UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Vanessa Munoz |
|MSI & MSII Patient Assessment Tool . |Assignment Date: 1/26/16 |
| ( 1 PATIENT INFORMATION |Agency: LRMC |
|Patient Initials: S.M. |Age: 52 |Admission Date: 1/23/16 |
|Gender: Female |Marital Status: Divorced |Primary Medical Diagnosis |
| | |Small bowel obstruction |
|Primary Language: English | |
|Level of Education: College |Other Medical Diagnoses: (new on this admission) |
|Occupation (if retired, what from?): Retired from nursing |UTI |
|Number/ages children/siblings: | |
|1 son age 22 | |
|Brother- 55 | |
|Sister-58 | |
|Served/Veteran: |Code Status: Full code |
|If yes: Ever deployed? Yes or No | |
|Living Arrangements: Alone in a house |Advanced Directives: Yes |
| |If no, do they want to fill them out? |
| |Surgery Date: N/A Procedure: |
| |CT of abdomen |
|Culture/ Ethnicity /Nationality: | |
|Non-Hispanic White | |
|Religion: Christian |Type of Insurance: United Healthcare-Medicare |
|( 1 CHIEF COMPLAINT: |
|“ I have a small bowel obstruction” |
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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay) |
|Pt is a 52 y/o female with a hx of abd surgeries and small bowel obstructions, this has been a recurrent problem since |
|2014. She came in to the ER on 1/23 because she had been having abdominal pain for about 3 days and had not had a |
|Bowel movement for 3 days. Her abdomen is distended and pt says she is in pain, 7 out of 10. She also has an electrolyte |
|Imbalance. Percocet has been helping with her pain, she has also been up and walking down the hallway. Today she is |
|Getting a CT of the abdomen and is having her magnesium replaced. An enema was given later on in the day and she had |
|A bowel movement. After the bowel movement the patient says she felt much better. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of disease
|Date |Operation or Illness |
| |AICD pacemaker |
| |Hysterectomy |
| |DVT |
|2/4/14 |Bowel resection |
|3/1/14 |SGI colonoscopy |
|4/22 |stent |
|8/07 |CHF, clotting disorder, DM, HTN, substance abuse |
|2006 |Aortic valve replacement |
|2012 |MI |
| |Hyperthyroid |
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| | |
|( 2 FAMILY MEDICAL HISTORY |
|( 1 immunization History |
|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |
|Routine childhood vaccinations | | |
|Routine adult vaccinations for military or federal service | | |
|Adult Diphtheria (Date) Pt couldn’t recall | | |
|Adult Tetanus (Date) Is within 10 years? Pt couldn’t recall | | |
|Influenza (flu) (Date) Is within 1 years? 3/2015 | | |
|Pneumococcal (pneumonia) (Date) Is within 5 years? Yes, 5/2012 | | |
|Have you had any other vaccines given for international travel or occupational purposes? Please List | | |
If yes: give date, can state “U” for the patient not knowing date received
|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |
|REACTIONS |Causative Agent | |
|Medications |Vancomycin |Anaphylactic reaction |
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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) |
|A bowel obstruction is a blockage of chyme in the intestinal lumen, the obstruction could occur in the small or large |
|bowel. There are many causes of obstruction including a hernia, intussusception, torsion, diverticulosis, tumor, paralytic |
|iluis, and fibrous adhesions. Obstructions can be either mechanical or functional. Mechanical obstruction is usually caused |
|by a lesion that makes a physical blockage; a functional obstruction is failure of motility (Huether, & McCance, 2008). |
|Some risk factors include scaring from abdominal surgeries, crohn’s disease which causes narrowing of the lumen, |
|swallowing a foreign object, tumors in the intestines, decreased blood supply to the intestines and abdominal cancer |
|(Mahnke, 2014). There are many different ways that an obstruction can be diagnosed. Diagnosis starts with a history of |
|present illness and medical history. An important assessment is checking bowel sounds. Imaging test are used to confirm |
|an obstruction, these include CT scan, MRI, X-ray and ultrasound (Mahnke, 2014). Treatment depends on the type and |
|severity of the obstruction. Obstructions can be treated non-surgically. Nonsurgical treatments include IV fluids, NG tube |
|to remove fluid, NPO, and enemas. If these options don’t work, or if there is a more severe obstruction, surgical |
|intervention is required; an ileostomy or colostomy may be required (WebMD, 2014). If treated successfully, the prognosis of an obstruction is good. Some |
|complications that can occur are sepsis, aspiration, abscesses, and death if left untreated. |
( 5 Medications: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN medication . Give trade and generic name.]
