Karacaprio.weebly.com



UNIVERSITY OF SOUTH FLORIDACOLLEGE OF NURSINGStudent: Kara CaprioMSI & MSII Patient Assessment Tool .Assignment Date: 10/02/2015 1 PATIENT INFORMATION Agency: Sarasota Memorial HospitalPatient Initials: F.W. Age: 68Admission Date: 9/30/2015Gender: Female Marital Status: MarriedPrimary Medical Diagnosis Mons and external vaginal cellulitis Primary Language: EnglishLevel of Education: Bachelors Other Medical Diagnoses: NoneOccupation (if retired, what from?): Retired Teacher Number/ages children/siblings: 2 daughters ( 38,40)Served/Veteran:If yes: Ever deployed? Yes or NoCode Status: Full Living Arrangements: Lives at home with husband Advanced Directives: YesSurgery Date: None Procedure: NoneCulture/ Ethnicity /Nationality: Caucasian Religion: Christian Type of Insurance: Self Pay 1 CHIEF COMPLAINT: Patient came into the emergency department indicating that she was having “lower abdominal pain in the pubic area since Saturday and there is a lump present.” She also indicated that a private doctor told her that she needed intravenous antibiotics. 3 HISTORY OF PRESENT ILLNESS: Mrs. F.W. is a mildly obese woman who presents to the emergency department with a two to three-day history of swelling, pain and redness outside her vagina and on the central pelvic area. She reports that she has been having subjective fevers. She denies any vaginal discharge or bleeding, denies any trauma or bug bites to this area. She denies any other alleviating or exacerbating factors. Patient was admitted to the hospital for management of cellulitis with IV antibiotics. 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of diseaseDate Operation or IllnessDiverticular diseaseHypertension taking Lisinopril Hypercholesterolemia taking gemfibrozilDiabetes patient is taking Januvia Acute renal failure2005Appendectomy2000Colonoscopy 2000Endoscopy 2008Parathyroidectomy 2 FAMILY MEDICAL HISTORYAge (in years)Cause of Death (if applicable)AlcoholismEnvironmental AllergiesAnemiaArthritisAsthmaBleeds EasilyCancerDiabetesGlaucomaGoutHeart Trouble(angina, MI, DVT etc.)HypertensionKidney ProblemsMental Health ProblemsSeizuresStomach UlcersStrokeTumorFather83Non-contributory to problem FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mother85Non-contributory to problem FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Brother FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sister38,40 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX relationship FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX relationship FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX relationship FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comments: Include age of onset 1 immunization History (May state “U” for unknown, except for Tetanus, Flu, and Pna)YesNoRoutine childhood vaccinations FORMCHECKBOX FORMCHECKBOX Routine adult vaccinations for military or federal service FORMCHECKBOX FORMCHECKBOX Adult Diphtheria (Date) FORMCHECKBOX FORMCHECKBOX Adult Tetanus (2010) FORMCHECKBOX FORMCHECKBOX Influenza (flu) ( 10/1/2015) FORMCHECKBOX FORMCHECKBOX Pneumococcal (pneumonia) (2013) FORMCHECKBOX FORMCHECKBOX Have you had any other vaccines given for international travel or occupational purposes? Please List FORMCHECKBOX FORMCHECKBOX If yes: give date, can state “U” for the patient not knowing date received 1 ALLERGIES OR ADVERSE REACTIONSNAME of Causative AgentType of Reaction (describe explicitly)MedicationsMorphineCauses her to become nauseous and upset stomach PercocetGI distressOther (food, tape, latex, dye, etc.)None 5 PATHOPHYSIOLOGY: Cellulitis is a bacterial infection of the skin and the tissues beneath the skin. Cellulitis involves the dermal layer of the skin and the subcutaneous tissue. The main bacteria’s responsible for cellulitis are staphylococcus and streptococcus. Cellulitis is fairly common and affects people of all races and ages. Men and women appear to be equally affected Cellulitis can occur as an extension of a skin wound, as an ulcer, or from furuncle or carbuncles. Cellulitis usually begins as a small area of pain and redness on the skin. This area spreads to surrounding tissues, resulting