UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Vanessa Munoz |
|Patient Assessment Tool . |Assignment Date: 9/25/15 |
| ( 1 PATIENT INFORMATION |Agency: LRMC |
|Patient Initials: M.M |Age: 68 |Admission Date: 9/21/15 |
|Gender: Female |Marital Status: Divorced |Primary Medical Diagnosis with ICD-10 code: |
| | |715.16 Primary localized osteoarthritis |
|Primary Language: English | |
|Level of Education: College |Other Medical Diagnoses: (new on this admission) |
|Occupation (if retired, what from?): Retired from teaching 1st grade | |
|Number/ages children/siblings: | |
|2 sons (ages 38, 45) | |
|2 brothers | |
|2 sisters (63, 52) | |
|Served/Veteran: No |Code Status: Full code |
|Living Arrangements: |Advanced Directives: |
|Lives at home alone, doesn’t have difficulty getting around on her own |No, does not wish to fill any out at the moment |
| |Surgery Date: 9/21/15 |
| |Procedure: total knee arthroplasty (right) |
|Culture/ Ethnicity /Nationality: Non-Hispanic white | |
|Religion: Church of God |Type of Insurance: Otherins |
|( 1 CHIEF COMPLAINT: |
|“My knee just hurts” |
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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |
|Patient is a 68 year old female who was diagnosed with osteoarthritis in her right knee in 2014. She had a scheduled knee |
|replacement on 9/21. She tolerated the procedure well and recovered in M5. She was pain in her right knee, 4/10. |
|Movement makes the pain worse, and resting relieves the pain. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation
|Date |Operation or Illness |
|Unknown |HTN: propranolol 10mg, 1 tab, oral bid |
|2005 |Malignant GIST: surgery |
|2005 |Hysterectomy |
|( 2|Age (in years) |
|FAM| |
|ILY| |
|MED| |
|ICA| |
|L | |
|HIS| |
|TOR| |
|Y | |
| | |
| |Father: prostate cancer, smoker |
| |Brother: Agent orange from Vietnam |
| |2nd brother: Was in a car accident at 19 that left permanent head trauma |
|( 1 immunization History |
|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |
|Routine childhood vaccinations | | |
|Routine adult vaccinations for military or federal service | | |
|Adult Diphtheria (Date) | | |
|Adult Tetanus (Date) | | |
|Influenza (flu) (Date) | 9/24/15 | |
|Pneumococcal (pneumonia) (Date) | 9/24/15 | |
|Have you had any other vaccines given for international travel or occupational purposes? Please List | | |
|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |
|REACTIONS |Causative Agent | |
|Medications |None | |
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|Other (food, tape, latex, dye, |None | |
|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) |
|Osteoarthritis is a disorder of the synovial joints. A joint is where two bones meet. The ends of bones are covered by |
|articular cartilage which helps the bones glide over each other smoothly (Huether, & McCance, 2008). The articular and |
|cartilage is damaged and lost over the years. Since nothing is covering the ends of the bones anymore they become dense |
|hard. Risk factors include long term stress on the joints, trauma, inflammation of the joints, diabetic neuropathy, skeletal |
|deformities, and taking drugs that stimulate collagen digesting enzymes, such as steroids. Signs and symptoms usually |
|occur later on in life but can start as early as the 40s. These signs and symptoms include joint stiffness, tenderness, |
|deformity, limited range of motion and pain. Osteoarthritis is diagnosed by radiologic studies. Treatment of osteoarthritis |
|includes resting, range of motion exercises, taking anti-inflammatory mediations and pain medications. Another option is |
|surgery. |
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( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]
|Name |Concentration (mg/ml) |Dosage Amount (mg) |
|alendronate |70mg |1 tab |
|Route |Frequency |
|oral |Q week |
|Pharmaceutical class |Home Hospital or Both |
|Bisphosphonates | |
|Indication |
|Treatment of postmenopausal osteoporosis |
|Side effects/ |
|Musculoskeletal pain |
|Headache |
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|Nursing considerations |
|Take first thing in the morning |
|30 minutes before other medications, beverages and food |
|Take with 6-8 ounces of water |
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|Name |Concentration |Dosage Amount |
|apixaban (Eliquis) |1 tab |2.5 mg |
|Route |Frequency |
|oral |bid |
|Pharmaceutical class |Home Hospital or Both |
|Factor xa inhibitor | |
|Indication |
|Decreases risk of stroke/embolism associated with nonvavular afib |
|Side effects/ |
|Bleeding |
|Hypersensitivity reactions |
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|Nursing considerations |
|Inform pt they may bruise and bleed more easily or longer than usual |
