent | |
|Medications |None | |
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|Other (food, tape, latex, dye, |Pollen |Runny nose. |
|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) Orthostatic (Postural) Hypotension |
|Mechanics of Disease: According to the text Understanding Pathophysiology orthostatic hypotension is defined as a |
|decrease in systolic blood pressure for a minimum of 20 mm Hg within three minutes of ambulating to a standing |
|position (Huether & McCance, 2012). In a normal situation when a person stands, the gravitation on the circulation are |
|counteracted by reflex arteriolar and venous constriction as well as an increase in heart rate. Valve closure in the venous |
|system, contraction of leg muscles, and a decline in intrathoracic pressure also aid in compensation. Upon moving |
|into an upright position baroreceptors respond to shifts in volume caused by postural changes. The baroreceptors then |
|increase the heart rate and constrict the systemic arterioles, resulting in a maintained arterial blood pressure. In people |
|with orthostatic hypotension these mechanisms are defective or inadequate causing the blood to pool upon position |
|change and arterial pressure cannot be maintained. Orthostatic hypotension can be idiopathic and may be acute or |
|chronic. Acute orthostatic hypotension is caused when the regulatory mechanisms are inert due to altered body chemistry, |
|drug action, prolonged immobility, starvation, physical exhaustion, conditions of volume deficits, and any condition that |
|results in venous pooling. Chronic orthostatic hypotension may be secondary to a specific disease or can be idiopathic. |
|Risk Factors: The risk of idiopathic orthostatic hypotension is greater in men than in women who are between the ages of 40 and 70 (Huether & McCance, 2012). Risk |
|factors also include patients who are on certain medications such as, antihypertensives and antidepressives. Patients with adrenal insufficiency, metabolic |
|disorders, or diseases of the central or peripheral nervous system are at risk for chronic orthostatic hypotension. Patients with any of the conditions mentioned |
|in the above section may be at risk for acute orthostatic hypotension. |
|How To Diagnose: Diagnosis of orthostatic hypotension begins with evaluating and identifying the cause or underlying disease process. Orthostatic vital signs can |
|be obtained and used to diagnose a patient if there is at least a 20 mm Hg drop in the systolic pressure and 10 mm Hg in the diastolic within three minutes of |
|moving to a standing position (Huether & McCance, 2012). Orthostatic hypotension can cause dizziness, blurriness, loss of vision, and syncope. These signs and |
|symptoms can also be used as a part of diagnosing. |
|How To Treat: No curative treatment is available for idiopathic orthostatic hypotension however; it can be managed with a combination of medication and nondrug |
|therapies (Huether & McCance, 2012). This may include an increase in fluid and salt intake, wearing thigh-high stockings, and consuming mineralocorticoids and |
|vasoconstrictors. Acute and secondary forms resolve when the underlying problem is treated. |
|Prognosis: There is a good prognosis for acute and secondary forms of orthostatic hypotension and can often times be resolved by correcting the underlying issue |
|(Huether & McCance, 2012). Idiopathic orthostatic hypotension has a good prognosis when managed adequately through medication and other therapies. |
|Genetic: Specific diseases may be genetically inherited and by having these diseases one may develop orthostatic hypotension. |
( 5 Medications: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN medication . Give trade and generic name.]
|Name: amlodipine (Norvasc) |Concentration |Dosage Amount: 5 mg= 1 tab |
|Route: PO |Frequency: 1xDaily |
|Pharmaceutical class: Calcium channel blockers |Home Hospital or Both: Taken at home and in the hospital. |
|Indication: Management of hypertension. |
|Adverse/ Side effects: Adverse and side effects include dizziness, fatigue, peripheral edema, angina, bradycardia, hypotension, palpitations, gingival hyperplasia,|
|and nausea. |
|Nursing considerations/ Patient Teaching: This medication should be used cautiously in patients with severe hepatic impairment, aortic stenosis, and a history of |
|heart failure and is contraindicated with a systolic blood pressure less than 90 mm Hg. Additive hypotension may occur when used concurrently with fentanyl, other|
|antihypertensives, nitrates and ingestion of alcohol. Monitor BP and pulse before therapy, during dose titration, and periodically during therapy. Monitor ECG |
|periodically during prolonged therapy. Monitor intake and output ratios and daily weight. Advise patient to take medication as directed even if feeling well. |
|Instruct patient to contact health care professional if heart rate is less than 50 bpm. Caution patient to change positions slowly to minimize orthostatic |
|hypotension. |
|Name: atorvastatin (Lipitor) |Concentration |Dosage Amount: 40mg= 1 tab |
|Route: PO |Frequency: 1xDaily hs |
|Pharmaceutical class: hmg coa reductase inhibitors |Home Hospital or Both: Taken at home and the hospital. |
|Indication: Management of primary hypercholesterolemia and mixed dyslipidemia. |
|Adverse/ Side effects: Adverse effects of this medication include rhabdomyolysis and angioneurotic edema. Side effects of this medication include abdominal cramps,|
|constipation, diarrhea, flatus, heartburn, and rashes. |
|Nursing considerations/ Patient Teaching: This medication is contraindicated in patients with hypersensitivity and active liver disease. This medication should be |
|used cautiously in patients with a history of liver disease, alcoholism, renal impairment, and concurrent use of gemfibrozil and azole antifungals. Monitor liver |
|function tests prior to initiation of therapy and as clinically indicated. If patient develops muscle tenderness during therapy, CPK levels should be monitored. If|
|CPK levels are greater than 10 times the upper limit of normal or myopathy occurs, therapy should be discontinue. Monitor for signs and symptoms of immune-mediated|
|necrotizing myopathy (proximal muscle weakness and increased serum creatinine kinase), persisting despite discontinuation of statin therapy. Instruct patient to |
|notify health care professional if unexplained muscle pain, tenderness, or weakness occurs, especially if accompanied by fever or malaise. |
|Name: clopidogrel (Plavix) |Concentration |Dosage Amount: 75mg= 1 tab |
|Route: PO |Frequency: 1xDaily |
|Pharmaceutical class: platelet aggregation inhibitors |Home Hospital or Both: Taken at the hospital. |
|Indication: used to help treat DVT |
|Adverse/ Side effects: Adverse effects of this medication include GI bleeding, drug rash with eosinophilia and systemic symptoms, bleeding, neutropenia, and |
|thrombotic thrombocytopenic purpura. Side effects include depression, dizziness, chest pain, edema, and hypercholesterolemia. |