in the typical signs of inflammation- redness, swelling, warmth, and pain. A person with cellulitis can also develop fever and swollen lymph nodes in the area of infection. The infection usually occurs in the lower extremities. Usually cellulitis develops in the area where there is a break in the skin, such as a cut, puncture wound or insect bite. In some cases when cellulitis develops without an apparent sign of injury it may be due to microscopic cracks in the skin that are inflamed or irritated. People who have diabetes or conditions that compromise the function of the immune system such as HIV or those receiving chemotherapy are at risk to developing cellulitis. Conditions that reduce the circulation of blood such as obesity also increase a person’s risk for cellulitis. A history and physical can be helpful in diagnosing cellulitis; a culture for bacteria is also done to determine the causative bacteria. Cellulitis is commonly treated with antibiotics. (Huether&McCance,2008, p. 1102) 5 Medications: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN medication . Give trade and generic name.]Name: piperacillin (Zosyn)Concentration 64mgDosage Amount 3.375gmRoute: Intravenous Piggy back Frequency every 8 hours Pharmaceutical class: Extended spectrum penicillin’s Home Hospital or BothIndication: infectionsAdverse/ Side effects: seizures, pseudomembranous colitis, Stevens- Johnson Syndrome, Toxic epidermal necrolysisNursing considerations/ Patient Teaching: Patient should report rash and signs of super infection (black tarry overgrowth on tongue) tell health care provider is fever and diarrhea occur.Name: gemfibrozil (Lopoid)Concentration 600mgDosage Amount 600mgRoute: oral Frequency: 2 times daily Pharmaceutical class: fibric acid derivativesHome Hospital or BothIndication: Management of hyperlipidemia Adverse/ Side effects: Dizziness, headache, blurred vision, abdominal pain, diarrhea.Nursing considerations/ Patient Teaching: Teach patient that this medication should be used in conjunction with dietary restrictions (fat, cholesterol, alcohol, exercise). Notify the health care provider if they experience severe stomach pains with nausea, vomiting, fever chills, sore throat, rash.Name: lisinopril (Prinivil)Concentration 10mgDosage Amount 10mgRoute: oralFrequency Once a day Pharmaceutical class: ace inhibitors Home Hospital or BothIndication: Management of hypertension Adverse/ Side effects: Dizziness, fatigue, angioedema, hypotension, chest pain.Nursing considerations/ Patient Teaching: Notify health care provider is rash, mouth sores, sore throat, fever, swelling of hands or feet occur. Make sure to change positions slowly to reduce orthostatic hypotension.Name: sitagliptin (Januvia)Concentration 100mg Dosage Amount 100mgRoute oralFrequency once dailyPharmaceutical class: enzyme inhibitorsHome Hospital or BothIndication: Improve glycemic control Adverse/ Side effects: Headache, pancreatitis, angioedema, Stevens- Johnson syndrome Nursing considerations/ Patient Teaching: Explain to the patient that therapy is long term, proper testing of blood glucose and urine ketones, advise patient to stop taking and notify the health care provider if patient experiences, rash, hives, swelling of the face, lips, tongue occur. Name: Insulin Humulin R Concentration: 10mL vile Dosage Amount: Sliding Scale Route: Subcutaneous Frequency: Sliding scale Pharmaceutical class: pancreaticsHome Hospital or BothIndication: Control of hyperglycemia in patients with diabetes Adverse/ Side effects: hypoglycemia, anaphylaxis, swelling Nursing considerations/ Patient Teaching: Instruct patients on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur. 