|Name carvedilol (Coreg) |Concentration 25mg/1tab |Dosage Amount 1tab |
|Route oral |Frequency q12h |
|oral | |
|Pharmaceutical class |Home Hospital or Both |
|Beta blocker | |
|Indication |
|HTN |
|Adverse/ Side effects |
|Dizziness |
|Fatigue |
|Weakness |
|Bradycardia |
|Heart failure |
|Pulmonary edema |
|Diarrhea |
|Hyperglycemia |
|Angioedema |
|Nursing considerations/ Patient Teaching |
|Monitor BP and pulse frequently, hold if pulse is less than 50 bpm |
|Monitor I&Os, daily weights |
|Do not suddenly discontinue |
|Caution pt to change positions slowly and avoid driving |
|Monitor glucose levels |
|Name |Concentration |Dosage Amount |
|clonidine (Catapres) |0.3mg |1 tab |
|Route |Frequency |
|oral |tid |
|Pharmaceutical class |Home Hospital or Both |
|adrenergic | |
|Indication |
|HTN |
|Adverse/ Side effects |
|Drowsiness |
|Dry mouth |
|Dizziness |
|Nursing considerations/ Patient Teaching |
|Take at same time every day |
|Caution pt to change positions slowly and avoid driving |
|Name |Concentration |Dosage Amount |
|Oxycodone 5mg + acetaminophen 325mg (Percocet 5/325) |5mg/325mg |1 tab |
|Route |Frequency |
|Oral |Q6h |
|Pharmaceutical class |Home Hospital or Both |
|Pain medication | |
|Indication |
|Pain |
|Adverse/ Side effects |
|Constipation |
|Nausea |
|Vomiting |
|Somnolence |
|Headache |
|Blurred vision |
|Dry mouth |
|Nursing considerations/ Patient Teaching |
|Avoid alcohol and other CNS depressants |
|Watch for respiratory depression |
|Instruct patient to change positions slowly |
|Name |Concentration |Dosage Amount |
|furosemide (Lasix) |40mg |1 tab |
|Route |Frequency |
|oral |bid |
|Pharmaceutical class |Home Hospital or Both |
|Loop diuretic | |
|Indication |
|HTN |
|Adverse/ Side effects |
|Dehydration |
|Hypocalcemia |
|Hypomagnesemia |
|Nyponatremia |
|Dizziness |
|Nursing considerations/ Patient Teaching |
|Instruct pt to notify health care provider if wt gain occurs |
|Contact provider of rash, muscle weakness, cramps, or numbness occurs |
|Continue taking medication even if feeling better |
|Name |Concentration |Dosage Amount |
|lisinopril (Prinivil) |2.5mg |1 tab |
|Route |Frequency |
|oral |daily |
|Pharmaceutical class |Home Hospital or Both |
|Antihypertensives | |
|Indication |
|Hypertension |
|Side effects/Adverse |
|Dizziness, cough, diarrhea, impaired renal function, hyperkalemia, and angioedema |
|Nursing considerations/ Patient Teaching |
|monitor blood pressure and pulse before and during therapy |
|assess for signs of angioedema (facial swelling, dyspnea) |
|and monitor renal function with BUN and creatinine levels. |
|Name |Concentration |Dosage Amount |
|warfarin (Coumadin) |10 mg/1 tab |10mg |
|Route |Frequency |
|oral |daily |
|Pharmaceutical class |Home Hospital or Both |
|Anticoagulants | |
|Indication |
|Treat DVT |
|Adverse/ Side effects |
|Cramps, nausea, fever, and bleeding/ |
|Nursing considerations/ Patient Teaching |
|Chronic alcohol ingestion may decrease the drug’s action, do not use in conjunction with aspirin or NSAIDs |
|maintain consistent consumption of vitamin K foods |
|assess for signs of bleeding, such as bleeding gums, nosebleed or tarry stools. |
|Assess for additional thrombosis (pain, redness, and swelling), |
|monitor PT and INR, monitor hepatic function before and during therapy, administer at the same time each day, advise patient to use a soft toothbrush, electric |
|razor and avoid injury to reduce the risk of bleeding. Advise patient to avoid alcohol during therapy. Educate patient on the importance of routine blood work to |
|monitor PT and INR. |
|Name |Concentration |Dosage Amount |
|Magnesium oxide |400mg/1 tab |800mg |
|Route |Frequency |
|Oral |bid |
|Pharmaceutical class |Home Hospital or Both |
|Electrolyte replacement | |
|Indication |
|Hypomagnesemia correction |
|Adverse/ Side effects |
|Diarrhea |
|Nursing considerations/ Patient Teaching |
|Assess for hypermagnesemia |
|Advise pt to not take within 2 hours of other medications |
|Name |Concentration |Dosage Amount |
|levothyroxine |125 mcg |1 tab |
|Route |Frequency |
|Oral |Acbr |
|Pharmaceutical class |Home Hospital or Both |
|Thyroid preparations | |
|Indication |
|hypothyroidism |
|Adverse/ Side effects |
|Headache |
|Angina |
|Tachycardia |
|Sweating |
|Hyperthyroidism |
|Heat intolerance |
|Nursing considerations/ Patient Teaching |
|Assess apical pulse and BP prior to and periodically during therapy |
|Teach pt to take at same time everyday |
|Name |Concentration |Dosage Amount |
|ceftriaxone (Rocephin) |1000mg/50mL |200mL/hr |
|Route |Frequency |
|IVPB | |
|Pharmaceutical class |Home Hospital or Both |