|Nursing considerations/ Patient Teaching: This medication is contraindicated in patients with pathologic bleeding and concurrent use of omeprazole or esomeprazole.|
|Use cautiously in patients at risk for bleeding or with a history of GI bleeding. Monitor patient for signs of thrombotic thrombocytic purpura. Monitor bleeding |
|time during therapy. Prolonged bleeding time, which is time-and dose-dependent, is expected. Monitor CBC with differential and platelet count periodically during |
|therapy. Neutropenia and thrombocytopenia may rarely occur. Advise patient to notify health care professional promptly if fever, chills, sore throat, rash, or |
|unusual bleeding or bruising occurs. Instruct patient to notify health care professional of all prescriptions, OTC, vitamins, or herbal products being taken and or|
|before taking them. |
|Name: enoxaparin (Lovenox) |Concentration |Dosage Amount: 90mg= o.9ml |
|Route: subcu inj |Frequency: q12 |
|Pharmaceutical class: anticoagulants |Home Hospital or Both: Taken at the hospital. |
|Indication: DVT prophylaxis |
|Adverse/ Side effects: Common side effects are bleeding, anemia, and headaches. |
|Nursing considerations/ Patient Teaching: Contraindicated in major bleeding. Use cautiously in severe hepatic or renal disease, retinopathy, and uncontrolled |
|hypertension. Exercise extreme caution in severe uncontrolled hypertension, bacterial endocarditis, bleeding disorders, history of thrombocytopenia related to |
|heparin. Risk of bleeding may increase by concurrent use of drugs that affect platelet function and coagulation. Assess for signs of bleeding and hemorrhage |
|(bleeding gums, nose bleed, unusual bruising, black tarry stools). Notify healthcare provider if these occur. Observe injection site for hematomas, ecchymosis, or |
|inflammation. Alternate injection sites daily between the left and right anterolateral and left and right posterolateral abdominal wall. Do not aspirate or |
|massage. Instruct patient not to take aspirin, naproxen, or ibuprofen without consulting health care professional. |
|Name: folic acid (folate) |Concentration |Dosage Amount: 1mg= 1 tab |
|Route: PO |Frequency: 1xDaily |
|Pharmaceutical class: water soluble vitamins |Home Hospital or Both: Taken at the hospital. |
|Indication: Prevention and treatment of megaloblastic and macrocytic anemias. |
|Adverse/ Side effects: Side effects include rash, irritability, difficulty sleeping, malaise, confusion, and fever. |
|Nursing considerations/ Patient Teaching: This medication is contraindicated in uncorrected pernicious, aplastic, or normocytic anemias. The use of pyrimethamine, |
|methotrexate, trimethoprim, and triamterene prevent the activation of folic acid. Assess patient for signs of megaloblastic anemia (fatigue, weakness, dyspnea) |
|before and periodically throughout therapy. Explain that folic acid may make urine more intensely yellow. Instruct patient to notify health care professional if |
|rash occurs, which may indicate hypersensitivity. |
|Name: insulin aspart (NovoLOG) |Concentration |Dosage Amount: sliding scale BG-100/15 |
|Route: subcu inj |Frequency: 3xDaily ac before meals |
|Pharmaceutical class: pancreatics |Home Hospital or Both: Taken at the hospital. |
|Indication: Control of hyperglycemia in type 2 DM. |
|Adverse/ Side effects: Adverse effects include hypoglycemia and anaphylaxis. Side effects include lipodystrophy, pruritis, and erythema. |
|Nursing considerations/ Patient Teaching: This medication is contraindicated in hypoglycemia. Use cautiously in stress and infection, and renal/ hepatic |
|impairment. Corticosteroids and estrogens may increase insulin requirements. Assess for symptoms of hypoglycemia (anxiety, restlessness, tingling in hands and |
|feet, chills, cold sweats, confusion, cool pale skin, difficulty in concentration, headache, nausea, tachycardia, and tremor. Mild hypoglycemia may be treated by |
|ingestion of oral glucose. Severe hypoglycemia is a life-threatening emergency; treatment consists of IV glucose, glucagon, or epinephrine. Check type, dose, and |
|expiration date with another nurse. Instruct patient on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur. |
|Name: insulin aspart (NovoLOG) |Concentration |Dosage Amount: Sliding scale BG-180/15 |
|Route: subcu inj |Frequency: 1xdaily hs bedtime |
|Pharmaceutical class: pancreatics |Home Hospital or Both: Taken at the hospital. |
|Indication: Control of hyperglycemia in type 2 DM. |
|Adverse/ Side effects: Adverse effects include hypoglycemia and anaphylaxis. Side effects include lipodystrophy, pruritis, and erythema. |
|Nursing considerations/ Patient Teaching: This medication is contraindicated in hypoglycemia. Use cautiously in stress and infection, and renal/ hepatic |
|impairment. Corticosteroids and estrogens may increase insulin requirements. Assess for symptoms of hypoglycemia (anxiety, restlessness, tingling in hands and |
|feet, chills, cold sweats, confusion, cool pale skin, difficulty in concentration, headache, nausea, tachycardia, and tremor. Mild hypoglycemia may be treated by |
|ingestion of oral glucose. Severe hypoglycemia is a life-threatening emergency; treatment consists of IV glucose, glucagon, or epinephrine. Check type, dose, and |
|expiration date with another nurse. Instruct patient on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur. |
|Name: lisinopril (Prinvil) |Concentration |Dosage Amount: 20mg= 1 tab |
|Route: PO |Frequency: 1xDaily |
|Pharmaceutical class: ace inhibitors |Home Hospital or Both: Taken at the hospital and at home. |
|Indication: Management of hypertension. |
|Adverse/ Side effects: Common side effects include dizziness, cough, and hypotension. Common adverse effects include angioedema. |
|Nursing considerations/ Patient Teaching: Use cautiously in patients with renal impairment, hypovolemia, hyponatremia. Monitor BP and pulses frequently during |
|initial dose adjustment and periodically during therapy. Assess patient for signs of angioedema (facial swelling, and dyspnea). May cause increase in BUN/ |
|creatinine. Instruct patient to take medication as directed the same time each day, even if feeling well. Take missed doses as soon as remembered but not if almost|
|time for next dose. Warn patient not to discontinue therapy unless directed by a health care professional. Caution patient to avoid salt substitutes containing |
|potassium or foods containing high levels of potassium. Instruct patient to notify health care professional if rash, mouth sores, sore throat, fever, swelling of |
|hands or feet, irregular heartbeat, chest pain, swelling of face, eyes, lips, or tongue. |
|Name: pantoprazole (Protonix) |Concentration |Dosage Amount: 40mg= 1 tab |
|Route: PO |Frequency: 1xDaily ac |
|Pharmaceutical class: Proton Pump Inhibitors |Home Hospital or Both: Taken at the hospital. |