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.Diet ordered in hospital? Low sodium diet Analysis of home diet (Compare to “My Plate” and Diet patient follows at home? Regular diet Consider co-morbidities and cultural considerations):24 HR average home diet: The patient admits that she should be following a low sodium, low fat diet because of her hypertension and hypercholesterolemia however; she indicates that she does not follow a strict diet. After comparing the patient’s 24-hour home diet to “My Plate” the patient may be unaware that what she is eating is well over the amount of sodium, cholesterol, and saturated fat that should be in her diet. Because the patient is already diagnosed with hypertension and hypercholesterolemia, it is important to maintain a low fat low sodium diet in order to decrease possible health complications. The patient can be taught to take out certain cold cuts like turkey and replace them with fresh chicken, also when purchasing canned foods, such as vegetables select those labeled "reduced sodium," "low sodium," or "no salt added.” Instead of just eating foods like chicken, the patient can also eat things like fresh fish as an alternative. Baking the fish is also a healthier way to cook instead of steaming or broiling. Ways to reduce saturated fat intake include, replacing solid fats like butter with vegetable oils rich in monounsaturated and polyunsaturated fats, such as corn, canola, olive, peanut, and soybean oil when cooking.Breakfast: Nothing just a 12floz cup of coffee with 2tbs of creamLunch: One turkey sandwich with mayonnaise, cheese, and lettuce. One medium size apple Dinner: 2 chicken thighs baked with skin, one cup of broccoli cooked with salt and ? cup of mashed potatoes cooked with butter. Snacks: lays chips, vanilla yogurt 8oz container Liquids (include alcohol): bottle water (16floz) orange juice (8floz) coffee with creamer (12floz)1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)Who helps you when you are ill? Patient indicates that her husband and her daughters are there to help her when she is ill.How do you generally cope with stress? or What do you do when you are upset?Patient indicates that in order to cope with stress she talks with her husband and her daughters because they are very helpful and supportive.Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)Patient indicates that she is feeling a little anxious being in the hospital. +2 DOMESTIC VIOLENCE ASSESSMENT Have you ever felt unsafe in a close relationship? __No_____________________________________________________Have you ever been talked down to?__No_____________ Have you ever been hit punched or slapped?? _No_____________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?? ____N/A__________________Are you currently in a safe relationship? Yes 4 DEVELOPMENTAL CONSIDERATIONS:Erikson’s stage of psychosocial development: FORMCHECKBOX Trust vs. FORMCHECKBOX Mistrust FORMCHECKBOX Autonomy vs. FORMCHECKBOX Doubt & Shame FORMCHECKBOX Initiative vs. FORMCHECKBOX Guilt FORMCHECKBOX Industry vs. FORMCHECKBOX Inferiority FORMCHECKBOX Identity vs. FORMCHECKBOX Role Confusion/Diffusion FORMCHECKBOX Intimacy vs. FORMCHECKBOX Isolation FORMCHECKBOX Generativity vs. FORMCHECKBOX Self absorption/Stagnation FORMCHECKBOX Ego Integrity vs. FORMCHECKBOX DespairCheck 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: Integrity vs. Despair: According to Erikson’s stages of psychosocial development from age 65 and older we are in the stage of integrity vs. despair in this stage, as we become senior citizens we start to slow down in how productive we are, and explore life as a retired person. During this time in our lives we start to contemplate our accomplishments and develop integrity if we see ourselves as having lead a successful life. However if we see our lives as unproductive, experiencing guilt about our past or about what we did not accomplish in life we become dissatisfied with life and develop despair (McLeod, 2008).Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:I believe that my patient is in the integrity stage because when talking to the patient and gathering her information she seems very happy with her life and she was proud of the things she accomplished throughout her life and in her job when she had one. The patient expressed to me how she loves spending time with her two daughters and her grandchildren. When not in the hospital the patient indicated that she spends much of her time traveling and enjoying life with both her husband and her grandchildren. Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:I do not believe that the patient’s condition and hospitalization has a great impact on her developmental stage of life. The patient indicated that she was very happy with the life she lived when she was younger and she is also happy with where she is now in life, she feels she lived a good and successful life. Although the patient does not want to be in the hospital and just wants to go home, this has no impact on her developmental stage because it has nothing to do with her being successful in life. The patient indicates that she just has to get rid of the infection and then she will be ok to go home and keep living her life, therefore the hospitalization has no impact on what she thinks of herself.+3 CULTURAL ASSESSMENT: “What do you think is the cause of your illness?”Patient indicates that she is unsure of why she developed cellulitis and is not even sure of how it could of happened. What does your illness mean to you?Patient indicates that she does not really see cellulitis as an illness just an infection that she is happy to get rid of. +3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)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??__No_ Have you or a partner ever had an abnormal pap smear?_NO_______________Have you or your partner received the Gardasil (HPV) vaccination? _NOAre you currently sexually active??? Yes__________________________ If yes, are you in a monogamous relationship? ______Yes When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?? None _________________________________How long have you been with?your current partner?__35 years Have any medical or surgical conditions changed your ability to have sexual activity?? _Patient indicates that since she developed cellulitis she has not been sexually active due to the vaginal pain.__________________________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? __Patient indicates that her religious beliefs have a great importance in your life. She indicates that she prays daily. _Do your religious beliefs influence your current condition?__Patient indicates that she believes that her religious beliefs do not affect her 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? N/AHow much?(specify daily amount)For how many years? X yearsN/A(age thru ) N/APack Years:If applicable, when did the patient quit? N/ADoes anyone in the patient’s household smoke tobacco? If so, what, and how much? NoHas the patient ever tried to quit? N/AIf yes, what did they use to try to quit? N/A2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No What? N/AHow much? N/AFor how many years? N/AVolume:(age thru )Frequency: If applicable, when did the patient quit?N/A3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No If so, what? N/AHow much? N/AFor how many years? N/A(age thru ) Is the patient currently using these drugs? Yes NoIf not, when did he/she quit?4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/RisksNo5. For Veterans: Have you had any kind of service related exposure?N/A 10 Review of Systems NarrativeGastrointestinalImmunologic FORMCHECKBOX Nausea, vomiting, or diarrhea FORMCHECKBOX Chills with severe shakingIntegumentary FORMCHECKBOX Constipation FORMCHECKBOX Irritable Bowel FORMCHECKBOX Night sweats FORMCHECKBOX Changes in appearance of skin FORMCHECKBOX GERD FORMCHECKBOX Cholecystitis FORMCHECKBOX Fever FORMCHECKBOX Problems with nails FORMCHECKBOX Indigestion FORMCHECKBOX Gastritis / Ulcers FORMCHECKBOX HIV or AIDS FORMCHECKBOX Dandruff FORMCHECKBOX Hemorrhoids FORMCHECKBOX Blood in the stool FORMCHECKBOX Lupus FORMCHECKBOX Psoriasis FORMCHECKBOX Yellow jaundice FORMCHECKBOX Hepatitis FORMCHECKBOX Rheumatoid Arthritis FORMCHECKBOX Hives or rashes FORMCHECKBOX Pancreatitis FORMCHECKBOX Sarcoidosis FORMCHECKBOX Skin infections: cellulitis FORMCHECKBOX Colitis FORMCHECKBOX Tumor FORMCHECKBOX Use of sunscreen SPF:15 FORMCHECKBOX Diverticulitis FORMCHECKBOX Life threatening allergic reactionBathing routine: once a day FORMCHECKBOX Appendicitis: appendix removed FORMCHECKBOX Enlarged lymph nodesOther: FORMCHECKBOX Abdominal AbscessOther:Be sure to answer the highlighted area FORMCHECKBOX Last colonoscopy? 