UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Emily Stromsnes |
|MSI & MSII Patient Assessment Tool . |Assignment Date: 3/11/15 |
| ( 1 PATIENT INFORMATION |Agency: LRMC |
|Patient Initials: N.M. |Age: 60 |Admission Date: 3/7/15 |
|Gender: F |Marital Status: Married |Primary Medical Diagnosis: Dehydration, |
|Primary Language: English | |
|Level of Education: Graduated High School, some college |Other Medical Diagnoses: (new on this admission) |
|Occupation (if retired, what from?): disabled |No |
|Number/ages children/siblings: 3 children (Boy 33, Girl 36, boy 41) | |
|3 Siblings (Boy 59, Boy 57, Boy 55) | |
|Served/Veteran: No |Code Status: Full code |
|If yes: Ever deployed? Yes or No | |
|Living Arrangements: Lives with husband |Advanced Directives: No |
| |If no, do they want to fill them out? No |
| |Surgery Date: 3/11/15 Procedure: Colonoscopy |
|Culture/ Ethnicity /Nationality: Caucasian | |
|Religion: Catholic |Type of Insurance: Medicare |
|( 1 CHIEF COMPLAINT: |
| “ N/V, diarrhea, and I was severely dehydrated” |
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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay) |
|O: Started 6 weeks ago |
|L: abdomen |
|D: 6 weeks |
|C: N/V, diarrhea |
|A: Dehydration |
|R: Medication side effects |
|T: Ginger ale, saltine crackers, rest |
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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 |
|1997 |Right and left carpal tunnel surgery |
|1998 |Hysterectomy |
|2000 |Total knee replacement |
|2014 |Hand surgery “ trigger finger” |
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|( 2 FAMILY MEDICAL HISTORY |
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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) 04/12/1990 | | |
|Adult Tetanus (Date) Is within 10 years? | | |
|Influenza (flu) (Date) Is within 1 years? 10/7/14 | | |
|Pneumococcal (pneumonia) (Date) Is within 5 years? | | |
|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 |PCN |Rash |
| |Dilaudid |Violent |
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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) |
|Multiple sclerosis is a demyelination of the white matter of the brain and spinal cord(Osborn, Wraa, Watson, & Holleran, 2014). Risk factors include a genetic |
|influence, trigger of environmental stimulus or a virus. Common signs of MS are vertigo, gait disturbances, fatigue, and bladder disturbance. Symptoms are |
|separated into four categories: motor (weakness in the lower extremities), sensory (loss of proprioception, and numbness), cerebellar (ataxia, slurred speech) and |
|miscellaneous (emotional disturbances). Diagnostic test include: CSF test( look for inflammatory proteins), MRI (look for lesions). Treatment includes: drug |
|therapy and symptom management. Types of MS include: Primary progressive- progression w/o remission. Secondary progressive: relapse remitting and progresses into |
|primary progressive w/o remission. Relapsing remission attacks followed by partial or complete remission. Progressive-relapsing progression of the disease w/ |
|attacks. |
( 5 Medications: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN medication . Give trade and generic name.]