|3rd gen cephalosporin | |
|Indication |
|UTI |
|Adverse/ Side effects |
|Clostridium-difficile associated diarrhea |
|Rash |
|Phlebitis |
|Allergic reactions |
|Nursing considerations/ Patient Teaching |
|Assess for infection |
|Report signs of superinfection |
|Name |Concentration |Dosage Amount |
|Magnesium sulfate |2g/ 100mL | |
|Route |Frequency |
|IVPB | |
|Pharmaceutical class |Home Hospital or Both |
|Minerals electrolytes | |
|Indication |
|Hypomagnesemia |
|Adverse/ Side effects |
|Drowsiness |
|Diarrhea |
|Flushing |
|Hypothermia |
|Nursing considerations/ Patient Teaching |
|Explain purpose of medication |
|Monitor mag levels |
|Name |Concentration |Dosage Amount |
|Potassium chloride |10 mEq 1 tab |40 mEq |
|Route |Frequency |
|oral | |
|Pharmaceutical class |Home Hospital or Both |
|Electrolyte replacement | |
|Indication |
|Hypokalemia |
|Adverse/ Side effects |
|Abdominal pain |
|Diarrhea |
|Flatulence |
|Nausea/ vomiting |
|Arrhythmias |
|Nursing considerations/ Patient Teaching |
|Avoid salt substitues |
|Report dark tarry stools |
|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |
|Diet ordered in hospital? Heart healthy |Analysis of home diet (Compare to “My Plate” and |
|Diet patient follows at home? Cardiac/ mechanical Coumadin |Consider co-morbidities and cultural considerations): |
|24 HR average home diet: |Pateint |
| |Myplate recommendations |
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|Breakfast: 2 eggs with two slices of toast |Grains 4oz 6 oz |
| |Veggies 1.75 cups 2 ½ cups |
|Lunch sandwich (whole wheat bread with cream spinach |Fruit 0 2 cups |
| |Dairy 0.25 cups 3 cups |
|Dinner: : chicken breast with baked potatoes |Protein 5 oz 5 ½ oz |
|Snacks: No |Sat. fat 9g 22 g max |
| |Sodium 2243mg 2300mg max |
|A pitcher of tea every other day |Total cal 1482 2000 max |
|[pic] |This patient could make some adjustments to her diet to make it healthier. I |
| |would recommend not drinking soda and tea, and drinking water instead. A heart |
| |healthy diet would be appropriate since she has a history of cardiac disease. |
| |Some changes could be increasing vegetable and fruit intake and reducing fat and |
| |sodium intake. For the recurrent bowel obstructions, a low fiber diet would be |
| |beneficial (Huether, & McCance, 2008). |
|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |
|Who helps you when you are ill? |
|“my son” |
|How do you generally cope with stress? or What do you do when you are upset? |
|“ I don’t handle stress very well” |
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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? |
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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: |
|Generativity vs. Stagnation happens during middle adulthood, about the ages 40-65. The basic question people in this stage tend to ask themselves is “How can I |
|contribute to this world?” People who fall under generativity typically answer that question by caring or nurturing. They want to do things that will benefit the |
|future generation. The most important events in this stage are parenting and work. People who fall under the stagnation category find themselves failing to find a |
|way to contribute to the world. They’re often isolated in the community and feel like they cant do anything to improve conditions for future generations and this |
|often leads them to feel like they’ve failed (Varcarolis & Halter, 2010). |
|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |
|My patient does not talk about feeling like she hasn’t contributed to the community. She was a nurse and said she loved |
|Being able to help people but had to stop nursing because of her heart problems. She said she wishes she could still be a |
|Nurse but was glad she had the experience. She also said she loves nursing students when she’s in the hospital because |
|It gives her the chance to talk about her nursing career and give them advice. |
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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |
|Her condition has stopped her from being a nurse which she enjoyed but she seems to deal with it well. |
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|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” |
|“It’s anatomical, I blew out a heart valve and it went downhill from there” |
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|What does your illness mean to you? |
|“It’s a radical change of lifestyle” |
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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? _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? _No_______________________________________ |