2000HEENTOther:Hematologic/Oncologic FORMCHECKBOX Difficulty seeing Genitourinary FORMCHECKBOX Anemia FORMCHECKBOX Cataracts or Glaucoma FORMCHECKBOX nocturia FORMCHECKBOX Bleeds easily FORMCHECKBOX Difficulty hearing FORMCHECKBOX dysuria FORMCHECKBOX Bruises easily FORMCHECKBOX Ear infections FORMCHECKBOX hematuria FORMCHECKBOX Cancer FORMCHECKBOX Sinus pain or infections FORMCHECKBOX polyuria FORMCHECKBOX Blood Transfusions FORMCHECKBOX Nose bleeds FORMCHECKBOX kidney stonesBlood type if known: O+ FORMCHECKBOX Post-nasal dripNormal frequency of urination: 6 x/dayOther: FORMCHECKBOX Oral/pharyngeal infection FORMCHECKBOX Bladder or kidney infections FORMCHECKBOX Dental problemsMetabolic/Endocrine FORMCHECKBOX Routine brushing of teeth 2x/day FORMCHECKBOX Diabetes Type:2 FORMCHECKBOX Routine dentist visits 1 x/year FORMCHECKBOX Hypothyroid /Hyperthyroid FORMCHECKBOX Vision screening FORMCHECKBOX Intolerance to hot or coldOther: FORMCHECKBOX OsteoporosisOther:Pulmonary FORMCHECKBOX Difficulty BreathingCentral Nervous System FORMCHECKBOX Cough - dry or productiveWomen Only FORMCHECKBOX CVA FORMCHECKBOX Asthma FORMCHECKBOX Infection of the female genitalia FORMCHECKBOX Dizziness FORMCHECKBOX Bronchitis FORMCHECKBOX Monthly self breast exam FORMCHECKBOX Severe Headaches FORMCHECKBOX Emphysema FORMCHECKBOX Frequency of pap/pelvic exam yearly FORMCHECKBOX Migraines FORMCHECKBOX Pneumonia Date of last gyn exam? 2014 FORMCHECKBOX Seizures FORMCHECKBOX Tuberculosis FORMCHECKBOX menstrual cycle regular irregular FORMCHECKBOX Ticks or Tremors FORMCHECKBOX Environmental allergies FORMCHECKBOX menarche age? FORMCHECKBOX Encephalitis FORMCHECKBOX last CXR? FORMCHECKBOX menopause age?50 FORMCHECKBOX MeningitisOther:Date of last Mammogram &Result: 2014, and normal Other:Date of DEXA Bone Density & Result: Unknown CardiovascularMen OnlyMental Illness FORMCHECKBOX Hypertension FORMCHECKBOX Infection of male genitalia/prostate? FORMCHECKBOX Depression FORMCHECKBOX Hyperlipidemia FORMCHECKBOX Frequency of prostate exam? FORMCHECKBOX Schizophrenia FORMCHECKBOX Chest pain / Angina Date of last prostate exam? FORMCHECKBOX Anxiety FORMCHECKBOX Myocardial Infarction FORMCHECKBOX BPH FORMCHECKBOX Bipolar FORMCHECKBOX CAD/PVD FORMCHECKBOX Urinary RetentionOther: FORMCHECKBOX CHFMusculoskeletal FORMCHECKBOX Murmur FORMCHECKBOX Injuries or FracturesChildhood Diseases FORMCHECKBOX Thrombus FORMCHECKBOX Weakness FORMCHECKBOX Measles FORMCHECKBOX Rheumatic Fever FORMCHECKBOX Pain FORMCHECKBOX Mumps FORMCHECKBOX Myocarditis FORMCHECKBOX Gout FORMCHECKBOX Polio FORMCHECKBOX Arrhythmias FORMCHECKBOX Osteomyelitis FORMCHECKBOX Scarlet Fever FORMCHECKBOX Last EKG screening, when? 9/30/2015 FORMCHECKBOX Arthritis FORMCHECKBOX Chicken PoxOther:Other:Other:General Constitution FORMCHECKBOX Recent weight loss or gainHow many lbs?Time frame?Intentional?How do you view your overall health? Is there any problem that is not mentioned that your patient sought medical attention for with anyone? NOAny other questions or comments that your patient would like you to know?NO±10 PHYSICAL EXAMINATION:General Survey: A 68 year old pleasant white female, mildly obese who presented to the E.R. with pubic pain. Height 62inWeight 68.1BMI 27.54Pain: (include rating and location)Patient stated that pain is a 4 located in the pubic area Pulse 77Blood Pressure: 171/71 right bicep Respirations 16Temperature: (route taken?) 99.2 oral SpO2 98Is the patient on Room Air or O2 Room air Overall Appearance: [Dress/grooming/physical handicaps/eye contact] FORMCHECKBOX clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicapsOverall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] FORMCHECKBOX awake, calm, relaxed, interacts well with others, judgment intactSpeech: [e.g.: clear/mumbles /rapid /slurred/silent/other] FORMCHECKBOX clear, crisp dictionMood and Affect: FORMCHECKBOX pleasant FORMCHECKBOX cooperative FORMCHECKBOX cheerful FORMCHECKBOX talkative FORMCHECKBOX quiet FORMCHECKBOX boisterous FORMCHECKBOX flat FORMCHECKBOX apathetic FORMCHECKBOX bizarre FORMCHECKBOX agitated FORMCHECKBOX anxious FORMCHECKBOX tearful FORMCHECKBOX withdrawn FORMCHECKBOX aggressive FORMCHECKBOX hostile FORMCHECKBOX loud Other:Integumentary