|Indication: Indicated for erosive esophagitis associated with GERD. Decrease relapse rates of daytime and nighttime heartburn symptoms. |
|Adverse/ Side effects: Adverse effects include pseudomembranous colitis. Common side effects include headache, abdominal pain, diarrhea, and hypomagnesemia. |
|Nursing considerations/ Patient Teaching: Use cautiously in patients using high-doses for greater than one year. May increase risk of bleeding with warfarin. |
|Assess patient routinely for epigastric or abdominal pain and for frank or occult blood in stool, emesis, or gastric aspirate. Monitor bowel function. Diarrhea, |
|abdominal cramping, fever, and bloody stools should be reported to healthcare professional promptly as a sign of pseudomembranous colitis. Instruct patient to |
|notify health care professional immediately if rash, diarrhea, abdominal cramping, fever, or bloody stools occur and not to treat with antidiarrheals without |
|consulting health care professional. |
|Name: pyridoxine (Doxine) |Concentration |Dosage Amount: 25mg= 0.5 tab |
|Route: PO |Frequency: 1xDaily |
|Pharmaceutical class: water soluble vitamins |Home Hospital or Both: Taken at the hospital. |
|Indication: Treatment and prevention of pyridoxine deficiency. |
|Adverse/ Side effects: Side effects of this medication include sensory neuropathy and paresthesia. |
|Nursing considerations/ Patient Teaching: Use cautiously in patients with Parkinson’s disease. Asses patient for signs of vitamin B6 deficiency(anemia, dermatitis,|
|cheilosis, irritability, seizures, nausea, and vomiting) before and periodically during therapy. Extended release capsules and tablets should be swallowed whole, |
|without crushing, breaking, or chewing. Instruct patient to take medication as directed. |
|Name: acetaminophen (Tylenol) |Concentration |Dosage Amount: 650mg= 2 tab |
|Route: PO |Frequency: q4 PRN pain/fever |
|Pharmaceutical class: antipyretics/ nonopioid analgesics. |Home Hospital or Both: Taken at hospital and home. |
|Indication: Treatment of mild pain and fever. |
|Adverse/ Side effects: Adverse effects of this medication include hepatotoxicity and acute generalized exanthematous pustulosis, stevens-johnson syndrome, and |
|toxic epidermal necrolysis. Side effects include agitation, atelectasis, hypertension, and muscle spasms. |
|Nursing considerations/ Patient Teaching: This medication is contraindicated in products containing alcohol and aspartame as well as severe hepatic |
|impairment/active liver disease. Use cautiously in hepatic disease, alcoholism, and chronic malnutrition. Concurrent use of NSAIDS may increase the risk of adverse|
|renal effects. Asses overall health status and alcohol usage before administering acetaminophen. Patients who are malnourished or chronically abuse alcohol are at |
|a higher risk of developing hepatotoxicity with chronic use of usual doses of this drug. Do not exceed maximum daily dose of acetaminophen when considering all |
|routes of administration and all combination products containing acetaminophen. Increased serum bilirubin, LDH, AST, ALT and prothrombin time may indicate |
|hepatotoxicity. Advise patient to avoid alcohol if taking more than an occasional 1-2 doses. Advise patient to discontinue acetaminophen and notify health care |
|professional if rash occurs. |
|Name: albuterol (Accuneb) |Concentration |Dosage Amount: 2.5mg= 0.5ml |
|Route: Neb soln |Frequency: rtq3h ATC PRN SOB/wheezing |
|Pharmaceutical class: adrenergics |Home Hospital or Both: Taken at hospital and home. |
|Indication: Used as a bronchodilator to control and prevent reversible airway obstruction caused by asthma. |
|Adverse/ Side effects: Adverse effects include paradoxical bronchospasms. Side effects include nervousness, restlessness, tremor, chest pain, and palpitations. |
|Nursing considerations/ Patient Teaching: Use cautiously in patients with cardiac disease, hypertension, diabetes, glaucoma, and seizure disorders. Excess inhaler |
|use may lead to tolerance and paradoxical bronchospasm. Use with MAO inhibitors may lead to hypertensive crisis. Assess lung sounds, pulse, and BP before |
|administration and during peak of medication. Observe for paradoxical bronchospasm (wheezing). If condition occurs, withhold medication and notify healthcare |
|professional immediately. Instruct patient to notify health care professional if there is no response to the usual dose or if contents of one canister are used in |
|less than 2 weeks. Asthma and treatment regimen should be re-evaluated and corticosteroids should be considered. Need for increased use to treat symptoms indicates|
|decrease in asthma control and need to reevaluate patient’s therapy. |
|Name: Dextrose 50% |Concentration: 50% |Dosage Amount: 12.5g=25ml |
|Route: IV syringe |Frequency: PRN hypoglycemia (50-69) |
|Pharmaceutical class: carbohydrates |Home Hospital or Both: Taken at the hospital. |
|Indication: Treatment of hypoglycemia. |
|Adverse/ Side effects: Side effects include fluid overload, hypokalemia, hypomagnesemia, and hyperglycemia. |
|Nursing considerations/ Patient Teaching: Use cautiously in known diabetic patients and chronic alcoholics. Assess the hydration status of patients receiving IV |
|dextrose. Monitor intake and output and electrolyte concentrations. Monitor serum glucose regularly. Monitor IV site regularly for phlebitis and infection. Assess |
|nutritional status, function of gastrointestinal tract, and caloric needs of the patient. Explain the purpose of dextrose administration to the patient. |
|Name: docusate (Colace) |Concentration |Dosage Amount: 100mg= 1 cap |
|Route: PO |Frequency: 2xDaily PRN constipation |
|Pharmaceutical class: laxative |Home Hospital or Both: Taken at the hospital. |
|Indication: Prevention of constipation. |
|Adverse/ Side effects: Common side effects are throat irritation and diarrhea. |
|Nursing considerations/ Patient Teaching: Contraindicated in abdominal pain, nausea or vomiting, especially when associated with a fever. Excessive or prolonged |
|use may lead to dependence. Assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Assess color, consistency, amount of |
|stool produced. Do not confuse Colace with Cozaar. Administer with a full glass of water or juice. May be administered on an empty stomach for more rapid results. |
|Advise patients that laxatives should only be used for short-term therapy. Instruct patient with cardiac disease to avoid straining during bowel movements. |
|Name: glucagon (GlucaGen) |Concentration |Dosage Amount: 1mg |
|Route: IM inj |Frequency: PRN hypoglycemia. |
|Pharmaceutical class: pancreatics |Home Hospital or Both: Taken at the hospital. |
|Indication: Acute management of severe hypoglycemia when administration of glucose is not feasible. |
|Adverse/ Side effects: Adverse side effects include anaphylaxis. Side effects include nausea and vomiting. |
|Nursing considerations/ Patient Teaching: Use cautiously in prolonged fasting, starvation, adrenal insufficiency, or chronic hypoglycemia. Large doses may enhance |