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|Name |Concentration |Dosage Amount |
|celecoxib (Celebrex) |100mg |1 cap |
|Route |Frequency |
|oral |daily |
|Pharmaceutical class |Home Hospital or Both |
|Cox-2 inhibitor | |
|Indication |
|Relief of signs and symptoms of osteoarthritis |
|Side effects/ |
|Dizziness |
|Headache |
|Nausea |
|Edema |
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|Nursing considerations |
|Notify health care provider if signs of GI toxicity (abdominal pain, black stools) |
|Name |Concentration |Dosage Amount |
|duloxetine (Cybalta) |20mg |1 cap |
|Route |Frequency |
|Oral |daily |
|Pharmaceutical class |Home Hospital or Both |
|SSNRI | |
|Indication |
|Chronic musculoskeletal pain (from osteoarthritis) |
|Side effects/ |
|Fatigue |
|Drowsiness |
|Insomnia |
|Decreased appetite |
|Dry mputh |
|N/V |
|NSM |
|Dysuria |
|Sweating |
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|Nursing considerations |
|Take at same time each day |
|Alert emergence of anxiety, agitation, panic attacks, insomnia |
|May cause drowsiness so avoid driving and operating heavy machinery |
|Notify health care provider for signs of serotonin syndrome (mental status change, tachycardia, hyperthermia, hyperreflexia, incoordination) |
|Avoid alcohol |
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|Name |Concentration |Dosage Amount |
|lansoprazole (Prevacid) |30 mg |1 cap |
|Route |Frequency |
|Oral |Daily |
|Pharmaceutical class |Home Hospital or Both |
|Proton pump inhibitor | |
|Indication |
|Reduce risk of NSAID associated gastric ulcer |
|Side effects/ |
|Dizziness |
|Headache |
|Diarrhea |
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|Nursing considerations |
|Avoid driving, may cause dizziness |
|Avoid alcohol, NSAIDs, and foods that may cause GI irritation |
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|Name |Concentration |Dosage Amount |
|gabapentin |600mg |2 caps |
|Route |Frequency |
|oral |daily |
|Pharmaceutical class |Home Hospital or Both |
|analgesic adjuncts | |
|Indication |
|Neurotic pain |
|Side effects/ |
|Confusion |
|Depression |
|Dizziness |
|Suicidal thoughts |
|Drowsiness |
|Rhabdomylosis |
|Ataxia |
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|Nursing considerations |
|Do not take within 2 hours of taking an antacid |
|Avoid driving, may cause dizziness |
|Notify if suicidal thoughts occur |
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|Name |Concentration |Dosage Amount |
|propranolol (Inderal) |10 mg |1 tab |
|Route |Frequency |
|Oral |bid |
|Pharmaceutical class |Home Hospital or Both |
|Beta blocker | |
|Indication |
|Management of hypertension |
|Side effects/ |
|Fatigue |
|Weakness |
|Dizziness |
|Erectile dysfunction |
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|Nursing considerations |
|Monitor BP frequently |
|Do not abruptly discontinue |
|Take at the same time each day |
|Tell pt to get up slowly because medication can cause orthostatic hypotension |
|Diabetic pt should monitor BG |
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|Name |Concentration |Dosage Amount |
|aspirin |325 mg |1 tab |
|Route |Frequency |
|oral |daily |
|Pharmaceutical class |Home Hospital or Both |
|salicylates | |
|Indication |
|Osteoarthritis, pain |
|Side effects/ |
|Bleeding |
|Dyspepsia |
|Epigastric distress |
|Tinnitus |
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|Nursing considerations |
|Take with full glass of water |
|Report ringing in ears or abnormal bleeding |
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|Name |Concentration |Dosage Amount |
|pantoprazole |40mg |1 EC tab |
|Route |Frequency |
|oral |daily |
|Pharmaceutical class |Home Hospital or Both |
|Proton pump inhibitor | |
|Indication |
|Reduces heartburn symptoms |
|Side effects/ |
|Headache |
|Pseudomembranous colitis |
|Abdominal pain |
|hypomagnesemia |
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|Nursing considerations |
|Avoid alcohol, NSAIDs and aspirin because it may increase GI irritation |
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|Name |Concentration |Dosage Amount |
|polyethylene glycol |17 mg |1 packet |
|Route |Frequency |
|oral |daily |
|Pharmaceutical class |Home Hospital or Both |
|osmotic | |
|Indication |
|Constipation |
|Side effects/ |
|Uticaria |
|Abdominal bloating |
|Cramping |
|Nausea |
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|Nursing considerations |
|Should not be used for more than 2 weeks |
|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |
|Diet ordered in hospital? Regular |Analysis of home diet (Compare to “My Plate” and |
|Diet pt follows at home? Regular |Consider co-morbidities and cultural considerations): |