|Name Pantoprazole Protonix |Concentration |Dosage Amount 20 Mg |
|Route Oral |Frequency QD |
|Pharmaceutical class Proton Pump Inhibitor |Home Hospital or Both |
|Indication GERD. Decrease heartburn |
|Adverse/ Side effects: Pseudomembranous Colitis, abdominal pain, diarrhea, hyperglycemia |
|Nursing considerations/ Patient Teaching: Take as directed, avoid alcohol, notify a healthcare provider if rash, diarrhea, abdominal cramping, fever or bloody |
|stool develops |
|Name Primidone Mysoline |Concentration |Dosage Amount 50mg |
|Route oral |Frequency QD |
|Pharmaceutical class N/A |Home Hospital or Both |
|Therapeutic Class: Anticonvulsants | |
|Indication: Complex partial and focal seizures |
|Adverse/ Side effects: Suicidal thoughts, ataxia, drowsiness, vertigo, N/V |
|Nursing considerations/ Patient Teaching: Contact a health care professional if thoughts of suicide, or attempt to commit suicide, new or worse depression, panic |
|attacks, trouble sleeping occur |
|Name Ondansetron Zofran |Concentration |Dosage Amount 4mg |
|Route IV Push |Frequency Q4H |
|Pharmaceutical class five ht3 antagonists |Home Hospital or Both |
|Indication prevention of nausea and vomiting |
|Adverse/ Side effects: headache, dizziness, constipation, diarrhea, abdominal pain |
|Nursing considerations/ Patient Teaching Take as directed, Notify a health care physician if irregular heartbeat or involuntary movement of the eyes, face, or |
|limbs occur |
|Name Interferon Beta 1a Avonex |Concentration |Dosage Amount 3mcg |
|Route IM |Frequency QWK Tuesday |
|Pharmaceutical class: interferons |Home Hospital or Both |
|Indication: relapsing forms of MS |
|Adverse/ Side effects: Seizures, depression, dizziness, fatigue, headache, sinusitis, abdominal pain, UTI |
|Nursing considerations/ Patient Teaching: teach proper administration, take the correct amt., keep constant schedule, use Acetaminophen if flu- like symptoms occur|
|Name enoxaparin Lovenox |Concentration |Dosage Amount 40mg |
|Route sq |Frequency QD |
|Pharmaceutical class Anti-thrombolytics |Home Hospital or Both |
|Indication: Prevention of DVT, PE, VTE, |
|Adverse/ Side effects Dizziness, headache, bleeding, anemia, thrombocytopenia |
|Nursing considerations/ Patient Teaching: Report any signs of unusual bleeding, bruising, itching, rash, fever, swelling, or difficulty breathing to a healthcare |
|professional right away |
|Name Duloxetine Cymbalta |Concentration |Dosage Amount 20Mg |
|Route oral |Frequency BID |
|Pharmaceutical class SSNRI |Home Hospital or Both |
|Indication Major Depressive disorder or general anxiety disorder |
|Adverse/ Side effects: Neuroleptic Malignant Syndrome, seizures, suicidal thoughts, hepatotoxicity, serotonin syndrome, fatigue, drowsiness, N/V, diarrhea |
|Nursing considerations/ Patient Teaching: Have patient and family to be alert for emergence of anxiety, agitation, panic attacks, hostility and impulsivity and |
|contact a health care professional |
|Name metoclopramide Reglan |Concentration |Dosage Amount 5Mg |
|Route Iv push |Frequency Q6H |
|Pharmaceutical class N/A |Home Hospital or Both |
|Therapeutic Class: antiemetics | |
|Indication management of gastro esophageal reflux |
|Adverse/ Side effects drowsiness, extrapyramidal reactions, restlessness, neuroleptic malignant syndrome, dry mouth, constipation |
|Nursing considerations/ Patient Teaching Take as directed, avoid taking alcohol with this drug and other CNS depressants while taking this medication |
|Name sodium chloride Slo-Salt |Concentration .9 |Dosage Amount 100 mL/hr |
|Route IV |Frequency Continuous |
|Pharmaceutical class N/A |Home Hospital or Both |
|Therapeutic Class: mineral and electrolyte replacement/supplements | |
|Indication hydration, maintenance of fluid and electrolyte status |
|Adverse/ Side effects HF, pulmonary edema, edema, hypernatremia, hypervolemia |
|Nursing considerations/ Patient Teaching Explain to the patient the purpose of the infusion |
|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |
|Diet ordered in hospital? NPO |Analysis of home diet (Compare to “My Plate” and |
|Diet patient follows at home? Regular |Consider co-morbidities and cultural considerations): |
|24 HR average home diet: | |
| |This patient ate in all of the food categories, however she |
|Breakfast: Yogurt |Underrate fruits, vegetables, grains and dairy products |
| |This patient actually overconsumed protein in her diet. |
|Lunch: Fried fish, one cup of green beans and one cup of corn | |
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|Dinner: |I would advise this patient to add more food groups into her |
| |Diet, for example vegetables (squash, zucchini), and dairy |
|Snacks: Pretzels, Apple |(cheese) along with more fruits and grains. |
| |My patient only likes to eat one meal a day, perhaps |
|Liquids (include alcohol): 2 bottles of Water, 1 5oz. glass of red wine |More meals spread out would allow her to plan better and get more of a variety in|
| |her diet |
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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 a reference.|
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| |rains |
| |Vegetables |
| |Fruits |
| |Dairy |
| |Protein Foods |