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|Are you currently sexually active? __No_________________________ If yes, are you in a monogamous relationship? ____________________ When sexually active, what |
|measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? _Birth control pills_________________________________ |
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|How long have you been with your current partner?__N/A___________________________________________________ |
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|Have any medical or surgical conditions changed your ability to have sexual activity? __the defibrillator ____________________ |
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|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?
_”Huge significance” _____________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_”Absolutely more than anything else” ______________________________________________________________________
______________________________________________________________________________________________________
|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |
|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |
| If so, what? Cigarettes |How much?(specify daily amount) |For how many years? 30 years |
| |Pack a day |(age 17 thru 47 ) |
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|Pack Years: 15 | |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? no|Has the patient ever tried to quit? |
| |If yes, what did they use to try to quit? |
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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |
| What? |How much? |For how many years? |
| |Volume: |(age thru ) |
| |Frequency: | |
| 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? Marijuana |
| |How much? |For how many years? |
| |$10/week?? |(age 24 thru now ) |
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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 |
|Not currently, as a nurse yes |
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|5. For Veterans: Have you had any kind of service related exposure? |
|N/A |
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( 10 Review of Systems Narrative
| |Gastrointestinal |Immunologic |
| | Nausea, vomiting, or diarrhea | Chills with severe shaking |
|Integumentary | Constipation Irritable Bowel | Night sweats |
| Changes in appearance of skin | GERD Cholecystitis | Fever |
| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |
| Dandruff | Hemorrhoids Blood in the stool | Lupus |
| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |
| Hives or rashes | Pancreatitis | Sarcoidosis |
| Skin infections | Colitis | Tumor |
| Use of sunscreen no SPF: | Diverticulitis | Life threatening allergic reaction |
|Bathing routine: 1x/day |Appendicitis | Enlarged lymph nodes |
|Other: | Abdominal Abscess |Other: |
|Be sure to answer the highlighted area | Last colonoscopy? 2014 | |
|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: A+ |
| Post-nasal drip |Normal frequency of urination: ~10 x/day |Other: |
| Oral/pharyngeal infection |Bladder or kidney infections | |
| Dental problems | |Metabolic/Endocrine |
|Routine brushing of teeth 3 x/day | | Diabetes Type: |
| Routine dentist visits x/year | |Hypothyroid /Hyperthyroid |
|Vision screening | | Intolerance to hot or cold |
|Other: Pt does not visit the dentist because | | Osteoporosis |
|She said they refuse to fix her teeth? | |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? 15 | Encephalitis |
|last CXR? December | menopause age? 30 | Meningitis |
|Other: |Date of last Mammogram &Result: 2007, normal |Other: |
| |Date of DEXA Bone Density & Result: 2010, normal | |
|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? 1/26/16 |Arthritis | Chicken Pox |
|Other: |Other: |Other: |
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|General Constitution |
|Recent weight loss or gain |
|How 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? |
|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: |
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|General Survey: The patient is a 52 year old female who is alert and oriented x3 with an extensive cardiac and bowel obstruction history |
|Height 165.1 cm |
|Weight 60.3kg |
|BMI 22.1 |
|Pain: (include rating and location) |
|7/10 abdomen |
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|Pulse 54 |
|Blood Pressure: (include location) |
|169/81 L arm |
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|Respirations 18 |
