UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Alana Sciuto |
|Patient Assessment Tool . |Assignment Date: 10/4/13 |
| ( 1 PATIENT INFORMATION |Agency: Tampa General Hospital (TGH) |
|Patient Initials: B.P. |Age: 57 years old |Admission Date: 10/3/13 |
|Gender: Male |Marital Status: Married |Primary Medical Diagnosis with ICD-10 code: Acute renal failure - 586 |
|Primary Language: English | |
|Level of Education: H.S. Graduate |Other Medical Diagnoses: (new on this admission): N/A |
|Occupation (if retired, what from?): Retired, Heavy Equipment Operator | |
|Number/ages children/siblings: 2 children: 1 boy (age 25) and one girl,(age 23) 1 sister | |
|(age 55) , 2 brothers (ages 60 and 58) | |
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|Served/Veteran: No. |Code Status: FULL |
|Living Arrangements: Patient lives at home with his wife. |Advanced Directives: Yes. |
| |If no, do they want to fill them out? |
| |Surgery Date: N/A Procedure: |
|Culture/ Ethnicity /Nationality: U.S. Citizen. | |
|Religion: Non denomination. |Type of Insurance: Medicare. |
|( 1 CHIEF COMPLAINT: |
|“I have not been able to keep anything down for days.” |
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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |
|B.P. is a 57 y.o. male who was admitted to TGH from ED on 10/3/13 from Brandon Urgent Care after experiencing a week of flu like symptoms and experiencing nausea, |
|vomiting, and abdominal pain for the last 3 days. Patient has not been able to keep food or liquids down for past 3 days. |
|OLDCART for abdominal pain: |
|O: 10/1/13 |
|L: Abdomen (mid) |
|D: Constant |
|C: Aching |
|A: Palpation |
|R: Rest, pain medication |
|T: Rest, pain medication |
|S: Pt rates pain a 7 out of 10. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation
|Date |Operation or Illness |
|10/4/13 |Acute Renal Failure |
|10/4/13 |Wegener’s granulomatosis |
|2/4/13 |GERD |
|2/4/12 |Aseptic necrosis of head and neck of femur |
|2013 |CKD Stage 4, GFR 15-29 ml/min |
|2011 |Osteoporosis |
|12/2/12 |Esophagogastrodudenoscopy (EGD) |
|2/6/13 |Total hip arthroplasty |
|2010 |Hypertension |
|2013 |Proteinuria |
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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 (patient unsure of 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 |Fosamax |Headaches, dizziness |
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|Other (food, tape, latex, dye, |No known allergies. | |
|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) |
|Renal failure is when the kidneys are unable to clear the blood of the waste products of protein metabolism (urea and creatinine). Urea is the end product of |
|protein catabolism resulting from the breakdown of ammonia in the liver and it is the primary method of nitrogen excretion of the body. When the body is unable to |
|excrete urea, it accumulates and causes toxicity to develop (Osborne, et al., 2010). |
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( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]
|Name: 0.9% NaCl infusion |Concentration (1000 ml bag ) |Dosage Amount (70 ml/hr) |
|Route: intravenous |Frequency: continuous |
|Pharmaceutical class: mineral and electrolyte replacements/supplements |Home Hospital or Both |
|Indication: pt unable to keep oral fluids down |
|Side effects/Nursing considerations: HF, PULMONARY EDEMA, edema, hypernatremia, hypervolemia, hypokalemia, extravasation, irritation at IV site |
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|Name: amlodipine (NORVASC) |Concentration: 5 mg |Dosage Amount: 1 X 5 mg tablet |
|Route: oral |Frequency: daily |
|Pharmaceutical class: calcium channel blockers |Home Hospital or Both |
|Indication: control hypertension |
|Side effects/Nursing considerations: headache, dizziness, fatigue, peripheral edema, angina, bradycardia, hypotension, palpitations, gingival hyperplasia, nausea, |
|flushing |
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|Name: enoxaparin (LOVENOX) |Concentration: 30 mg |Dosage Amount: 30 mg |
|Route: subcutaneous |Frequency: once daily |
|Pharmaceutical class: antithrombotic |Home Hospital or Both |
|Indication: prevention of blood clots |
|Side effects/Nursing considerations: dizziness, headache, insomnia, edema, constipation, ↑ liver enzymes, nausea, vomiting, urinary retention, ecchymoses, |
|pruritus, rash, urticarial, hyperkalemia, bleeding, anemia, thrombocytopenia, erythema at injection site, hematoma, irritation, pain, fever |
