UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDACOLLEGE OF NURSING3137535127000Student: Brooke HylerMSI & MSII Patient Assessment ToolAssignment Date: 01/30/15 1 PATIENT INFORMATIONAgency: TGH UDPatient Initials: M.L.Age: 52Admission Date: 01/26/15Gender: MaleMarital Status: MarriedPrimary Medical Diagnosis Primary Language: EnglishCellulitis—682.9Level of Education: 2 Years CollegeOther Medical Diagnoses: (new on this admission)Occupation: Bank ClerkFever—780.60Number/ages children/siblings: 2 Daughters (ages 22 & 20)Superficial Thrombophlebitis—451.9No Siblings Served/Veteran: NOIf yes: Ever deployed? Yes or NoCode Status: Full CodeLiving Arrangements: Patient lives in a house in the city with his wife and dog.Advanced Directives: YesIf no, do they want to fill them out?Surgery Date: No Surgery Procedure: NoneCulture/ Ethnicity /Nationality: American/CaucasianReligion: NoneType of Insurance: Hillsborough Healthcare 1 CHIEF COMPLAINT: “My left foot starting swelling and hurting really bad.” “I thought it was a flu-like symptom.” 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)A 52 year old male presented to the Emergency Department on 01/26/15 with complaints of left lowerextremity pain and swelling. Patient reports he attributed the swelling and symptoms to recent flu-likesymptoms. He reported associated symptoms of subjective fever, chills, and headache. Patient’s left lowerextremity developed worsening edema, pain, and erythema upon hospitalization. Patient reports an associated5/10 pain score. He explains that the pain worsens to a 7/10 pain score upon exertion and ambulation to thebathroom. Patient denies any other aggravating symptoms including chest pain, dyspnea, numbness or tinglingin the affected extremity. Patient explains the swelling had started on 01/25/15 and worsened on 01/26/15. Patient reports extreme pain associated with an accompanied headache and has been taking 250mg of Tylenol for the past two weeks (since 01/11/15). Patient expresses willingness to eliminate his headache. Patient’s pain,swelling, and accompanied headache are currently being monitored and controlled through scheduledmedications. 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of diseaseDate Operation or Illness2000Vascular Surgery09/27/13Deep Vein Thrombosis (DVT)09/27/13Hx of blood transfusion09/27/13Duodenal ulcer10/16/13Lung Surgery10/16/13Vein Ligation 2 FAMILY MEDICAL HISTORYAge (in years)Cause of Death (if applicable)AlcoholismEnvironmental AllergiesAnemiaArthritisAsthmaBleeds EasilyCancerDiabetesGlaucomaGoutHeart Trouble(angina, MI, DVT etc.)HypertensionKidney ProblemsMental Health ProblemsSeizuresStomach UlcersStrokeTumorFather76 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mother74 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Daughter22 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Grandfather (paternal)60Stroke FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Daughter’s asthma onset: 2009Paternal Grandfather died of stroke in 1991.Patient cannot recall any other family history onset dates for anything else listed above. 1 immunization History (May state “U” for unknown, except for Tetanus, Flu, and Pna)YesNoRoutine childhood vaccinations FORMCHECKBOX FORMCHECKBOX Routine adult vaccinations for military or federal service FORMCHECKBOX FORMCHECKBOX Adult Diphtheria (Date unknown) FORMCHECKBOX FORMCHECKBOX Adult Tetanus (Date unknown) FORMCHECKBOX FORMCHECKBOX Influenza (flu) (Every year) FORMCHECKBOX FORMCHECKBOX Pneumococcal (pneumonia) (Date unknown) FORMCHECKBOX FORMCHECKBOX Have you had any other vaccines given for international travel or occupational purposes? NONE FORMCHECKBOX FORMCHECKBOX 1 ALLERGIES OR ADVERSE REACTIONSNAME of Causative AgentType of Reaction (describe explicitly)MedicationsNONENONEOther (food, tape, latex, dye, etc.)NONENONE 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)The patient was admitted to the hospital with redness, swelling, edema, and pain associated with cellulitis. Cellulitisis an infection of the dermis and subcutaneous tissue usually caused by Staphylococcus aureus (Huether, pg. 1053). Cellulitis can occur as a secondary cause to multiple different skin disorders, or injuries. It can be secondary to a skinwound, or ulcer. The