|24 HR average home diet: | |
|Breakfast: Either a bowl of yogurt with fruit or cereal and |Pateint |
| |Myplate recommendations |
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|milk |Grains 2oz 6 oz |
|Lunch: light lunch, usually a small piece of meat with a |Veggies 2 ¼ cups 2 ½ cups |
|salad |Fruit 0 2 cups |
|Dinner: Grilled chicken with a side of vegetables and a |Dairy 1 ¼ cups 3 cups |
|salad |Protein 6 oz 5 ½ oz |
|Snacks: Occasionally has popcorn at night |Oils 6 tsp 6 tsp max |
| |Sat. fat 9g 22 g max |
|Liquids (include alcohol): Water with lemon |Unsat fat 2002mg 2300mg max |
| |Empty cal 59 258 max |
| |Total cal 932 2000 max |
|[pic] |My patient has a well balanced diet, there are a few things she lacks in her diet|
| |but she meets most of the goals set my . What I would recommend |
| |for my patient is too eat more grains. She can do this by eating rice with her |
| |lunch or dinner. I would also recommend that she drink a glass of milk before |
| |going to sleep so she can meet her dairy needs. She does eat fruit for breakfast |
| |some days but I would recommend a side of fresh fruit for breakfast or a snack |
| |each day. |
|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |
|Who helps you when you are ill? |
|“somebody from church or my son” |
|How do you generally cope with stress? or What do you do when you are upset? |
|“I pray about it” |
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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |
|None |
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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_____________________________________________ _________ |
|Have you ever been talked down to? ”I think everybody has at one point”______________ _________________ _______ Have you ever been hit punched or slapped? Yes, by|
|her 1st grade students sometimes_______________________ _____ |
|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? |
|_Yes, raped by her father. The first time was at the age of 8_ ___________________________________ ______ |
|If yes, have you sought help for this? _No_ _____________________ |
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|Are you currently in a safe relationship? Yes |
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|( 4 DEVELOPMENTAL CONSIDERATIONS: |
|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |
|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair |
|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |
|patient’s age group: |
|The ego integrity vs despair happens in late adulthood. People in the ego integrity stage are happy with their lives |
|and are proud of their life accomplishments. Those in despair feel like they have not done enough with their life and wish they could |
|have done more and regret not accomplishing their goals earlier in life. (Varcarolis & Halter, 2010) |
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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 in the ego integrity stage. Her age puts her in this stage. My patient told me stories about her life, many things she went |
|through surprised me. She was around alcoholics growing up and was abused as a child, but even if she went through rough times she |
|has a very positive outlook on life. In the short time I talked to her she kept telling me how she was blessed and had many good people |
|in her life. |
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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |
|The osteroarthritis does not seem to have negatively impacted her life. She said she was in pain before the procedure but that she leave |
|wasn’t worried because she previously had a knee replacement on her left knee and it helped her out a lot. She said she was ready to |
|the hospital and go visit her church friends. |
|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” |
|Falling a lot, osteoarthritis |
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|What does your illness mean to you? |
|It meant I couldn’t do the things I liked to do but after this procedure I’ll be able to again |
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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__________________________When sexually active, what measures do you take to prevent acquiring a sexually transmitted |
|disease or an unintended pregnancy? _Birth control pill and a intrauterine device_________________________________ |
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|How long have you been with your current partner?_No current partner_______________________________________ |
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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?