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|Temperature: (route taken?) 36.7 |
|SpO2 100% |
|Is the patient on Room Air or O2 |
|RA |
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|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 |
| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |
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|Integumentary |
| Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities Patient has scars on abdomen from past surgeries |
| Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin |
| Central access device Type: Location: Date inserted: |
|Fluids infusing? no yes - what? |
| |
|HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline |
| Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge |
| Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |
| PERRLA pupil size / 3 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |
| Ears symmetric without lesions or discharge Not assessed, pt was able to hear me clearly 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: Abnormalities noted |
|Comments: |
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|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |
|Percussion resonant throughout all lung fields, dull towards posterior bases |
|Sputum production: thick thin Amount: scant small moderate large |
|Color: white pale yellow yellow dark yellow green gray light tan brown red |
|Lung sounds: |
|RUL CL LUL CL |
|RML CL LLL CL |
|RLL CL |
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|CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent |
|Cardiovascular: No lifts, heaves, or thrills |
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|Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |
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|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |
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|Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |
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|Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP:3 PT: 3 |
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|No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |
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|Location of edema: pitting non-pitting |
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|Extremities warm with capillary refill less than 3 seconds |
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|GI Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |
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|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation |
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|Last BM: (date 1 / 21 / 16 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |
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|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |
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|Nausea emesis Describe if present: |
| |
|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |
| |
|Other – Describe: |
| |
| |
| |
|GU Urine output: Clear Cloudy Color: amber Previous 24 hour output: 1126.98 mLs N/A |
| |
|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |
| |
|CVA punch without rebound tenderness |
| |
| |
|Musculoskeletal: ( Full ROM intact in all extremities without crepitus |
| |
|Strength bilaterally equal at ____5__ RUE ___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 paresthesia |
| |
| |
| |
|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 Not assessed |
| |
|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 |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |
|diagnostic tests): |
|Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need prior to and after surgery, and pertinent to |
|hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that |
|is done preop) then include why you expect it to be done and what results you expect to see. |
| |
|Lab |
|Dates |
|Trend |
|Analysis |
| |
|WBC |
| |
|Normal: 4.5-11.0 |
| |
|7.8 |
| |
| |
| |
| |
|1/22/16 |
|No second set of labs |
|WBCs fight infections. A low WBC count means there are less cells available to fight infections. WNL |
| |
|RBCs |
| |
|Normal: 3.8-5.1 |
| |
|4.18 |
| |
| |
| |
| |
|1/22/16 |
|No second set of labs |
|The main function of RBCs is to transport oxygen throughout the body. A low RBC could indicate bleeding. High RBC can mean the body is compensating for low oxygen |
|levels. WNL |
| |
|HgB |
| |
|Normal: 12.0-16.0 |
| |
|13.1 |
| |
| |
| |
| |
|1/22/16 |
|No second set of labs |