|the effect of warfarin. Assess for signs of hypoglycemia (sweating, hunger, weakness, headache, dizziness, tremor, and tachycardia) prior to and periodically |
|during therapy. Assess neurologic status throughout therapy. Assess nutritional status. Assess for nausea and vomiting after administration. Teach patient and |
|family signs and symptoms of hypoglycemia. Feed patient supplemental carbohydrates orally to replenish liver glycogen and prevent secondary hypoglycemia as soon as|
|possible after awakening. |
|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |
|Diet ordered in hospital? 1800 ADA Diabetic |Analysis of home diet (Compare to “My Plate” and |
|Diet patient follows at home? Regular |Consider co-morbidities and cultural considerations): |
|24 HR average home diet: |In this typical day the patient consumed 1,568 calories. She ate 5 ounces of |
| |grains (2 oz. whole grain, 3 oz. refined grains) when her daily target is 6. She |
| |consumed 1 ¼ cup of vegetables when her daily goal is 2 1/2. She consumed 2 ¼ cup|
| |of fruits when her daily goal is 2 cups. She consumed ¾ cup of dairy when the |
| |daily goal is 3 cups. Her protein intake was 7 ½ ounces when her daily goal is 5 |
| |1/2. The patient’s total intake of empty calories was 437 when her goal is 258. |
| |The patient consumed 22 grams of saturated fat when her goal is 22 grams. The |
| |patient consumed 2635 mg of sodium when her limit is 2300. |
|Breakfast: 5 pork sausage links, 1 large egg cooked with nonstick spray, 1 cup of|Breakfast: Remove the 5 pork sausage links and replace with 1 cup of cheerios |
|coffee with 2 tbsp. of low-fat milk and 1 tbsp. of sugar. |cereal and 1 cup of low-fat milk. Remove the 1 tbsp. of sugar. |
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|Lunch: Turkey sandwich- 2 thin slices of turkey with 1 slice of Swiss cheese, ½ |Lunch: Add 1 cup of salad, garden lettuce, tomato, carrots, no dressing. |
|cup of shredded lettuce, and a thin slice of tomato on two slices of whole wheat | |
|bread. 1 full glass of water. | |
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|Dinner: 1 baked chicken leg quarter skin eaten, with 1 cup of green beans (cooked|Dinner: Cook the rice without salt. Add ½ cup of cooked carrots. |
|with salt), 1 cup of white rice (cooked with salt). 1 full glass of water. | |
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|Snacks: 1 cup of cranberry juice, 4 Oreo cookies, 1 apple |Snacks: Reduce to two Oreo cookies. Add a container of fat free yogurt. |
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|Liquids (include alcohol): 3 more glasses of water. |Liquids: Add another 3 glasses of water making a total of 8 glasses throughout |
| |the day. |
| |The patient would now be consuming 1558 calories. Having an intake of 5 ½ ounces |
| |of grains, 2 ½ cups of vegetables, 2 ¼ cups of fruit, 2 ¾ cups of dairy, and 6 |
| |ounces of protein. The empty calories were reduced to 236. Saturated fat was |
| |decreased to 15 grams and sodium intake was decreased to 2026 mg. |
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|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |
|Who helps you when you are ill? |
|The patient’s daughter that she lives with helps her when she is ill. |
|How do you generally cope with stress? or What do you do when you are upset? |
|The patient indicated she likes to go to the park when she is upset. |
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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |
|The patient feels overwhelmed about being sick and 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.” |
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|Have you ever felt unsafe in a close relationship? _Yes______________________________________________________ |
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|Have you ever been talked down to?___Yes____________ Have you ever been hit punched or slapped? ___Yes___________ |
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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? |
|____Yes______________________________________ If yes, have you sought help for this? _No longer with anyone. _____________________ |
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|Are you currently in a safe relationship? Single. |
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|( 4 DEVELOPMENTAL CONSIDERATIONS: |
|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |
|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair |
|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |
|patient’s age group: |
|According to Kurudi Neeraja, author of Growth and Development for Nursing Students (2006), generativity is defined as being the concern for establishing and |
|guiding the next generation. Kurudi Neeraja also defines stagnation as a feeling of personal improvement and an excessive concern or preoccupation with the self. |
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|Neeraja, K. P. (2006) . Textbook of Growth and Development for Nursing Students. Jaypee Brothers. |
|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |
|This patient is in the Erikson stage of generativity vs. self-absorption/ stagnation. This patient exhibits generativity by |
|the creation and raising of her children. Her children come to visit her often and she enjoys looking after her |
|grandchildren. This patient shows little self-absorption in that she is more concerned in the well-being and progression of |
|her children’s lives. |
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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |
|The patient has needed help from her children ever since she had the stroke. She used to live by herself but since the |
|stroke she has been living with her daughter. In the meantime she still plans to be there to help take care of her children |
|and grandchildren in whatever ways she can. |
|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” |
|The patient stated “the life I used to live and my old habits”. |
| |
| |
|What does your illness mean to you? |
|“That I need to be careful when I’m on my medications and get my leg fixed.” |
| |
| |
|+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” |
| |
|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? Yes___________________________________________ |
|Have you or a partner ever had an abnormal pap smear?___Yes_______________________________________________ Have you or your partner received the Gardasil (HPV) |
|vaccination? ___No_____________________________________ |
| |
|Are you currently sexually active? __No_________________________ If yes, are you in a monogamous relationship? ____________________ When sexually active, what |
|measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? _Condom_________________________________ |
| |
|How long have you been with your current partner?_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?