infected area is warm, erythematous, swollen, and painful. Typically cellulitis is localized to thelower extremities versus any other area of the body. Risk factors include people who have had known injuries, weakenedimmune systems, skin conditions, chronic swelling of the arms of legs, obesity and history of cellulitis (Huether, pg. 1053). There are no found genetic factors associated with cellulitis. This infection can be treated with systemic antibiotics,as well as therapy to relieve any associated pain that may accompany the infection. Generally cellulitis can be associatedwith other vasculature issues such as chronic venous insufficiency and stasis dermatitis (Huether, pg. 1053). 5 Medications: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN medication . Give trade and generic name.]Name acetaminophen (Tylenol)ConcentrationDosage Amount 325 mgRoute OralFrequency Q 4 hours PRNPharmaceutical class Non-opioid analgesics; antipyreticsHome Hospital or BothIndication Relief of moderate pain associated with headache.Adverse/ Side effects Hepatotoxicity, increased liver enzymes, renal failure, acute generalized exanthematous pustulosis, Stevens-Johnson syndrome, toxic epidermal necrolysis.Nursing considerations/ Patient Teaching Use cautiously in hepatic/renal disease and alcoholism; Monitor for possible increases in serum bilirubin, LDH, AST, ALT, and prothrombin time [may indicate hepatotoxicity]; Teach patients that chronic excessive use of >4 g/day may lead to hepatotoxicity, renal or cardiac damage. Advise patient to avoid alcohol and to discontinue it and contact a health care provider if rash occurs.Name docusate sodium (Colace)ConcentrationDosage Amount 100 mgRoute OralFrequency 2 times DailyPharmaceutical class Stool softeners; laxativesHome Hospital or BothIndication Management of regular voidance.Adverse/ Side effects Mild cramps, diarrhea, throat irritation, rashes.Nursing considerations/ Patient Teaching Excessive or prolonged use may lead to dependence; should not be used if prompt results are desired. Inform patient that laxatives should be used only for short-term therapy. Advise patient to not use laxatives when abdominal pain, nausea, vomiting, or fever is present.Name doxycycline (Vibramycin)Concentration 100 mL/hrDosage Amount 100 mg IVPB in sodium chloride 0.9%Route IntravenousFrequency Q 12 hoursPharmaceutical class Tetracyclines; anti-infectivesHome Hospital or BothIndication Eradication of cellulitis infectionAdverse/ Side effects Pseudomembranous colitis; drug rash with eosinophilia and systemic symtoms; erythema multiforme; Stevens-Johnson syndrome; toxic epidermal necrolysis; diarrhea; nausea; vomiting; photosensitivity; phlebitis at IV site.Nursing considerations/ Patient Teaching Monitor bowel function and assess for rash periodically during therapy. Assess IV site frequently for signs of thrombophlebitis. May decrease the effectiveness of estrogen-containing oral contraceptives. Instruct patient to notify healthcare professional immediately if rash, diarrhea, abdominal cramping, fever, or bloody stools occur.Name enoxaparin (Lovenox)ConcentrationDosage Amount 40 mgRoute SubcutaneousFrequency DailyPharmaceutical class Anti-thrombotics; anti-coagulantsHome Hospital or BothIndication DVT prophylaxisAdverse/ Side effects Bleeding, anemia, hyperkalemia, increased liver enzymes, nausea, alopecia.Nursing considerations/ Patient Teaching Assess for signs of bleeding and hemorrhage (bleeding gums, nosebleed, etc.) Monitor CBC, platelet count, and stools for occult bleeding during therapy. Advise patient to report any signs and symptoms of unusual bleeding or brusing.Name ondansetron (Zofran)ConcentrationDosage Amount 4 mgRoute OralFrequency Q 6 hours PRNPharmaceutical class Five ht3 antagonists; anti-emeticsHome Hospital or BothIndication Management of nausea/vomitingAdverse/ Side effects Headache, dizziness, drowsiness, torsade de pointes, QT interval prolongation, constipation, diarrhea, abdominal pain.Nursing considerations/ Patient Teaching Monitor ECG in patients with hypokalemia, hypomagnesemia, HF, bradyarrhythmias, or patients taking medications that prolong QT interval. Advise patient to notify healthcare provider immediately if symptoms of irregular heart beat occurs.Name pantoprazole (Protonix)ConcentrationDosage Amount 40 mgRoute OralFrequency DailyPharmaceutical class Proton pump inhibitors; anti-ulcer agentsHome Hospital or BothIndication Peptic ulcer prophylaxisAdverse/ Side effects Pseudomembranous colitis, abdominal pain, diarrhea, flatulence, hypermagnesemia.Nursing considerations/ Patient Teaching Use cautiously in patients using high-doses for >1 year. May cause abnormal liver function tests and may cause hypermagnesemia. Monitor bowel function. Instruct patient to notify healthcare professional immediately if rash, diarrhea, abdominal cramping, fever, or bloody stools occur.Name VancomycinConcentration 1 gram/200mL200mL/hrDosage Amount 1,000 mg IVPB in D5WRoute IntravenousFrequency Q 8 hoursPharmaceutical class Anti-infectivesHome Hospital or BothIndication Eradication of cellulitis infectionAdverse/ Side effects Nephrotoxicity, phlebitis, hypersensitivity reactions including anaphylaxis, chills, fever, “red man” syndrome.Nursing considerations/ Patient Teaching Monitor IV site closely for any signs of irritation. Observe patient for signs and symptoms of anaphylaxis. Use cautiously in renal impairment and intestinal obstruction. Instruct patient to notify healthcare professional if symptoms of hypersensitivity, tinnitus, vertigo, or hearing loss occur. 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.Diet ordered in hospital? Regular DietAnalysis of home diet (Compare to “My Plate” and Diet patient follows at home? Regular DietConsider co-morbidities and cultural considerations):24 HR average home diet:In relation to “My Plate,” the patient follows a relativelyBreakfast: Bagel/ Cream cheese/ 2 scrambled eggshealthy diet excluding his fast-food intake during lunch. The patient’s diet is sufficient in protein, howeverLunch: Ham Sandwich: 2 slices of Ham/ 2 slices of cheese/ consuming more lean meat proteins instead of fatty meats Lettuce/ Tomatoes. Soup: Chicken Noodle Soup, Tomato Soup (3 cups). Fastfood: McDonald’s Double Cheeseburger/ Medium Fry/ Crispy Chicken Sandwich/ Filet-O-Fishwould be healthier for his diet. According to “My Plate,” the patient is lacking is sufficient fruits, vegetables, grains, and dairy throughout his 24 hour daily consumption. It would be recommended that this patient eat a diet lower inDinner: Chicken Breast with Rice (2 cups)/ 8oz. Steak/ Mashed Potatoes (1 ? cups)/ Fried Chicken Strips/ Corn (1/2 cup)/ Peas (1/2 cup)fats and sugar, and higher in lean protein mixed with healthy greens. Also according to “My Plate,” the patient drinks a healthy amount of liquids. The recommendedwater intake is 2-2.5 liters, without the consumption ofSnacks: Patient reports that he typically does not snack.carbonated sugar drinks like soda. The patient’s 24 hourdiet follows these guidelines. Overall, according to “MyLiquids (include alcohol): Water (2-2.5 liters)/ Apple Juice (8-16oz)/ Tea (8-16 oz)/ Beer rarely and socially (8oz.)Plate,” the patient is consuming a relatively healthy diet with recommendations to exclude fast foods and increase his intake of lean proteins, fruits, grains, vegetables, and dairy.1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)Who helps you when you are ill?Patient states that his wife is his support when he is ill. (Wife is present at bedside throughout shift.)How do you generally cope with stress? or What do you do when you are upset?Patient explains that he likes to sit out on his back porch with his dog when he is stressed or upset.Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)Patient denies and recent difficulties. Patient expresses mild anxiety about his current hospitalization.+2 DOMESTIC VIOLENCE ASSESSMENT 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.”Have you ever felt unsafe in a close relationship? No, never.Have you ever been talked down to? No. Have you ever been hit punched or slapped?? No.Have you been emotionally or physically harmed in other ways by a person in a close relationship with you??No. If yes, have you sought help for this?? NONE.Are you currently in a safe relationship?Patient states, “Yes I am in a safe relationship.” 