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|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |
|Who helps you when you are ill? |
|“Husband ” |
|How do you generally cope with stress? or What do you do when you are upset? |
|“Vent, go out on the boat, do something fun.” |
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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? ____Yes___________________________ |
|Have you ever been talked down to?___Yes__________ |
|Have you ever been hit punched or slapped? ___Yes___________ |
|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? |
|_______________________Yes___________________ If yes, have you sought help for this? ____No____________ |
|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: |
| Having a life goal that involves family, a career and society. Having the ability to care for other people or not being able to grow as a person because of self |
|absorption. (Halter Pg. 23) |
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|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |
|My patient is a sixty year old woman, who has had MS for less than five years is on disability and does not work. She has been |
|In and out of the hospital for the last couple of years for miscellaneous things and until recently she has not had a medical |
|Problem that has not been able to be fixed. She is currently not making a contribution to society and I wonder if that will affect how |
|She feels toward herself |
|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |
|My Patient wonders if this disease will keep her going to the hospital again and again until it consumes her financially and |
|Emotionally. She stated earlier that she views sickness as laying in a hospital bed and that is what she is doing but she still views |
|Herself pretty healthy. My patient will eventually start to see that she is sick and that will affect her emotional health. |
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|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” |
|“Infection, somehow my injections for MS contribute to my illness.” |
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|What does your illness mean to you? |
|“Laying in a hospital bed, and unable do daily chores or activities” |
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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?__________Yes__________________________________ |
|Have you or your partner received the Gardasil (HPV) vaccination? _________________No_______________ |
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|Are 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? _______hysterectomy |
|___________________________ |
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|How long have you been with your current partner?________Forty Years ______________________ |
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|Have any medical or surgical conditions changed your ability to have sexual activity? __No__________________ |
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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?
_____”Very important” ________ _______________________________________________
______________________________________________________________________________________________________
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 |
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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? |
| |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? Wine |How much? One glass |For how many years? |
| |Volume: six oz |(age 36 thru 60 ) |
| |Frequency: once a month | |
| If applicable, when did the patient quit? | | |
|N/A |
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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? |
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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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|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 SPF: 30 | Diverticulitis | Life threatening allergic reaction |
|Bathing routine: once a day |Appendicitis | Enlarged lymph nodes |
|Other: | Abdominal Abscess |Other: |
|Be sure to answer the highlighted area | Last colonoscopy? 2008 | |
|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: AB- |
| Post-nasal drip |Normal frequency of urination: 3x/day |Other: |
| Oral/pharyngeal infection | Bladder or kidney infections | |
| Dental problems | |Metabolic/Endocrine |
| Routine brushing of teeth 2x/day | | Diabetes Type: |
| Routine dentist visits 2x/year | | Hypothyroid /Hyperthyroid |
|Vision screening | | Intolerance to hot or cold |
|Other: | | Osteoporosis |
| | |Other: |
|Pulmonary | | |
| Difficulty Breathing | |Central Nervous System |
| Cough - dry or productive |Women Only | CVA |
| Asthma | Infection of the female genitalia | Dizziness |
| Bronchitis | Monthly self breast exam | Severe Headaches |
| Emphysema | Frequency of pap/pelvic exam 1 yr | Migraines |
| Pneumonia | Date of last gyn exam? 11/5/14 | Seizures |
| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |
| Environmental allergies | menarche age? 16 | Encephalitis |
|last CXR? | menopause age? | Meningitis |
|Other: |Date of last Mammogram &Result: 2014, ok |Other: |
| |Date of DEXA Bone Density & Result: 1997 | |