|Name: folic acid (FOLVITE) |Concentration: 1 mg |Dosage Amount: 1 mg |
|Route: oral |Frequency: BID |
|Pharmaceutical class: water soluble vitamins |Home Hospital or Both |
|Indication: treatment of anemia |
|Side effects/Nursing considerations: rash, irritability, difficulty sleeping, malaise, confusion, fever |
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|Name: ondansetron HCI (ZOFRAN) |Concentration: 2 mL = 4 mg of 4 mg/2mL 4 |Dosage Amount: 4 mg |
|Route: intravenous |Frequency: Q6H PRN |
|Pharmaceutical class: ht3 antagonist |Home Hospital or Both |
|Indication: Nausea |
|Side effects/Nursing considerations: headache, dizziness, drowsiness, fatigue, weakness, TORSADE DE POINTES, QT interval prolongation, constipation, diarrhea, |
|abdominal pain, dry mouth, ↑ liver enzymes, extrapyramidal reactions |
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|Name: oxyCODONE-acetampinophen (PERCOCET) |Concentration: 5-325 mg per tablet |Dosage Amount: 1 – 2 tablet |
|Route: oral |Frequency: Q4H PRN |
|Pharmaceutical class: opiod agonist |Home Hospital or Both |
|Indication: abdominal pain |
|Side effects/Nursing considerations: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred |
|vision, diplopia, miosis, RESPIRATORY DEPRESSION, orthostatic hypotension, constipation, dry mouth, nausea, vomiting, urinary retention, flushing, sweating, |
|physical dependence, psychological dependence, tolerance |
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|Name: pantoprazole (PROTONIX) |Concentration: 40 mg |Dosage Amount: 1 X 40 mg tablet |
|Route: oral |Frequency: daily |
|Pharmaceutical class: proton pump inhibitor |Home Hospital or Both |
|Indication: treatment of GERD |
|Side effects/Nursing considerations: headache, abdominal pain, diarrhea, eructation, flatulence, hyperglycemia, hypomagnesemia (especially if treatment duration ≥3|
|mo), bone fracture |
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|Name: prednisone (DELTASONE) |Concentration: 5 mg |Dosage Amount: 1 X 5 mg tablet |
|Route: oral |Frequency: daily |
|Pharmaceutical class: anti-inflammatories (steroidal) (intermediate |Home Hospital or Both |
|acting)
immune modifiers | |
|Indication: control of Wegener’s Granulomatosis |
|Side effects/Nursing considerations: depression, euphoria, headache, ↑ intracranial pressure (children only), personality changes, psychoses, restlessness, |
|cataracts, ↑ intraocular pressure, hypertension, PEPTIC ULCERATION, anorexia, nausea, vomiting, acne, ↓ wound healing, ecchymoses, fragility, hirsutism, petechiae,|
|adrenal suppression, hyperglycemia, fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis, THROMBOEMBOLISM, thrombophlebitis, weight gain, |
|weight loss, muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain, cushingoid appearance (moon face, buffalo hump), ↑ susceptibility to |
|infection |
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|Name: prochlorperazine (COMPAZINE) |Concentration: 10 mg tablet |Dosage Amount: 1 X 10 mg tablet |
|Route: oral |Frequency: Q6H PRN |
|Pharmaceutical class: phenothiazines |Home Hospital or Both |
|Indication: management of nausea |
|Side effects/Nursing considerations: : NEUROLEPTIC MALIGNANT SYNDROME, extrapyramidal reactions, sedation, tardive dyskinesia, blurred vision, dry eyes, lens |
|opacities, ECG changes, hypotension, tachycardia, constipation, dry mouth, anorexia, drug-induced hepatitis, ileus, pink or reddish-brown discoloration of urine, |
|urinary retention, photosensitivity, pigment changes, rashes, galactorrhea, AGRANULOCYTOSIS, leukopenia, hyperthermia, allergic reactions |
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|Name: Vitamin B12 (CYANOCOBALAMIN) |Concentration: 100 mcg |Dosage Amount: 1 X 100 mcg tablet |
|Route: oral |Frequency: daily |
|Pharmaceutical class: vitamin |Home Hospital or Both |
|Indication: management of anemia |
|Side effects/Nursing considerations |
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|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |
|Diet ordered in hospital? Pt is NPO |Analysis of home diet (Compare to “My Plate” and |
|Diet pt follows at home? Regular |Consider co-morbidities and cultural considerations): |
|24 HR average home diet: |Based on my analysis of the patient’s diet, I can conclude that my patient does |
| |not have a very balanced diet. The patient rarely consumes fruits or vegetables |
| |and is consuming foods with high levels of cholesterol and fat. The patients BMI |
| |is also 25.8, which puts him in the overweight category, indicating further need |