__The patient indicated that her religion is very important to her and she prays every day. ____________________________________________________________________________________________________
______________________________________________________________________________________________________
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? Cigarettes. |How much?(specify daily amount) |For how many years? 34 years |
| |A pack a week. |(age 20 thru 54 ) |
| | | |
|Pack Years: 5 | |If applicable, when did the patient quit? |
| | |February, 2015 |
| | | |
|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? The patient has quit. |
|No. |If yes, what did they use to try to quit? Nothing. |
| |
| |
|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |
| What? Wine |How much? Only a few times a year. |For how many years? |
| |Volume: 5 ounces |(age 21 thru February,2015 |
| | |) |
| |Frequency: few times a year | |
| If applicable, when did the patient quit? | | |
|February,2015 | | |
| |
| |
|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |
| If so, what? crack |
| |How much? ½ pack a day |For how many years? 34 years |
| | |(age 18 thru January,2015 ) |
| | | |
| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |
| |February, 2015. | |
| | | |
|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |
|No. |
| |
| |
|5. For Veterans: Have you had any kind of service related exposure?N/A |
| |
| |
| |
| |
| |
( 10 Review of Systems Narrative
| |Gastrointestinal |Immunologic |
| | Nausea, vomiting, or diarrhea | Chills with severe shaking |
|Integumentary | Constipation Irritable Bowel | Night sweats |
| Changes in appearance of skin | GERD Cholecystitis | Fever |
| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |
| Dandruff | Hemorrhoids Blood in the stool | Lupus |
| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |
| Hives or rashes | Pancreatitis | Sarcoidosis |
| Skin infections | Colitis | Tumor |
| Use of sunscreen (Does not use sunscreen) | Diverticulitis | Life threatening allergic reaction |
|SPF: | | |
|Bathing routine: 2xdaily |Appendicitis | Enlarged lymph nodes |
|Other: | Abdominal Abscess |Other: |
|Be sure to answer the highlighted area | Last colonoscopy? 3 years ago. | |
|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: 8 x/day |Other: |
| Oral/pharyngeal infection | Bladder or kidney infections | |
| Dental problems | |Metabolic/Endocrine |
| Routine brushing of teeth 2 x/day | | Diabetes Type: 2 |
| Routine dentist visits 1 x/year | | Hypothyroid /Hyperthyroid |
|Vision screening (2014) | | Intolerance to hot or cold |
|Other: | | Osteoporosis |
| | |Other: |
|Pulmonary | | |
| Difficulty Breathing | |Central Nervous System |
| Cough - dry or productive |Women Only | CVA (February,2015) |
| 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? 2014 | Seizures |
| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |
| Environmental allergies | menarche age? 14 | Encephalitis |
|last CXR? 3/21/15 | menopause age? 44 | 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? | Anxiety |
|Myocardial Infarction (sometimes) | 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?(upon admission) |Arthritis | Chicken Pox |
|Other: |Other: |Other: |
| | | |
|General Constitution |
|Recent weight loss or gain |
|How many lbs? |
|Time frame? |
|Intentional? |
|How do you view your overall health? “The habits I used to have led to the illnesses I have today”. |
|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |
|No. |
| |
| |
| |
| |
| |
| |
|Any other questions or comments that your patient would like you to know? |
|No. |
| |
| |
| |
| |
|±10 PHYSICAL EXAMINATION: |
| |
|General Survey: Patient is a 54 year old female with a weakened and painful left leg. Patient also has a weakened left arm and decreased sensation along the left |
|side of her body due to a previous CVA. |
|Height: 5’ 6” |
|Weight: 86.4kg |
|BMI: 30 |
|Pain: (include rating and location) 9/10 pain radiating down the left leg. |
| |
| |
|Pulse: 68 |
|Blood Pressure: (include location) |
|128/84 (Right arm) |
| |
| |
| |
|Respirations: 16 |
| |
| |
| |
|Temperature: (route taken?) |
|SpO2: 99% |
|Is the patient on Room Air or O2: RA |
| |
| |
|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |
| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |
| |
| |
|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |
| awake, calm, relaxed, interacts well with others, judgment intact |
| |
|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |
| clear, crisp diction |
| |
|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 |
|If anything is not checked, then use the blank spaces to |
|describe what was assessed in the physical exam that |
|was not WNL (within normal limits) |
| Peripheral IV site Type: 20 gauge Location: right ac Date inserted: 3/23 |
|Fluids infusing? no yes - what? |
| |
|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- 12 inches & left ear- 12 inches |
| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |
|Dentition: |
|Comments: |
| |
|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |
|Percussion resonant throughout all lung fields, dull towards posterior bases |
|Sputum production: thick thin Amount: scant small moderate large |
|Color: white pale yellow yellow dark yellow green gray light tan brown red |
|Lung sounds: |
|RUL Clear LUL Clear |
|RML Clear LLL Diminished |
|RLL Diminished |
| |
|CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent |
|Cardiovascular: No lifts, heaves, or thrills |
| |
|Heart sounds: S1 S2 audible 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. Pain in left leg. Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |
| |
|Apical pulse: +2 Carotid: +2 Brachial: +2 Radial: +2 Femoral: +2 Popliteal: +2 DP:+2 PT: +2|
| |
|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: pitting non-pitting |
| |
|Extremities warm with capillary refill less than 3 seconds |
| |
| |
| |
|GI 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 |
| |
|Last BM: (date 3 / 23 /15 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |
| |
|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |
| |
|Nausea emesis Describe if present: |
| |
|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |
| |
|Other – Describe: |
| |
| |
| |
|GU Urine output: Clear Cloudy Color: yellow Previous 24 hour output: 1200 mLs N/A |
| |
|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |
| |
|CVA punch without rebound tenderness |
| |
| |
|Musculoskeletal: ( Full ROM intact in all extremities without crepitus |
| |
|Strength bilaterally equal at ___+5____ RUE __+4_____ LUE __+5_____ RLE & __+3_____ 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 paresthesia. Left lower extremity pain and weakness. Decreased sensation along|
|left side of the body. |
| |
| |
| |
|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |
| |
|CN 2-12 grossly intact. Patient has decreased sensation along left side of body. Sensation intact to touch, pain, and vibration. Patient has decreased|
|touch sensation along left side of body. Romberg’s Negative |
| |
|Stereognosis, graphesthesia, and proprioception intact. Graphesthesia only intact on right side. Gait smooth, regular with symmetric length of the stride. |
|Patient has an unsteady gait with weakness in the left leg. |
| |
|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |
| |
|Did not have a reflex hammer. |
| |
| |
|±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): |
|Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need prior to and after surgery, and pertinent to |
|hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that |
|is done preop) then include why you expect it to be done and what results you expect to see. |
| |
|Lab |
|Dates |
|Trend |
|Analysis |
| |
|Sodium |
|140 |
|144 |
|143 |
|Normal (135-145) |
| |
|3/24/15 |
|3/23/153 |
|3/21/15 |
|Upon admit, the patient’s sodium was within the normal range and continued to stay within the normal range. |
|Measures the amount of sodium in the blood. High and low sodium values indicate an imbalance of sodium in the body. High sodium causes intracellular dehydration and |