| |11191997,ok | |
|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? 2/3/15 |Arthritis | Chicken Pox |
|Other: Cardio Cath |Other:osteoarthritis |Other: |
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|General Constitution |
|Recent weight loss or gain |
|How many lbs? 12 |
|Time frame? six weeks |
|Intentional? No |
|How do you view your overall health? “healthy” |
|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: |
|Height: 5 3” |
|Weight 89.2 |
|BMI 34.8 |
|Pain: (include rating and location) |
|No Pain |
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|Pulse 85 |
|Blood Pressure: (include location) |
|136/72 RA |
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|Respirations 18 |
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|Temperature: (route taken?) 36.7 Oral |
|SpO2 |
|94% |
|Is the patient on Room Air or O2: |
|Room Air |
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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 |
|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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| Central access device Type: 20 Gage Location: LAC Date inserted: 3/9/15 |
|Fluids infusing? no yes - what? Normal Saline |
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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 4 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |
| Ears symmetric without lesions or discharge Whisper test heard: right ear- 20 inches & left ear- 20 inches |
| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |
|Dentition: |
|Comments: |
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|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |
|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: CL |
|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 3 /10/15 ) 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: |
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|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |
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|Other – Describe: |
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|GU Urine output: Clear Cloudy Color: Yellow Previous 24 hour output: mLs N/A |
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|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |
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|CVA punch without rebound tenderness |
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|Musculoskeletal: ( Full ROM intact in all extremities without crepitus |
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|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] |
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|vertebral column without kyphosis or scoliosis |
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|Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia |
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|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |
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|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |
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|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride |
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|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |
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|Triceps: +2 Biceps: +2 Brachioradial: +2 Patellar: +2 Achilles: +2 Ankle clonus: positive negative Babinski: positive |
|negative |
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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |
|diagnostic tests): |
|Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need prior to and after surgery, and pertinent to |
|hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that |
|is done preop) then include why you expect it to be done and what results you expect to see. |
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|Lab |
|Dates |
|Trend |
|Analysis |
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|Creatinine |
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|3/10/15 |
|3/11/15 |
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|.6 |
|.6 |
|Her Creatinine level did not change. This is a test preformed to test kidney function. |
|This patient is taking many drugs that are metabolized by the kidneys although her creatinine is in the therapeutic range it would be beneficial to keep an eye on |
|this lab. |
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|Mg |
|3/10/15 |
|3/11/15 |
|1.8 |
|1.9 |
|The Mg level has an upward trend. This test is used to asses electrolyte balance |
|This patients Mg is in the normal range of 1.6-2.6, although this person’s Mg may need to be monitored to asses renal function and for dehydration |
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|Potassium |
|3/10/15 |
|3/11/15 |
|3.9 |
|3.9 |
|Her potassium level did not change. Test is used to monitor acidosis, renal failure, dehydration, and monitor the effectiveness of therapeutic interventions, |
|This patient’s potassium is in the normal therapeutic range of (3.5-5.3) The potassium still needs to be monitored because a rising or falling level could interfere |
|with her Na/K+ pump. (Cardiac) |
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|WBC |