|Hgb is the protein that carries oxygen. A low hgb could indicate that the patient lost blood during surgery . WNL |
| |
|Hct |
| |
|Normal: 40.7-50.3 |
| |
|41.1 |
| |
| |
| |
| |
|1/22/16 |
|No second set of labs |
|Hct is the percentage of RBCs in whole blood. A low level could be caused from bleeding during a surgical procedure. WNL |
| |
|Plt |
| |
|Normal: 150-450 |
| |
|231 |
| |
| |
| |
| |
|1/22/16 |
|No second set of labs |
|Platelets assist in blood clotting. High levels could indicate clotting problem and low could indicate a bleeding problem. WNL |
| |
|BUN |
| |
|Normal: 6-20 |
| |
|16 |
| |
| |
| |
| |
|1/22/16 |
|No second set of labs |
|BUN is checked for kidney function, it is a product of protein breakdown in the kidneys. High or low BUN could indicated kidney failure WNL |
| |
|Na |
| |
|Normal 135-145 |
| |
|140 |
| |
| |
| |
| |
|1/22/16 |
|No second set of labs |
|Sodium plays a role in maintaining blood pressure. Water follows sodium in the body. A high sodium level could increase blood volume and therefore increase blood |
|pressure, it is also indicative of dehydration. Low sodium levels could mean there’s too much water, or not enough sodium. WNL |
| |
|K |
| |
|Normal 3.5-5 |
| |
|3.0 |
| |
|2.9 |
| |
| |
| |
| |
|1/22/16 |
| |
|1/25/16 |
|The patients potassium level was low and continued to decreased by 0.1 from admission. The low potassium could be due to the obstruction in the bowel, it is not |
|being absorbed. |
|Potassium helps move nutrients into cells and takes waste out of cells. It also plays a role in nerve and muscle function. A low level could indicate not enough |
|potassium in diet. High levels could indicate renal failure, dehydration, infection, or a side effect of NSAIDs. |
| |
|Mg |
| |
|Normal 1.5-2 |
| |
|0.8 |
| |
|1.9 |
| |
| |
| |
| |
|1/22/16 |
| |
|1/25/16 |
|Magnesium levels were extremely low. The obstruction caused electrolyte imbalances in the body, magnesium absorption was affected since the obstruction was in the |
|small intestine. |
|Magnesium helps muscle function and helps regulate the heartbeat. |
| |
|Cr |
| |
|Normal: 0.7-1.4 |
| |
|0.7 |
| |
| |
| |
| |
|1/22/16 |
|No second set of labs |
|Creatinine levels determine how the kidneys are functioning in the body. It is a waste product found in the muscle. High creatinine levels could indicate renal |
|problems. Low levels could indicate muscle dystrophy . WNL |
| |
|CT of abdomen |
|1/26/16 |
|N/A |
|The results were not posted by the time I left clinicals that day |
| |
|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing, multidisciplinary treatments and procedures, such as diet, vitals, activity, |
|scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.) |
|The patient is on a heart healthy and low fiber diet in the hospital, she follows a heart healthy diet at home but not a low fiber diet. The patients vitals are |
|taken every 4 hours. Her last set of vitals were: T 36.7 HR 54 BP 169/81 RR 18 O2 100 RA Glucose 125 and pain 7/10. She walks around the floor every few hours on her|
|own to improve gastric mobility. She has bathroom privileges without assistance. She has a scheduled CT of the abdomen to confirm the small bowel obstruction. No |
|surgical intervention was recommended. Patient is only staying in the hospital until she has a bowel movement and her magnesium levels are back to a normal level. |
|Patient is drinking a lot of fluids and is walking in order to improve mobility, but if she doesn’t have a bowel movement by noon, the doctor ordered an enema. After|
|the enema was given, patient did have a bowel movement and her pain was relieved. Her abdomen was still slightly distended. She is being discharged tomorrow. No |
|consult was placed but I believe a nutrition consult should be added. She has recurrent obstructions but does not follow a low fiber diet like recommended for |
|patients with bowel obstructions. I also believe the patient is not coping well. She has a history of substance abuse and currently uses marijuana daily; although |
|she stated that “her doctor recommended it” for medical reasons. She also stated that she does not take pain medication at home because she is scared that she will |
|abuse the pain medication. I believe she needs information on coping mechanisms. |
| |
| |
|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
| |
|1. Acute pain r/t distended abdomen as evidenced by patient states 7 out of 10 on numeric pain scale |
| |
| |
| |
|2. Risk for deficient fluid volume r/t excessive loss through normal routes (diarrhea) |
| |
| |
| |
|3. Risk for infection r/t development of inflammation process |
| |
| |
| |
