UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: April Bickham |

|Patient Assessment Tool . |Assignment Date: 10/1/14 |

| ( 1 PATIENT INFORMATION |Agency: LRMC |

|Patient Initials: GS |Age: 25 |Admission Date: 9/29/14 |

|Gender: Female |Marital Status: Married |Primary Medical Diagnosis with ICD-10 code: |

| | |(633.10)- Ectopic Pregnancy “Tubal pregnancy without intrauterine |

| | |pregnancy” |

|Primary Language: English |Other Medical Diagnoses: (new on this admission) |

| |(219.9)- Fibroids “Leiomyoma of uterus” |

| |(620.2)- Ovarian Cyst |

| |(625.9)- Pain associated with female genital organs |

|Level of Education: High School | |

|Occupation (if retired, what from?): Customer Service | |

|Number/ages children/siblings: children- 1 female (3 yo), 1 male (2 yo) Siblings: 2- 1 | |

|sister (28 yo), 1 brother (23 yo) | |

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

|Living Arrangements: Lives with husband and 2 children |Advanced Directives: Yes |

| |If no, do they want to fill them out? |

| |Surgery Date: 9/29/14 Procedure: |

|Culture/ Ethnicity /Nationality: African American/ American | |

|Religion: Christian |Type of Insurance: Medicaid |

|( 1 CHIEF COMPLAINT: |

|“I had pain in my lower abdomen when I first came to the hospital” “There is still pain at a 7 out of 10 from the surgery” “The pain was worse on the right side |

|when I came in, but now it is sore all over” “My belly was also getting bigger along with the pain” |

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

|Patient was admitted to the ER with abdominal pain. In August the patient had pregnancy complications and a “D & C” procedure. Since then, the patient states pain |

|felt and increasing abdominal girth which led her to seek care at the hospital. Patient had surgery for an ectopic pregnancy and was also found to have fibroids in|

|the uterus as well as ovarian cyst. Patient has been recovering from surgery and is being discharged today (10.1.14). Onset of the pain was in August after D & C. |

|Location was is lower abdominal region with pain more severe on right side. Duration of pain had lasted from August up until patient sought hospital care related |

|to pain. Characteristics of the pain pre-operation were “aching and stabbing” at time while the pain post-operation is “sore and achy”. Aggravating factors are |

|movement and relieving factors are pain medications (Percocet and Ibuprofen). Treatment for the original problem (ectopic pregnancy) was surgery and analgesics for|

|current pain relief. |

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

|Date |Operation or Illness |

|9/29/14 |“Laparotomy Exploration” (related to ectopic pregnancy) |

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|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

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|( 1 immunization History |

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

|Routine childhood vaccinations | | |

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

|Adult Diphtheria (Date) | | |

|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 | | |

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

|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) |

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

|Name |Concentration (mg/ml) |Dosage Amount (mg) |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

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

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

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

|24 HR average home diet: | |

|Breakfast: | |

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|Lunch: | |

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|Dinner: | |

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|Snacks: | |

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|Liquids (include alcohol): | |

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

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

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

|Who helps you when you are ill? |

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

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

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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? _______________________________________________________ |

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|Have you ever been talked down to?_______________ Have you ever been hit punched or slapped?  ______________ |

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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?  |

|__________________________________________ If yes, have you sought help for this?  ______________________ |

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|Are you currently in a safe relationship? |

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|( 4 DEVELOPMENTAL CONSIDERATIONS: |

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

|Role Confusion/Diffusion Intimacy vs. 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: |

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|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |

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

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|+3 CULTURAL ASSESSMENT: |

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

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|What does your illness mean to you? |

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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?____________________________________________________________________ |

|Do you prefer women, men or both genders? _____________________________________________________________ |

|Are you aware of ever having a sexually transmitted infection? _______________________________________________ |

|Have you or a partner ever had an abnormal pap smear?_____________________________________________________ Have you or your partner received the Gardasil (HPV) |

|vaccination? ___________________________________________ |

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|Are you currently sexually active?   ___________________________When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease|

|or an unintended pregnancy?  __________________________________ |

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|How long have you been with your current partner?________________________________________________________ |

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|Have any medical or surgical conditions changed your ability to have sexual activity?  ___________________________ |

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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |

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

What importance does religion or spirituality have in your life?

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Do your religious beliefs influence your current condition?