“That’s a biggie, very big part in my life.Without God, I couldn’t do anything.”_______________________________________
Do your religious beliefs influence your current condition?
“Of course, I know I’m going to get better”________________________________________________________________________
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|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |
|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |
| If so, what? |How much?(specify daily amount) |For how many years? X years |
| | |(age thru ) |
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|Pack Years: | |If applicable, when did the patient quit? |
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|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? |
|No | |
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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |
| What? |How much? (give specific volume) |For how many years? |
| | |(age thru ) |
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| If applicable, when did the patient quit? | | |
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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |
| If so, what? |
| |How much? |For how many years? |
| | |(age thru ) |
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| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |
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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |
|No |
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( 10 Review of Systems
|General Constitution |Gastrointestinal |Immunologic |
| Recent weight loss or gain | Nausea, vomiting, or diarrhea- from anesthesia | Chills with severe shaking |
|Integumentary | Constipation- from narcotics after surgery | Night sweats |
| |Irritable Bowel | |
| 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:15 | Diverticulitis | Life threatening allergic reaction |
|Bathing routine: showers every morning |Appendicitis | Enlarged lymph nodes |
|Other | Abdominal Abscess |Other: |
| | Last colonoscopy? 2010 | |
|HEENT |Other: |Hematologic/Oncologic |
| Difficulty seeing |Genitourinary | Anemia |
| Cataracts or Glaucoma- both | 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: O+ |
| Post-nasal drip- since she had chemo |Normal frequency of urination: 3 x/day |Other: |
| Oral/pharyngeal infection | Bladder or kidney infections | |
| Dental problems | |Metabolic/Endocrine |
| Routine brushing of teeth 2 x/day | | Diabetes Type: |
| Routine dentist visits 2 x/year | | Hypothyroid /Hyperthyroid |
|Vision screening- next one scheduled in October | | Intolerance to hot or cold |
|Other: Had cataract surgery and glaucoma | | Osteoporosis |
|stent placed. Has hearing aids | |Other: dx with Raynauds syndrome when she was young |
|Pulmonary | | |
| Difficulty Breathing- only on extreme exertion | |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 |
| |-she used to but not anymore | |
| Pneumonia | Date of last gyn exam? Doesn’t remember | Seizures |
| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |
| Environmental allergies | menarche age? 14 | Encephalitis |
|last CXR? Week of September 14th, 2015 | menopause age? 39 | Meningitis |
|Other: |Date of last Mammogram &Result: June 29, 2015/ clear |Other: |
| |Date of DEXA Bone Density & Result: | |
| |July 9. 2015/ bones are brittle | |
|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, August 2015 |Arthritis | Chicken Pox |
|Other: |Other: |Other: |
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|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |
|No |
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|Any other questions or comments that your patient would like you to know? |
|No |
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|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |
|General Survey: Pt is a well developed 68|Height: 163cm |Weight: 72.3 BMI: 27.2 |Pain: (include rating & location) |
|y/o with no visible signs of distress and| | |4/10, right knee |
|is alert and oriented x3 | | | |
| |Pulse: 98 |Blood 135/65, left arm | |
| | |Pressure: | |
| | |(include location) | |
|Temperature: (route taken?) |Respirations: 18 | | |
|36.8 C, oral | | | |
| |SpO2 92% RA |Is the patient on Room Air or O2: RA |
|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |
| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |
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|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |
| awake, calm, relaxed, interacts well with others, judgment intact |
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|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |
| clear, crisp diction |
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|Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat |
| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |
|Other: |
|Integumentary | |
| Skin is warm, dry, and intact | |
| Skin turgor elastic | |
| No rashes, lesions, or deformities | |
| Nails without clubbing | |
| Capillary refill < 3 seconds | |