|hypervolemia. Low sodium causes hypoosmolality. |
| |
|Potassium |
|4.2 |
|4.2 |
|3.7 |
|Normal (3.5-5) |
| |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s potassium was within the normal range and continued to stay within the normal range. |
|Measures the amount of potassium in the blood. High and low potassium values indicate an imbalance of potassium in the body. High potassium can cause intestinal |
|cramping and decreased cardiac conduction and more rapid repolarization of the heart muscle. Low potassium can cause skeletal muscle weakness and cardiac |
|dysrhythmias |
| |
|Chloride |
|108 |
|113 |
|107 |
|Normal (95-105) |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s chloride was elevated and trended upward more but has begun to trend downward. |
|Measures the amount of chloride in the blood. High chloride levels may be due to things such as, metabolic acidosis or respiratory alkalosis. Low chloride levels may|
|be due to congestive heart failure or dehydration. Increases or decreases in chloride levels are proportionate to changes in sodium levels. |
| |
|Carbon Dioxide |
|25 |
|26 |
|26 |
|Normal (23-29) |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s carbon dioxide was within normal limits and stayed within normal limits. |
|Measures the amount of bicarbonate in the blood. High and low bicarbonate levels indicate an imbalance of bicarbonate in the blood. Low bicarbonate may indicate |
|diarrhea or kidney disease. High bicarbonate may indicate breathing disorders. |
| |
|Glucose |
|82 |
|77 |
|95 |
|Normal (70-100) |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s glucose was within normal limits and stayed within normal limits. |
|Measures the amount of glucose in the blood. High and low glucose levels indicate an imbalance of glucose in the body. High values may indicate diabetes or |
|pancreatic cancer. Low values may indicate too little food intake or too much insulin or other diabetic medications. |
| |
|BUN |
|10 |
|12 |
|17 |
|Normal(6-20) |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s BUN was within the normal range and continued to stay within the normal range. |
|Measures the amount of urea nitrogen in the blood. Typically done to check kidney function. High urea nitrogen may indicate kidney failure and congestive heart |
|failure. Low urea nitrogen may indicate liver failure or malnutrition. |
| |
|Creatinine |
|0.50 |
|0.70 |
|0.85 |
|Normal(0.6-1.3) |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s creatinine was within normal limits but then began to trend below normal limits. |
|Measures the amount of creatinine in the blood. Typically done to check kidney function. High creatinine may indicate kidney problems or loss of body fluid. Low |
|creatinine levels may indicate muscle problems. |
| |
|WBC |
|4.6 |
|5.4 |
|8.0 |
|Normal(4.5-10) |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s WBC was within normal limits and stayed within normal limits. |
|Measures the amount of infection fighting cells. High WBC values indicate an infection or inflammation in the body. Low WBC values can indicate a poor immune system.|
| |
|RBC |
|4.09 |
|3.72 |
|4.29 |
|Normal(4.2-5.4) |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s RBC was within normal limits then trended below normal limits. |
|Measures the amount of RBC in the body and how much oxygen your body tissue is getting. High RBC may indicate low blood oxygen level or a kidney tumor. Low RBC may |
|indicate anemia or bleeding after a surgery. |
| |
|HGB |
|11.7 |
|11.0 |
|12.3 |
|Normal(12.1-15.1) |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s HGB was within normal limits then trended below normal limits. |
|Measures the amount of hemoglobin in the blood and how much oxygen is being carried. High HGB may indicate failure of the right side of the heart. Low HGB may |
|indicate anemia or bleeding. It can also be caused by a nutrition deficit. |
| |
|HCT |
|36.3 |
|33.0 |
|38.5 |
|Normal(38- 47) |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s HCT was within normal limits then trended below normal limits. |
|Measures the percentage of the volume of whole blood that is made up of red blood cells. High HCT levels may indicate hypoxia and dehydration. Low HCT levels may |
|indicate anemia and bleeding. |
| |
|PLT |
|194 |
|189 |
|223 |
|Normal(150-400) |
| |
|3/24/15 |
|3/23/15 |
|3/21/15 |
|Upon admit, the patient’s PLT was within the normal range and continued to stay within the normal range. |
|Measures the amount of platelets in the blood. Platelets are used for clotting. Low platelet count means your risk for bleeding is much higher. High and low platelet|
|count may occur due to certain medications. |
| |
|Chest x-ray |
|3/21/15 |
|The chest x-ray showed no acute cardiopulmonary process or significant findings. |
|The patient came into the hospital due to hypotension so they wanted to rule out any cardio/pulmonary issues. |
| |
|CT of the head without contrast |
|3/21/15 |
|The CT showed generalized atrophy and areas of right cerebellar hemisphere infarct due to the previous stroke. |
|The patient recently had a stroke so any further complications of that were being ruled out. |
| |
|Ultrasound of the left venous lower extremity |
|3/22/15 |
|The ultrasound showed a DVT in the left popliteal vein that demonstrated normal patency. |
|The ultrasound was done to see why the patient was having pain and weakness in her left leg. |
| |
| |
|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing, multidisciplinary treatments and procedures, such as diet, vitals, activity, |
|scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.) The patients antihypertensive medication |
|doses have been adjusted; Norvasc to five milligrams and Lisinopril to twenty milligrams. There are plans to add a beta |
|blocker to the patient’s list of home medications. A chest x-ray was done and showed no acute cardio-pulmonary processes. A CT of the head without contrast was also |
|done and showed generalized atrophy with areas of chronic ischemic |
|demyelination from the previous stroke. An ultra-sound of the left lower extremity was also done due to pain and weakness in the left leg and showed a DVT in the |
|left popliteal vein demonstrating normal patency. Neurology and cardiology were both consulted. The patient will need an electroencephalogram (EEG). The patient’s |
|orthostatic vital signs will be obtained. The patient is receiving Plavix and Lovenox to prevent any further growth of the blood clot in the leg. The patient will |
|also be started on a three month treatment of anticoagulation of warfarin or Xarelto.The patient is on a diabetic diet. Vitals are checked every two hours as well as|
|accuchecks. The patients bathroom privileges are bedside commode with assistance. |
| |
|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
| |
|1. Ineffective peripheral tissue perfusion related to DVT and deficient knowledge of aggravating factors and disease process |
| |
|as evidence by extremity pain, paresthesia, and +4 circulation status (mildly compromised). |
| |
|2. Acute pain related to vascular inflammation as evidenced by patient statement of 9 out 10 pain level. |
| |
| |
| |
|3. Impaired physical mobility related to pain in extremity and loss of balance and coordination as evidenced by difficulty |
| |
|turning, gait changes, and +3 ambulation (moderately compromised). |
| |
|4. Risk for ineffective cerebral tissue perfusion related to antihypertensive medication. |
| |
| |
| |
|5. Risk for falls related to hypotension and left lower extremity weakness. |
| |
|6. Risk for injury related to vision loss and decreased tissue perfusion with loss of sensation. |
| |
|7. Risk for impaired skin integrity related to immobility. |
|8. Risk for bleeding related to antithrombotic medication use. |
| |
± 15 CARE PLAN
Nursing Diagnosis: 1. Ineffective peripheral tissue perfusion related to DVT and deficient knowledge of aggravating factors and disease process
as evidence by extremity pain, paresthesia, and +4 circulation status (mildly compromised).