FORMCHECKBOX Skin is warm, dry, and intact FORMCHECKBOX Skin turgor elastic FORMCHECKBOX No rashes, lesions, or deformities: changes to the ventral pelvis area, a cellulitic area of the mons that extends laterally to the lefy as well as down into the external labia. This area is red swollen and tender. FORMCHECKBOX Nails without clubbing FORMCHECKBOX Capillary refill < 3 seconds FORMCHECKBOX Hair evenly distributed, clean, without vermin FORMCHECKBOX Central access device Type: peripherial 18 gauge Location: right forearm Date inserted: 9/30/2015 Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what?HEENT: FORMCHECKBOX Facial features symmetric FORMCHECKBOX No pain in sinus region FORMCHECKBOX No pain, clicking of TMJ FORMCHECKBOX Trachea midline FORMCHECKBOX Thyroid not enlarged FORMCHECKBOX No palpable lymph nodes FORMCHECKBOX sclera white and conjunctiva clear; without discharge FORMCHECKBOX Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness FORMCHECKBOX PERRLA pupil size/ equal on both sides FORMCHECKBOX Peripheral vision intact FORMCHECKBOX EOM intact through 6 cardinal fields without nystagmus FORMCHECKBOX Ears symmetric without lesions or discharge FORMCHECKBOX Whisper test heard: Heard at equal distances in both ears FORMCHECKBOX Nose without lesions or discharge FORMCHECKBOX Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesionsDentition: Patient has no missing teeth with good oral hygiene Comments:Pulmonary/Thorax: FORMCHECKBOX Respirations regular and unlabored FORMCHECKBOX Transverse to AP ratio 2:1 FORMCHECKBOX Chest expansion symmetric FORMCHECKBOX Percussion resonant throughout all lung fields, dull towards posterior bases FORMCHECKBOX Sputum production: thick thin Amount: scant small moderate large Color: white pale yellow yellow dark yellow green gray light tan brown redLung sounds: respirations unlabored clear auscultation bilaterally RULCL LUL CLRML CL LLL CLRLL CLCL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - AbsentCardiovascular: FORMCHECKBOX No lifts, heaves, or thrills Heart sounds: FORMCHECKBOX S1 S2 audible FORMCHECKBOX Regular FORMCHECKBOX Irregular FORMCHECKBOX No murmurs, clicks, or adventitious heart sounds FORMCHECKBOX No JVDRhythm (for patients with ECG tracing – tape 6 second strip below and analyze) FORMCHECKBOX Calf pain bilaterally negative FORMCHECKBOX 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: 2 DP: 3 PT:2 FORMCHECKBOX 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 FORMCHECKBOX Extremities warm with capillary refill less than 3 secondsGI FORMCHECKBOX Bowel sounds active x 4 quadrants; no bruits auscultated FORMCHECKBOX No organomegaly FORMCHECKBOX Percussion dull over liver and spleen and tympanic over stomach and intestine FORMCHECKBOX Abdomen non-tender to palpation: abdomen is soft with tenderness in the lower abdomen pelvic area Last BM: (date 10 / 01 / 2015 ) Formed Semi-formed Unformed Soft Hard Liquid Watery Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red FORMCHECKBOX Nausea FORMCHECKBOX emesis Describe if present:Genitalia: FORMCHECKBOX Clean, moist, without discharge, lesions or odor FORMCHECKBOX Not assessed, patient alert, oriented, denies problems Other – Describe:GU Urine output: FORMCHECKBOX Clear FORMCHECKBOX Cloudy Color:yellow Previous 24 hour output: mLs N/A FORMCHECKBOX Foley Catheter FORMCHECKBOX Urinal or Bedpan FORMCHECKBOX Bathroom Privileges without assistance or with assistance FORMCHECKBOX CVA punch without rebound tenderness Musculoskeletal: Full ROM intact in all extremities without crepitus FORMCHECKBOX Strength bilaterally equal at _4______ RUE _4______ LUE _4______ RLE & __4_____ 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] FORMCHECKBOX vertebral column without kyphosis or scoliosis FORMCHECKBOX Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesiaNeurological: FORMCHECKBOX Patient awake, alert, oriented to person, place, time, and date FORMCHECKBOX Confused; if confused attach mini mental exam FORMCHECKBOX CN 2-12 grossly intact FORMCHECKBOX Sensation intact to touch, pain, and vibration FORMCHECKBOX Romberg’s Negative FORMCHECKBOX Stereognosis, graphesthesia, and