| |for dietary modifications. |
|Breakfast: Eggs with grits or potatoes and bacon, glass of milk or orange juice | |
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|Lunch: Patient described that he normally skips lunch because he isn’t hungry. He| |
|will sometimes have a snack instead. | |
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|Dinner: Pork chops or steak, corn, mashed potatoes. Patient described his diet as| |
|“southern foods.” | |
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|Snacks: Nutty Butty candy bar | |
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|Liquids (include alcohol): Can of coke (2- per week). Patient described that he | |
|does not drink 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? “My family.” |
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|How do you generally cope with stress? or What do you do when you are upset? “I watch TV and relax.” |
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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) “No.” |
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|+2 DOMESTIC VIOLENCE ASSESSMENT |
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|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |
|am going to ask some questions that help me to make sure that you are safe.” |
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|Have you ever felt unsafe in a close relationship? “No.” |
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|Have you ever been talked down to? “No.”__________ Have you ever been hit punched or slapped? “No.” |
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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? “No.” |
|__________________________________________ If yes, have you sought help for this? ______________________ |
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|Are you currently in a safe relationship? “Yes.” |
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|( 4 DEVELOPMENTAL CONSIDERATIONS: |
|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |
|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair |
|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: This stage deals with having success in work and parenthood. Success in these areas leads to feeling accomplished while being unsuccessful in |
|these areas leads to feelings of shallow involvement in the world. |
|() |
|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |
|I believe my patient is in the “generativity” stage because he described his children and family with a joyous tone and when I asked who helps him when he is ill |
|he described that his family helps him. He is also a grandparent, which him and his wife happily described to me. The patient is retired from his work due to |
|disability but the patient seemed to be accepting of this situation. |
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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: Disease has impacted the patient by enabling |
|him to retire due to disability. |
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|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” “I’m not sure.” |
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|What does your illness mean to you? “Well I can’t keep any food down.” |
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|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |
|Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |
|usually related to either infection, changes with aging and/or quality of life. All of these questions are confidential and protected in your medical record” |
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|Have you ever been sexually active? “Yes.” |
|Do you prefer women, men or both genders? “Women.” |
|Are you aware of ever having a sexually transmitted infection? “No.” |
|Have you or a partner ever had an abnormal pap smear? ”No.” |
|Have you or your partner received the Gardasil (HPV) vaccination? “No.” |
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|Are you currently sexually active? “Yes.” When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended |
|pregnancy? “None. My wife can’t get pregnant anymore.” |
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|How long have you been with your current partner? “Since we’ve been married, so a long time.” |
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|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?
“A good amount. We go to church.”
Do your religious beliefs influence your current condition?