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |
| | |Provide References | |
|Client will demonstrate adequate tissue perfusion as |Check the brachial, radial, dorsalis pedis, posterior|Diminished or absent peripheral pulses indicate |Goal was partially met, patient demonstrated adequate|
|evidenced by palpable peripheral pulses, warm and dry|tibial, and popliteal pulses bilaterally. If unable |arterial insufficiency with resultant ischemia |tissue perfusion as evidenced by radial and DP pulses|
|skin, adequate urine output, and absence of |to find them, use a Doppler stethoscope and notify |(Ackley& Ladwig, 2014, p. 811). Cardiac output was a |+2 bilaterally in all four extremities, skin was warm|
|respiratory distress by end of shift. |the physician immediately if new onset of absence of |significant predictor for objectively measured skin |and dry, urine output was at least 30ml an hour, and |
| |pulses. Note skin color and feel the temperature of |temperature. Subjective assessment of skin |patient was free of respiratory distress, however; |
| |the skin. Assess for pain in the extremities, noting |temperature was significantly related to cardiac |the patient was still experiencing pain and paralysis|
| |severity, quality, timing, and exacerbating and |output, systemic vascular resistance, and serum |in the left lower extremity by the end of my shift. |
| |alleviating factors. Check capillary refill. Note |lactate (Ackley& Ladwig, 2014, p. 811). In clients | |
| |skin texture and the presence of hair, ulcers, or |with venous insufficiency, the pain lessens with | |
| |gangrenous areas on the legs or feet. Note the |elevation of the legs and exercise. Venous | |
| |presence of edema in the extremities and rate |insuffiency is associated with aching, cramping, and | |
| |severity on a four-point scale. Measure the |discomfort (Ackley& Ladwig, 2014, p. 811). Nail beds | |
| |circumference of the ankle and calf at the same time |usually return to a pinkish color within 1 to 2 | |
| |each day in the early morning. Apply graduated |seconds after compression, greater than 3 seconds is | |
| |compression stockings as ordered. Remove the |abnormal (Ackley& Ladwig, 2014, p. 811). Thin, shiny,| |
| |stockings at least twice a day to assess the |dry skin with hair loss; brittle nails; and gangrene | |
| |condition of the extremity then reapply. Observe for |or ulcerations on toes and anterior surfaces of the | |
| |signs of DVT, including pain, tenderness, swelling in|feet are seen in clients with arterial insuffiency | |
| |the calf and thigh, and redness in the involved |(Ackley & Ladwig, 2014, p. 811). The use of graduated| |
| |extremity. Take serial leg measurements of the thigh |compression stockings was effective in preventing DVT| |
| |and calf circumferences. If DVT is present, observe |(Ackley & Ladwig, 2014, p. 812). Thrombosis with clot| |
| |for symptoms of a pulmonary embolism, including |formation is usually first detected as swelling of | |
| |dyspnea, pleuritic chest pain, cough, and sometimes |the involved leg and then as pain (Ackley & Ladwig, | |
| |hemoptysis, especially with a history of trauma. |2014, p. 813). Fatal pulmonary embolisms are reported| |
| |Change the client’s position slowly when getting the |in one third of trauma clients (Ackley & Ladwig, | |
| |client out of bed because of possible syncope. |2014, p. 813). There is a changing pattern in the | |
| | |etiology of syncope as a person ages (Ackley & | |
| | |Ladwig, 2014, p. 813). | |
|Long term: Client will verbalize knowledge of |For venous disease, teach the importance of wearing |Difficulties regarding putting on and removal of the |Goal was partially met in that the patient explained |
|treatment regimen, including appropriate exercise and|compression stockings as ordered, elevating the legs |compression stockings remain significant but are |knowledge of the treatment regimen and the |
|medications and their actions and possible side |at intervals, and watching for skin breakdown on the |counterbalanced by better comfort when they are on |medications but did not yet display knowledge of |
|effects by time of discharge. |legs. *Teach the client to recognize signs and |(Ackley & Ladwig, 2014, p. 814). Health care |appropriate exercise. |
| |symptoms that should be reported to a physician (e.g.|professionals should give clear, unambiguous and | |
| |change in skin temperature, color, or sensation or |tailored information (Ackley & Ladwig, 2014, p. 814).| |
| |the presence of a new lesion on the foot). Provide | | |
| |clear, simple instructions about plan of care. | | |
|Long term: Client will identify changes in lifestyle |If the client is overweight, encourage weight loss to|Obesity is a risk factor for development of both DVT |Goal was not yet met; patient has yet to identify |
|needed to increase tissue perfusion by time of |decrease venous disease. *Teach the client to examine|and pulmonary embolism (Ackley & Ladwig, 2014, p. |changes in lifestyle needed to increase tissue |
|discharge. |the feet carefully at frequent intervals for changes |812). In a study the strongest predictors of foot |perfusion by time of discharge. |
| |and new ulcerations. Recommend that the diabetic |ulceration were prior ulcer, insulin treatment, | |
| |client wear comfortable shoes and break them in |absent monofilaments, structural abnormality, | |
| |slowly. *Teach the client that she should have a |proteinuria, and retinopathy (Ackley & Ladwig, 2014, | |
| |comprehensive foot examination at least annually. |p. 814. Malnutrition contributes to anemia, which | |
| |Assess the clients nutritional status, paying special|further compounds the lack of oxygen to the tissues. | |
| |attention to obesity, hyperlipidemia, and |Obese clients have poor circulation in adipose tissue| |
| |malnutrition. |and increased coagulability (Ackley & Ladwig, 2014, | |
| | |p. 813). | |
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|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
|Consider the following needs: |
|□SS Consult |
|□Dietary Consult |
|□PT/ OT- To aid patient with her impaired mobility and any ambulatory devices that may be needed. |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appointments- if symptoms do not resolve patient should follow up with primary care doctor. Once the patient is started on warfarin or xarelto long term PT/INR levels will need to be monitored. |
|□Med Instruction/Prescription- If patient goes home with any medication she will be educated on the purpose of them, how to take them, and any side effect. A handout on the meds will also be included. |
|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
± 15 CARE PLAN
Nursing Diagnosis: 3. Impaired physical mobility related to pain in extremity and loss of balance and coordination as evidenced by difficulty
turning, gait changes, and +3 ambulation (moderately compromised).