| Hair evenly distributed, clean, without vermin | |
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| Peripheral IV site Type: Location: Date inserted: |
| no redness, edema, or discharge |
| Fluids infusing? no yes - what? |
| Peripheral IV site Type: Location: Date inserted: |
| no redness, edema, or discharge |
| Fluids infusing? no yes - what? |
| Central access device Type: Central venous cath Location: left side of chest Date inserted: 9/21/15 |
|Fluids infusing? no yes - what? |
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|HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline |
| Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge |
| Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |
| PERRLA pupil size / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |
| Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches |
| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |
|Dentition: |
|Comments: |
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|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |
| | | Lungs clear to auscultation in all fields without adventitious sounds |
| |CL – Clear |Percussion resonant throughout all lung fields, dull towards posterior bases |
| |WH – Wheezes |Sputum production: thick thin Amount: scant small moderate large |
| |CR - Crackles | Color: white pale yellow yellow dark yellow green gray light tan brown red |
| |RH – Rhonchi | |
| |D – Diminished | |
| |S – Stridor | |
| |Ab - Absent | |
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|Cardiovascular: No lifts, heaves, or thrills PMI felt at: |
|Heart sounds: S1 S2 Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |
|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |
| Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |
|Apical pulse: Carotid: Brachial: Radial: Femoral: Popliteal: DP: PT: |
|No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |
|Location of edema: pitting non-pitting |
|Extremities warm with capillary refill less than 3 seconds |
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|GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |
|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation |
|Urine output: Clear Cloudy Color: Previous 24 hour output: mLs N/A |
|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |
|CVA punch without rebound tenderness |
|Last BM: (date 9 / 23 / 15 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |
|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |
|Hemoccult positive / negative (leave blank if not done) |
|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |
| Other – Describe: |
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|Musculoskeletal: ( Full ROM intact in all extremities without crepitus |
|Strength bilaterally equal at ____5___ RUE ____5___ LUE _not assessed_____ RLE & ____5___ in LLE |
|[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] |
|vertebral column without kyphosis or scoliosis |
|Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias |
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|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |
|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |
|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride |
|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |
|Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: |
|positive negative |
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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 |
| |
|WBC 4.0 |
| |
|Normal: 4.5-11.0 |
|9.9.15 |
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|Only one set |
|WBCs fight infections. A low WBC count means there are less cells available to fight infections. |
| |
|RBC 4.1 |
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|Normal: 3.8-5.1 |
|9.9.15 |
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|Only one set |
|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 |
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|HGB 12.8 |
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|10.2 |
| |
|Normal: 12.0-16.0 |
|9.9.15 |
| |
|9.21.15 |
|The preop hgb value was within normal limits but after surgery the level dropped to an abnormal low level |
|Hgb is the protein that carries oxygen. A low hgb could indicate that the patient lost blood during surgery |
| |
|HCT 38.8 |
| |
|30.8 |
|Normal: 35-45 |
|9.9.15 |
| |
|9.9.15 |
|The preop hct value was within a normal range but decreased to an abnormal level after surgery |
|Hct is the percentage of RBCs in whole blood. A low level could be caused from bleeding during a surgical procedure |
| |
|PT 9.2 |
| |
|Normal: 10-14 sec |
|9.9.15 |
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|Only one set |
|Pt is the amount of time it takes for plasma to clot. It can be used to dx bleeding and clots. Low levels indicate its taking the blood longer to clot. |
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|INR 0.9 |
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|Normal 2-3 |
|9.9.15 |
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|Only one set |
