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? |

| |

|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: |

| |

|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. |

| |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|WBC 4.0 |

| |

|Normal: 4.5-11.0 |

|9.9.15 |

| |

| |

|Only one set |

|WBCs fight infections. A low WBC count means there are less cells available to fight infections. |

| |

|RBC 4.1 |

| |

|Normal: 3.8-5.1 |

|9.9.15 |

| |

|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 |

| |

|HGB 12.8 |

| |

|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 |

| |

|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. |

| |

|INR 0.9 |

| |

|Normal 2-3 |

|9.9.15 |

| |

|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 |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|+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. |

| |

| |

| |

| |

| |

| |

| |

|( 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 |

| |

| |

|3. Acute pain r/t right knee replacement as evidence by patient rates 4/10 on pain scale |

| |

| |

|4. |

| |

| |

|5. |

| |

| |

± 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 | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|±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 | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|± 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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