|4. Ineffective coping r/t inadequate coping methods as evidence by substance abuse |
| |
| |
| |
|5. |
| |
| |
| |
| |
| |
± 15 CARE PLAN
Nursing Diagnosis: Acute pain r/t distended abdomen as evidenced by patient states 7 out of 10 on numeric pain scale
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |
| | |Provide References | |
|Patient will report a tolerable pain level by end of |Ask the patient to state a tolerable pain level |The patient needs to state a pain level they are |Patient stated that a 4 or 5 out of 10 is a |
|shift | |comfortable with |comfortable pain level for her |
| |Assess pain frequently | | |
| | |Pain needs to be assessed in order to give pain |Pain was assess and managed throughout shift |
| | |medication | |
| |Encourage patient to ask for pain medication when | |Patient vocalized pain and asked for medication when |
| |needed |Patient may try to tolerate pain instead of asking |it was available |
| | |for medication when available | |
| | | | |
| |Review factors that aggravate or alleviate pain. |May pinpoint precipitating or aggravating factors | |
| | |(such as stressful events, food intolerance) or | |
| | |identify developing complications. | |
|State ability to obtain sufficient sleep and rest |Incorporate nonpharmacologic measures to assist with |the use of comfort measures will distract the patient|Patent watched TV as distraction and was taught |
| |control of pain. |from pain and may increase the effectiveness of |positioning |
| | |pharmacological measures. | |
| | | | |
| |Encourage patient to assume position of comfort |Reduces abdominal tension and promotes sense of | |
| |(knees flexed). |control. |Patient was taught this method but preferred sitting |
| | | |up |
|Citation: (Ackley & Ladwig, 2014) |
|(Vera 2013) |
|±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 |
± 15 CARE PLAN
Nursing Diagnosis: Risk for deficient fluid volume r/t excessive loss through normal routes (diarrhea)
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is |
| | |Provide References |Provided |
|Patient will maintain normal vital signs |Assess vital signs every two hours |We need to know if there is a change |Vital signs were at pateints baseline|
|throughout shift | |in patient status that needs to be | |
| | |addressed | |
| | | |No signs of hypovolemia were noted |
| |Watch for early signs of hypovolemia |Thirst is often first sign, catching | |
| | |signs early can prevent complications | |
| | | |Vitals were normal for patient, BP |
| |Give medications when appropriate |This can lower fever if present, |medication was given and electrolyte |
| | |fluids can be administered if BP |replacement was implemented |
| | |drops, HTN and HR will be managed | |
|Maintain adequate fluid volume as evidenced |Monitor I&O. Note number, character, and |Provides information about overall | |
|by moist mucous membranes, good skin turgor,|amount of stools; estimate insensible |fluid balance, renal function, and | |
|and capillary refill; stable vital signs; |fluid losses (diaphoresis). Measure urine |bowel disease control, as well as | |
|balanced I&O with urine of normal |specific gravity; observe for oliguria. |guidelines for fluid replacement. | |
|concentration/amount. | | | |
| |Observe for excessively dry skin and | | |
| |mucous membranes, decreased skin turgor, |Indicates excessive fluid loss or | |
| |slowed capillary refill. |resultant dehydration. | |
| | | | |
| |Monitor laboratory studies such as | | |
| |electrolytes (especially potassium, | | |
| |magnesium) and ABGs (acid-base balance). |Determines replacement needs and | |
| | |effectiveness of therapy. | |
|Citation: (Ackley & Ladwig, 2014) |
|(Vera 2013) |
|±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 |
References
Ackley, B. J. & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
(10th ed.). St Louis, MO: Elsevier.
Huether, S. E.; & McCance, K.L. (2008). Understanding pathophysiology (5th ed.). St. Louis, MO: Mosby.
Mahnke, D. (2014). Small Bowel Obstruction Information. Retrieved from care/health-library/diseases-and-conditions/small-bowel-obstruction
Vera, M. (2013). 7 Inflammatory Bowel Disease (IBD) Nursing Care Plans. Retrieved February 15, 2016, from
Unbound Medicine, Inc. (2014). Nursing Central (1.22.) [Mobile application software].
Retrieved from <
central/id300420397?mt=8>
varcarolis, E. M., & Halter, M. J. (2010). Foundations of psychiatric mental health nursing (7th ed.). St Louis,
MO: Elsevier.
WebMD. (2014, November 14). Bowel Obstruction. Retrieved from
disorders/tc/bowel-obstruction-topic-overview?page=2
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