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?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
|+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) |
|1. |
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|4. |
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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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