proprioception intact FORMCHECKBOX Gait smooth, regular with symmetric length of the strideDTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]Triceps: 2 Biceps: 2 Brachioradial: 2 Patellar: 2 Achilles: 2 Ankle clonus: positive negative Babinski: positive negative ±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS)LabDatesTrendAnalysisWhite Blood Cell (WBC)Normal (4.5-11)18.8 (H)7.6(N)9/30/201510/2/2015Upon admittance, the patients WBC were high indicating a possible infection, or inflammatory process occurring, however while in the hospital the WBC count has decreased significantly and are now in the normal rangeThe number of infection fighting cells were high upon admittance this points to the presence of an infection in the patient, and points to her diagnosis of cellulitis, now that she is being treated the WBC count is in the normal range.Blood urea nitrogen (BUN)Normal (8-23)46(H)21(N)Creatinine Normal (0.4-1.1)3.5(H)1.6(H)Glomerular filtration rate (GFR)Normal (>60)14(L)34(L)9/30/201510/2/2015Upon admittance, the patients BUN and creatinine levels were extremely high, and her GFR was significantly low indicating renal failure. However while in the hospital her BUN and creatinine levels are coming down to more normal levels and her GFR is starting to rise. A low GFR and high BUN and creatinine levels indicate renal failure, however throughout her hospital stay her renal failure continues to improve. This indicates that she has acute renal failure and with treatment her kidney failure is likely to improve.CT of pelvis9/30/2015This was the only CT taken during her hospital stayCT of her pelvis showed inflammatory changes of the skin and soft tissue, ventral pelvic wall extending into the labia with no underlying fluid collections.Sonographic evaluation of kidneys9/30/2015This was the only sonogram taken during her hospital stayThe sonogram showed no signs of hydronephrosis. Findings include acute renal failure and subtle renal lesions.+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: Patient has a diagnosis of mons and external vaginal cellulitis. Infectious disease is on board and is adjusting antibiotics including zosyn. Diabetes is poorly controlled as an outpatient she will be on sliding scale insulin while in the hospital during times of nothing by mouth and will have accu- checks frequently throughout the day. Hypercholesterolemia will be treated with continuation of gemfibrozil, and hypertension will be treated with Lisinopril. Patient will be on a regular diet and can be independently active. 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)1. Impaired tissue integrity related to inflammatory process damaging skin and underlying tissue, as evidence by destruction of skin surface, redness, swelling, and warmth of skin. 2. Acute pain related to irritation of the skin, impaired skin integrity, local inflammatory response of subcutaneous tissue from infection, as evidence by, reported pain level3.Risk for vascular trauma related to infusion of antibiotics 4. Risk for ineffective tissue perfusion related to edema. ± 15 CARE PLANNursing Diagnosis: Impaired tissue integrity related to inflammatory process damaging skin and underlying tissue, as evidence by destruction of skin surface, redness, swelling, and warmth of skin.Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Goal on Day Care is ProvidedPatient will report any altered sensation or pain at site of tissue impairment by end of shift.Monitor the site at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether the patient is experiencing changes in sensation of pain. Systematic inspection can identify impending problems early (Ackley&Ladwig,2010, p. 841-843)Goal met, patient reported no changes in tissue color, temperature and pain level at the site of tissue infection.Patient will describe measures to protect and heal the tissue, including wound care by discharge.Patient will be taught the importance of proper nutrition and daily hygiene in order to prevent further infection and help heal tissue.Essential elements such as hygiene and nutrition are important to promote tissue healing.