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |
| | |Provide References | |
|Client will meet mutually defined goals of increased |Screen for measures of physical function to assess |The abilities of the client should be assessed to |Goal was met; the patient’s activity goal today was |
|ambulation and exercise that include individual |strength of muscle groups including unassisted leg |determine how best to facilitate movement and protect|to be able to ambulate with assistance to the bedside|
|choice, preference and enjoyment in the exercise |stand, knee extension and strength, grip strength, |nurses from injuries and reduce musculoskeletal pain |commode also, to get up from the bed and into a |
|prescription by end of shift. |and chair stands. Monitor and record the client’s |(Ackley & Ladwig, 2014, p. 538). Use valid and |chair. |
| |ability to tolerate activity and use all four |reliable screening procedures and tools to assess the| |
| |extremities; note pulse rate, blood pressure, |clients preparation in exercise health screening | |
| |dyspnea, and skin color before and after activity. If|(Ackley & Ladwig, 2014, p. 538). Physical | |
| |the client is immobile, perform passive ROM exercises|rehabilitation interventions were found to be safe, | |
| |at least twice a day unless contraindicated. Help the|reduced disability, and resulted in few adverse | |
| |client achieve mobility and start walking as soon as |events (Ackley & Ladwig, 2014, p. 538). Early | |
| |possible if not contraindicated. If the client has |mobilization promotes improved function, reduces | |
| |had a CVA recognize that balance and mobility are |pain, and facilitates earlier return of independence | |
| |likely impaired and engage client in fall prevention |(Ackley & Ladwig, 2014, p. 539). Deconditioning of | |
| |strategies and protect from falling. For a client who|the cardiovascular system occurs within days and | |
| |is mostly immobile minimize cardiovascular |involves fluid shifts, fluid loss, decreased cardiac | |
| |deconditioning by positioning client in the upright |output, and increased resting heart rate (Ackley & | |
| |position several times daily. Watch for orthostatic |Ladwig, 2014, p. 540). Postural hypotension is very | |
| |hypotension when mobilizing. Have the client dangle |common in the elderly (Ackley & Ladwig, 2014, p. | |
| |at the side of the bed before standing up. *Teach the|540). | |
| |client progressive mobilization. | | |
|Long-term: Client will verbalize feeling of increased|Obtain any assistive devices needed for activity, |Assistive devices can help increase mobility (Ackley |Goal was not yet met; patient has not indicated |
|strength and ability to move by time of discharge. |such as gait belt, walker, or cane before the |& Ladwig, 2014, p. 538). Providing unnecessary |increased strength and ability to move at this time. |
| |activity begins. Active ROM exercises using both |assistance with transfers and bathing activities may | |
| |upper and lower extremities. Increase independence in|promote dependence and a loss of mobility (Ackley & | |
| |ADL’s encouraging self-efficacy and discouraging |Ladwig, 2014, p. 539). | |
| |helplessness as the client gets stronger. *Teach the | | |
| |client to use assistive devices such as a cane or | | |
| |walker. | | |
|Long-term: Client will engage in neuromotor exercise |Before activity, observe for, and if possible treat |Pain limits mobility and is often exacerbated by |Goal was not met; patient is not ready yet to engage |
|20 to 30 minutes per day including motor skills |pain with medication. Consult with physical therapist|movement (Ackley & Ladwig, 2014, p. 538). Prescribing|in these 20 to 30 minute exercises. |
|(balance, agility, coordination, and gait) |for further evaluation, strength training, gait |a regimen of regular physical activity that includes | |
|proprioceptive exercise training, and multifaceted |training, and development of a mobility plan. Refer |both aerobic exercise and muscle strengthening | |
|activities to improve and maintain physical function |client with physical therapy for resistance exercise |activities is beneficial to minimizing impaired | |
|and reduce falls by time of discharge. |training as able, involving all major muscle groups. |mobility (Ackley & Ladwig, 2014, p. 538). Progressive| |
| |Once the client is able to walk independently, |resistance-strength training for physical disability | |
| |suggest the client enter an exercise program or walk |in older clients resulted in increased strength and | |
| |with a friend. |positive improvements in some limitations (Ackley & | |
| | |Ladwig, 2014, p. 540). Clients should be instructed | |
| | |to use exercise logs or diary to improve adherence to| |
| | |the mobility enhancement prescription (Ackley & | |
| | |Ladwig, 2014, p. 541). | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
|Consider the following needs: |
|□SS Consult |
|□Dietary Consult |
|□PT/ OT -To aid patient with her impaired mobility and any ambulatory devices that may be needed. |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appointments- if symptoms do not resolve patient should follow up with primary care doctor. Once the patient is started on warfarin or xarelto long term PT/INR levels will need to be monitored. |
|□Med Instruction/Prescription- If patient goes home with any medication she will be educated on the purpose of them, how to take them, and any side effect. A handout on the meds will also be included. |
| |
|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
References
Ackley, B. J., & Ladwig, G. B. (2014) . Nursing Diagnosis Handbook. Maryland Heights, MO: Mosby Inc.
Huether, S. E., & McCance, K. L. (2012) . Understanding Pathophysiology. St. Louis, MO:
Mosby Inc.
Neeraja, K. P. (2006) . Textbook of Growth and Development for Nursing Students. Jaypee Brothers.
Nursing Central from Unbound Medicine. (2014) . Normal Values of Common Laboratory Tests. (Version 1.25)
[Software] . Available from
Guide/109505/all/Normal_Values_of_Common_Laboratory_Tests
United States Department of Agriculture. (2014) . My Plate SuperTracker. Retrieved from
.
Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2014) . Davis’s Drug Guide. (Version 1.25)
[Software]. (acetaminophen, albuterol, amlodipine, atorvastatin, clopidogrel, dextrose 50%, docusate,
enoxaparin, folic acid, glucagon, lisinopril, pantoprazole, pyridoxine). Available from
.
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