“No,”______________________________________________________________________________________________________
|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |
|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? 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? “No.” |
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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 |
|Pt states that he has had fluctuations in weight gain | | |
|and weight losses when trying new medications. | | |
|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: 1-2 times per day |Appendicitis | Enlarged lymph nodes |
|Other: | Abdominal Abscess |Other: |
| | Last colonoscopy? 2012 | |
|HEENT |Other: |Hematologic/Oncologic |
| Difficulty seeing |Genitourinary | Anemia |
|Pt wears reading glasses. | | |
| 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: 3-4 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 | | Intolerance to hot or cold |
|Once a year for reading glasses | | |
|Other: | | Osteoporosis |
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|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? Patient is unsure, not on chart. | 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? “every year or two” | Schizophrenia |
| Chest pain / Angina | Date of last prostate exam? Patient is unsure of | Anxiety |
| |exact date, not on chart. | |
|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? Patient is unsure, not on |Arthritis | Chicken Pox |
|chart. | | |
|Other: |Other: |Other: |
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|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? “No.” |
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|Any other questions or comments that your patient would like you to know? “No.” |
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|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |
|General Survey: Pt is a 57 y.o. male, |Height: 5’8” |Weight: 77.11kg, 170 lb BMI: |Pain: (include rating & location): 7 out |
|well nourished, no visible injury or | |25.8 |of 10, mid abdomen |
|distress, alert and oriented X 3. | | | |
| |Pulse:88 |Blood | |
| | |Pressure: 147/81, right arm | |
| | |(include location) | |
|Temperature: (route taken?) |Respirations: 17 | | |
|97.4, oral | | | |
| |SpO2: 98% |Is the patient on Room Air or O2: Room air |
|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: 20 gauge Location: left forearm Date inserted:10/3/13 |
| no redness, edema, or discharge |
| Fluids infusing? no yes - what? 0.9% NaCl |
| 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 / 3 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: No. |
|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: 5th intercostal space, midclavicular line |
|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) No ECG for this patient. |
| Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |
|Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3 |
|No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |
|Location of edema: pitting non-pitting |
|Extremities warm with capillary refill less than 3 seconds |
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|GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |
|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation |
|Urine output: Clear Cloudy Color: Previous 24 hour output: 350 mLs N/A |
|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |
|CVA punch without rebound tenderness |
|Last BM: (date 10 / 3 /13 ) 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: Abdomen is tender upon palpation in all four quadrants, CVA punch not assessed since patient has been diagnosed with stage 4 CKD. |
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|Musculoskeletal: Full ROM intact in all extremities without crepitus |
|Strength bilaterally equal at ___5____ RUE ____5___ LUE __5_____ RLE & ___5____ 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 |
|Romberg’s and gait not assessed. Patient was resting in bed and denies any gait problems. |
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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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|Chem Profile |
|- BUN 93 |
|- Creatinine 11.6 |
|- Calcium 8.3 |
|- Albumin 3.1 |
|- GRF 34 |
|10/4/13 |
|Patient’s previous baseline CR (from 2/2013 – 7/3013) lies within the ranges of 2.9-3.65. CR and BUN have been elevated over the last 24hrs. |
|Suspect etiology to be multifactorial with prerenal component in addition to progression of renal failure. Continue to monitor. |
| |
|CBC |
|- RBC 2.99 |
|- Heme 8.6 |
|- Hematocrit 24.7 |
|10/4/13 |
|Patient’s baseline Heme has trended down from previous baseline of 10-11. |
|Patient’s baseline Heme is generally lower due to anemia. Continue to monitor. |
| |
|Urine Chemistry |
|- Protein, total urine 21.8 |
|- Protein urine 80 |
|- Urine protein/Creatinine 1.56 |
|10/4/13 |
|Patient has elevated protein in the urine. Could not find baseline protein for patient. |
|Patient has history of proteinuria. Continue to monitor. |
| |
|Intake and output summary last 24 hrs |
|- Intake 2360 ml |
|- Output 350 ml |
|- Net 2010 ml |
|10/4/13 |
|Patient has a poor urine output over the past 24 hrs. |
|Suspect etiology to be related to renal failure. Continue to monitor strict I + O’s. |
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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.) |
|- Patient is scheduled to have urine elctrolytes, creatinine, eosinophils, and follow up results of renal ultrasound. |
|- Strict I +Os are ordered with gentle rehydration of 125 mL/hr of NS for next 24hrs. |
|- Labs will continue to be monitored over next 24hrs following reassessment for the need for dialysis. |
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|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
|1. Risk for electrolyte imbalance related to renal dysfunction as evidence by persistent vomiting. |
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|2. Impaired urinary elimination related to effects of disease as evidence by 24 hour urine output summary |
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|3. Imbalanced nutrition: less than body requirements related to effects of disease as evidence by nausea and vomiting |
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|4. Excess fluid volume related to effects of disease as evidence by decreased urine output. |
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|5. Fatigue related to effects of chronic uremia and anemia |
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± 15 CARE PLAN
Nursing Diagnosis: Risk for electrolyte imbalance related to renal dysfunction as evidence by persistent vomiting.