(Ackley&Ladwig,2010, p. 841-843)Goal not met, patient has not been discharged. However, the patient is being taught the importance of proper hygiene and nutrition in order to promote healing.Patient will exhibit no additional signs of new or worsening skin breakdown by the end of shift. Monitor the site at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection. Prescribed antibiotics will be given Determine whether the patient is experiencing changes in sensation of pain.Systematic inspection can identify impending problems earlyAntibiotics will get rid of the existing infection. (Ackley&Ladwig,2010, p. 841-843)Goal met, patient has no new signs or worsening signs of tissue infection. Patient will display timely healing of skin without complications by discharge. Monitor the status of the skin around the wound. Monitor skin care practices noting cleansing agents and frequency of cleaning.Inspect patient’s skin every shift, monitor nutrition and hygiene.Avoid hazardous cleansing agents, hot water, extreme friction or too frequent of cleansing Essential elements such as hygiene and nutrition are important to promote tissue healing.(Ackley&Ladwig,2010, p. 841-843)Goal not met, patient has not been discharged. However, there have been no reported complications. ±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 appointments □Med Instruction/Prescription □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No □Rehab/ HH □Palliative Care Nursing Diagnosis: Acute pain related to irritation of the skin, impaired skin integrity, local inflammatory response of subcutaneous tissue from infection, as evidence by, reported pain levelPatient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Goal on Day Care is ProvidedPatient will use the pain scale to identify current level of pain throughout shift Assess the patient for pain by using the pain scale routinely and at frequent intervals. Assess for characteristics of pain and pain location. The pain scale assists in determining the need for pain management, and program effectiveness.(Ackley&Ladwig,2010, p. 601-603)Goal met, patient used the pain scale to rate her level of pain frequently throughout shift. Patient will have a controlled level of pain (0-4) throughout the shift Assess the patient for pain by using the pain scale routinely and at frequent intervals. Assess for characteristics of pain and pain location.Administer prescribed pain medications as needed.The pain scale assists in determining the need for pain management, and program effectiveness.Pain medication may be needed in patients with severe pain. (Ackley&Ladwig,2010, p. 601-603)Goal met, patient reported a pain level of 4 or below throughout shift. Prescribed pain medications were administered if needed. Patient will be able to describe nonpharmacological methods that can be used to help achieve comfort by discharge.Provide teaching on the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeedback, visualization, guidance imagination, and breath control.Nonpharmacological techniques such as these help to increase relaxation, give a sense of control, and may improve coping?skills.(Ackley&Ladwig,2010, p. 601-603)Goal not met, patient has not been discharged. However, she is using some nonpharmacological methods such as progressive relaxation in order to reduce her pain. Patient will report ability to obtain sufficient amounts of rest and sleep per shift. Administer prescribed pain medication as needed.Use nonpharmacological methods such as massage to help the patient to relax.Decreasing pain will increase relaxation and decrease muscle tension. (Ackley&Ladwig,2010, p. 601-603)Goal met, patient reported that she was able to achieve adequate amounts of rest throughout the shift. ReferencesAckley,?B.?J., & Ladwig,?G.?B. (2010).?Nursing diagnosis handbook: An evidence-based guide to planning care?(9th?ed.). Maryland Heights, MO: Mosby.. (n.d.). Retrieved from ., & McCance,?K.?L. (2008).?Understanding pathophysiology?(4th?ed.). St. Louis, MO: Mosby/Elsevier.McLeod,?S. (2008). Erik Erikson | Psychosocial Stages | Simply Psychology. Retrieved from Central from Unbound Medicine ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download