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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? Yes No |

| If so, what? |How much?(specify daily amount) |For how many years? X years |

| | |(age thru ) |

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

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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? |

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

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

| | |(age thru ) |

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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? Yes No |

| If so, what? |

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

| | |(age thru ) |

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

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

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( 10 Review of Systems

|General Constitution |Gastrointestinal |Immunologic |

| Recent weight loss or gain | Nausea, vomiting, or diarrhea | Chills with severe shaking |

|Integumentary | Constipation Irritable Bowel | Night sweats |

| Changes in appearance of skin | GERD Cholecystitis | Fever |

| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |

| Dandruff | Hemorrhoids Blood in the stool | Lupus |

| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |

| Hives or rashes | Pancreatitis | Sarcoidosis |

| Skin infections | Colitis | Tumor |

| Use of sunscreen SPF: | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? | |

|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: x/day |Other: |

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

| Dental problems | |Metabolic/Endocrine |

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

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

|Vision screening | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

| | |Other: |

|Pulmonary | | |

| Difficulty Breathing | |Central Nervous System |

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

| Asthma | Infection of the female genitalia | Dizziness |

| Bronchitis | Monthly self breast exam | Severe Headaches |

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

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

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

| Environmental allergies | menarche age? | Encephalitis |

|last CXR? | menopause age? | Meningitis |

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

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

|Cardiovascular |Men Only |Mental Illness |

|Hypertension | Infection of male genitalia/prostate? | Depression |

| Hyperlipidemia | Frequency of prostate exam? | Schizophrenia |

| Chest pain / Angina | Date of last prostate exam? | Anxiety |

|Myocardial Infarction | BPH | Bipolar |

| CAD/PVD |Urinary Retention |Other: |

|CHF |Musculoskeletal | |

|Murmur | Injuries or Fractures |Childhood Diseases |

| Thrombus | Weakness | Measles |

|Rheumatic Fever | Pain | Mumps |

| Myocarditis | Gout | Polio |

| Arrhythmias | Osteomyelitis | Scarlet Fever |

| Last EKG screening, when? |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

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|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |

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|Any other questions or comments that your patient would like you to know? |

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

|General Survey: |Height: |Weight: BMI: |Pain: (include rating & location) |

| |Pulse: |Blood | |

| | |Pressure: | |

| | |(include location) | |

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

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

|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |

| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |

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|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |

| awake, calm, relaxed, interacts well with others, judgment intact |

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|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |

| clear, crisp diction |

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|Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat |

| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |

|Other: |

|Integumentary | |

| Skin is warm, dry, and intact | |

| Skin turgor elastic | |

| No rashes, lesions, or deformities | |

| Nails without clubbing | |

| Capillary refill < 3 seconds | |

| Hair evenly distributed, clean, without vermin | |

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

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

| 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- inches & left ear- 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 | |

| |S – Stridor | |

| |Ab - Absent | |

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|Cardiovascular: No lifts, heaves, or thrills PMI felt at: |

|Heart sounds: S1 S2 Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |

|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |

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

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

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

|Location of edema: pitting non-pitting |

|Extremities warm with capillary refill less than 3 seconds |

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|GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |

|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation |

|Urine output: Clear Cloudy Color: Previous 24 hour output: mLs N/A |

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

|CVA punch without rebound tenderness |

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

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

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

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

| Other – Describe: |

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

|Strength bilaterally equal at _______ RUE _______ LUE _______ RLE & _______ in LLE |

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

|vertebral column without kyphosis or scoliosis |

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

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

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

|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride |

|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |

|Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: |

|positive negative |

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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |

|diagnostic tests): |

|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. |

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|Lab |

|Dates |

|Trend |

|Analysis |

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|WBC |

|6.9 |

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|19.8 H |

|Normal (4.5-11) |

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|(03/18/2013) |

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|(03/22/2013) |

|Upon admit, the patients WBC were in the low normal range. However, WBC are trending upwards indicating either an infection or inflammatory process is occurring. |

|Number of infection fighting cells. High WBC indicates the presence of an infection or inflammation. High WBC is often indicated in an exacerbation of ulcerative |

|colitis. |

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|This should represent the patient’s trend of the exacerbation, such as after surgery, with new meds added, or since admission. |

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

|frequency if applicable.) |

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

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|5. |

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± 15 CARE PLAN

Nursing Diagnosis: (Which nursing diagnosis you are doing your care plan on goes here.)

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

| | |Provide References | |

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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 |

|□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:

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

| | |Provide References | |

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

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|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:

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

| | |Provide References | |

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

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|Consider the following needs: |

|□SS Consult |

|□Dietary Consult |

|□PT/ OT |

|□Pastoral Care |

|□Durable Medical Needs |

|□F/U appts |

|□Med Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |

|□Rehab/ HH |

|□Palliative Care |

References

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