|INR can be done as preop procedure. It is a ratio of the patients pt. Low INR means its taking longer to clot which can make bleeding a problem |
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|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and |
|frequency if applicable.) |
|Patient is on a regular diet at home and hospital. She has HTN but dose well managing it with a diet low in fats |
|and sodium, and by taking her beta-blocker. Her vitals are all within normal range (T-38.6 C, P- 98, BP- 135/65, |
|R-18, O2 92% RA). Vitals were taken q4h at while her stay at the hospital. She tolerates activity well after the |
|knee replacement. She will be going home with home health and her sister will always be staying with her for a |
|few weeks. |
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|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
|1. Impaired physical mobility r/t pain and weakness in knee associated with right knee replacement as evidenced by patient |
|states “my knee hurts when I move it” |
| |
|2. Risk for impaired tissue perfusion r/t surgical procedure |
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|3. Acute pain r/t right knee replacement as evidence by patient rates 4/10 on pain scale |
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|4. |
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|5. |
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± 15 CARE PLAN
Nursing Diagnosis:
|1. Impaired physical mobility r/t pain and weakness in knee associated with right knee replacement as evidenced by patient |
|states “my knee hurts when I move it” |
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |
| | |Provide References | |
|Verbalize feeling of increased ability to move and |Physical therapy: ambulate |Starting mobilization early will help promote |Patient states less pain walking to day than with |
|less pain with physical mobility by time of | |function and reduce pain quicker, this will also |previous day |
|discharge. |Strengthening exercises |decrease risk of medical complications | |
| | | | |
| |Use gait belt |Strengthening exercises prevent weakening of the | |
| | |muscles | |
| | | | |
| | |Using a gait belt is a safety measure to help prevent| |
| | |falls and stabilize patients | |
| | | | |
|Demonstrate use of walker |Teach pt proper technique and have her demonstrate |Using a walker will help patient be more stable while|Patient successfully demonstrated proper use of |
| | |walking and will decrease risk of falls. |walker and used it whenever she wanted to get out of |
| |Make sure patient is using walker each time she gets | |bed |
| |out of bed | | |
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| | | | |
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|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
|Consider the following needs: |
|*SS Consult |
|□Dietary Consult |
|*PT/ OT |
|□Pastoral Care |
|□Durable Medical Needs |
|*F/U appts |
|*Med Instruction/Prescription |
|□ are any of the patient’s medications available at a discount pharmacy? *Yes □ No |
|*Rehab/ HH |
|□Palliative Care |
|Patient will go home with home health, a walker and bedside commode have been provided for her. |
± 15 CARE PLAN
Nursing Diagnosis: Acute pain r/t right knee replacement as evidence by patient rates 4/10 on pain scale
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |
| | |Provide References | |
|Reduce pain from 4/10 or 2/10 by end of shift |Give pain medication that is prescribed at scheduled |Pain medication will help control and reduce the pain|The patient still reported a 4/10 pain level but said|
| |times, if patient wants to take the medication |and will also make the patient be more willing to |it was a tolerable level |
| | |ambulate. In order to know if the pain has gone done,| |
| |Ask patient what their pain level is |the patient has to be asked what their pain level is.| |
| | |An increased HR, BP, and RR can all indicate the | |
| |Make sure patient is ambulating |patient is in pain | |
| | | | |
| |Check vital signs | | |
| | | | |
|Patient will demonstrate how to use |Ask patient what nonpharmacological methods they |Nonpharmacological ways can be a form of distraction |Patient agrees that praying snd reading the bible |
|nonpharmacological methods to help control pain |already know |from the pain |help distract her from the pain |
| | | | |
| |Suggest nonpharmacological ways to control pain, such| | |
| |as meditation, or prayer since patient is religious | | |
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|± DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
| |
|Consider the following needs: |
|□SS Consult |
|□Dietary Consult |
|□PT/ OT |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appts |
|*Med Instruction/Prescription |
|* are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
References
Ackley, B. J. & Ladwig, G. B. (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.
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.
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