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |
| | |Provide References | |
|Patient will maintain a normal sinus heart rhythm |Monitor vital signs |Electrolyte imbalance can lead to changes in vital |All goals were accomplished on the day care was |
|with a regular rate | |signs. |provided. |
|Patient will maintain an absence of muscle cramping |Monitor cardiac rate and rhythm |Electrolyte imbalances can result in EKG changes. | |
|Patient will maintain normal serum potassium, sodium,|Monitor intake and output and daily weights |Weight gain is a sensitive and consistent sign of | |
|and calcium | |fluid volume excess. | |
|Patient will maintain normal serum pH |Monitor for abdominal distension and discomfort |Fluid and electrolyte imbalance can cause an adverse | |
| | |effect on GI function. | |
| |Assess neurological status and LOC |Electrolyte imbalances can cause changes in | |
| | |neurologic status. | |
| |Review and monitor ordered lab findings |To determine any electrolyte changes in patient. | |
| |Monitor the effects of ordered medications such as |Medications can have adverse effects on electrolyte | |
| |diuretics and heart medications |balance. | |
| |Administer fluids as ordered and monitor their |Patient requires fluid resuscitation due to | |
| |effects |dehydration. | |
| |Patient and family teaching of patients disease |Patient and family can report if they feel they are | |
| |process and signs and symptoms of electrolyte |experiencing any signs and symptoms of electrolyte | |
| |imbalances. |imbalance | |
| |Reference for all interventions: Ackley, B.J., & | | |
| |Ladwig, G.B. (2010). Nursing Diagnosis Handbook. St. | | |
| |Louis, MI: Moby Elsevier | | |
| | | | |
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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: Excess fluid volume related to effects of disease as evidence by decreased urine output.
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |
| | |Provide References | |
|Neither fluid volume excess or deficient volume will |Assess dietary intake and habits that may contribute |To identify potential sources of fluid such as foods |Dietary intake and habits was assessed on the day |
|occur. |to excess fluid volume. |high in sodium, medications that contain fluid, or |care was provided. The patient does consume foods |
| | |amount of fluid taken with medications. |that are high in sodium. Patient and family education|
| | | |was not performed on the day care was provided. |
| |Teach patient/family rationale for restrictions. |When the patient and family understands the reasoning| |
| | |for the restrictions then they will be more likely to| |
| | |adhere to them. | |
| |Teach and encourage need for frequent oral hygiene. |To minimize dry mouth associated with fluid | |
| | |restriction. | |
| |Reference for all interventions: Osborne, K.S., Wraa,| | |
| |C.E., & Watson, A.B. (2010). Medical-Surgical | | |
| |Nursing: Preparation for Practice. Upper Saddle | | |
| |River, NJ: Pearson. | | |
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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) |
| |
|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
Ackley, B.J., & Ladwig, G.B. (2010). Nursing Diagnosis Handbook. St. Louis, MI: Moby Elsevier
Osborne, K.S., Wraa, C.E., & Watson, A.B. (2010). Medical-Surgical Nursing: Preparation for Practice. Upper
Saddle River, NJ: Pearson.
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