|3/8/15 |
|3/10/15 |
|4.7 |
|5.5 |
|Her WBC level has risen in the last two days. This could be to her immune system fighting an infection. |
|This person’s WBC count is in the normal range, however the recent increase in WBC may indicate an infection occurring . |
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|+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.) |
|No accu. Checks were done. –Not a diabetic |
|Diet NPO |
|Colonoscopy- diarrhea, NV, |
|EGD- Gastritis |
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|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
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|1. Deficit Fluid Volume R/t active fluid volume loss AEB N/V, Diarrhea |
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|2. Deficit knowledge R/t Medication AEB: statements made that MS med. influenced her current condition |
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|3. Anxiety r/t health status AEB: weight loss, increased BP |
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|4. Ineffective denial R/t fear of loss of autonomy AEB: changing subject when talking about MS, not wanting any help to |
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|Walk to the bathroom or walk in the hallway. |
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± 15 CARE PLAN
Nursing Diagnosis: Deficit Fluid Volume R/t active fluid volume loss AEB N/V, Diarrhea
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |
| | |Provide References | |
| | | | |
|Control Nausea and vomiting |Administering Zofran |This patient needed medication to control her N/V to |This patient was given Zofran Q4H while in the |
| | |prevent further fluid loss. |hospital. |
|Educated on measures to prevent fluid loss |The BRAT diet |This patient needed to be educated on the BRAT diet |Patient had prior knowledge on the BRAT, I assessed |
| |(Bananas, Rice, Apple sauce, and toast) to decrease |so she has a remedy to try at home when she is |her knowledge and it was adequate. |
| |nausea |discharged. | |
| |Monitor fluid intake and output Q4H |If other means of hydration need to be administered |Urine output was not 30mL per hour because this |
|Maintain a urine output of 30ML per hour | |or increased ie. Increase Normal saline, or increase |patient was NPO that day (she was scheduled for a |
| | |fluid intake then this would be one of the tools used|colonoscopy.) |
| | |to help determine that. | |
| | | | |
|Patient will be able to say what is an appropriate |Educate on diet and fluid intake |This patient eats only one meal a day, rarely snacks |This patient was educated to increase her fluid |
|diet and fluid intake. | |and does not drink enough water throughout the day, |intake up to eight glasses of water a day and to |
| | |which influences her current condition and thus |spread out her meals as well as to include a variety |
| | |making it much worse. |of food in her meals. |
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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 appointments |
|□Med Instruction/Prescription |
|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
Nursing Diagnosis: Deficit knowledge R/t Medication AEB: statements made that MS med. influenced her current condition
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |
| | |Provide References | |
|Identify resources that can be used for information |Teach the patient what the side and adverse effects |This patient incorrectly stated that the MS | The patient was educated and understood that the |
|regarding medications |were for her MS medication |medication influenced her current condition. |medication Avonex did not influence her current |
| | | |condition of N/V and diarrhea. She was able to state |
| |Consult with pharmacy | |what the side and adverse effects were for her MS |
| | | |medication. |
|Ability to identify the rationale for treatment or |Teach the patient how to administer her medication |The patient did not understand what medications and |I explained what medications she was taking, and how |
|medications that she was taking |and EXPLAIN what each medication would be used for |why she was taking during her hospitalization |I would be administering them. I assessed her |
| | | |knowledge when I was finished explaining the |
| | | |medications to her. |
|Ability to identify when to seek health care |Teaching on when to seek professional health when |If the patient has never been taught when to come in |The patient was able to identify when to come into |
|intervention when taking medications at home |taking medications |for help this could lead to permanent damage or can |the hospital for adverse effects that are life |
| | |lead to death depending on the medication |threatening. |
References
Beck, M. (2008). Studies Lead You To Water; But How Much to Drink? Wall Street Journal- Eastern Edition.
Pp. D1-D3.
Halter, M. (2014). Varcarolis' foundations of psychiatric mental health nursing: A clinical approach. (7th ed.,
p. 23). St. Louis, Mo.: Elsevier.
Osborn, K, Wraa, C, Watson, A., & Holleran. (2014). Medical-surgical nursing: Preparation for
practice (2nd ed., p. 620). Upper Saddle River, New Jersey: Boston: Prentice Hall
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