4 DEVELOPMENTAL CONSIDERATIONS:Erikson’s stage of psychosocial development: FORMCHECKBOX Trust vs. FORMCHECKBOX Mistrust FORMCHECKBOX Autonomy vs. FORMCHECKBOX Doubt & Shame FORMCHECKBOX Initiative vs. FORMCHECKBOX Guilt FORMCHECKBOX Industry vs. FORMCHECKBOX Inferiority FORMCHECKBOX Identity vs. FORMCHECKBOX Role Confusion/Diffusion FORMCHECKBOX Intimacy vs. FORMCHECKBOX Isolation FORMCHECKBOX Generativity vs. FORMCHECKBOX Self absorption/Stagnation FORMCHECKBOX Ego Integrity vs. FORMCHECKBOX DespairCheck one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your patient’s age group: The stage Generativity vs. Stagnation is the stage that takes place during middle adulthood between the ages of approximately 40 and 65. During this time, adults strive to create or nurture things that will outlast them in life such as family and careers. They often have their children contribute to positive changes that benefit other people. If they fail to do this, they may become stagnant and feel as though they do not do anything good for the world.Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:The patient is in the stage Generativity vs. Stagnation while showing signs of Generativity. Upon interaction with the patient, he had positive comments regarding his two daughters and what they were doing in college. He seemed proud to be their father and seemed to enjoy positively bragging about their achievements.Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:The patient’s hospitalization did not seem to affect his developmental stage of life due to his apparent character and his expressive fulfillment when sharing information about his daughter’s achievements.+3 CULTURAL ASSESSMENT: “What do you think is the cause of your illness?”Patient reports, “I don’t know what caused my illness, I thought it was from the flu.”What does your illness mean to you?Patient expresses that his illness “doesn’t mean anything” to him. +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”Have you ever been sexually active? Yes Do you prefer women, men or both genders? WomenAre you aware of ever having a sexually transmitted infection? No, never Have you or a partner ever had an abnormal pap smear? No. Have you or your partner received the Gardasil (HPV) vaccination? Yes (wife has) 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?? Usage of condoms.How long have you been with?your current partner? 28 yearsHave any medical or surgical conditions changed your ability to have sexual activity?? NoDo you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?No, none.±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)What importance does religion or spirituality have in your life? Patient reports, “My wife and I are not religious.”Do your religious beliefs influence your current condition?Patient does not believe in anything religious and therefore does not believe anything influences his current condition.+3 Smoking, Chemical use, Occupational/Environmental Exposures:1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No If so, what? How much?(specify daily amount)For how many years? N/A yearsN/AN/A(age thru )N/APack Years: N/AIf applicable, when did the patient quit?N/ADoes anyone in the patient’s household smoke tobacco? If so, what, and how much? NOHas the patient ever tried to quit? N/AIf yes, what did they use to try to quit? N/A2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No What? Beer, sociallyHow much? For how many years?Volume: 8oz.(age 21 thru 52 )Frequency: “Rarely” If applicable, when did the patient quit?NEVER3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No If so, what?N/AHow much?For how many years?N/A(age thru )N/A Is the patient currently using these drugs? Yes NoIf not, when did he/she quit?N/A4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/RisksNONE5. For Veterans: Have you had any kind of service related exposure?N/A 10 Review of Systems NarrativeGastrointestinalImmunologic FORMCHECKBOX Nausea, vomiting, or diarrhea FORMCHECKBOX Chills with severe shakingIntegumentary FORMCHECKBOX Constipation FORMCHECKBOX Irritable Bowel FORMCHECKBOX Night sweats FORMCHECKBOX Changes in appearance of skin (swelling and redness in LLE) FORMCHECKBOX GERD FORMCHECKBOX Cholecystitis FORMCHECKBOX Fever FORMCHECKBOX Problems with nails FORMCHECKBOX Indigestion FORMCHECKBOX Gastritis / Ulcers (Duodenal Ulcer 2013) FORMCHECKBOX HIV or AIDS FORMCHECKBOX Dandruff FORMCHECKBOX Hemorrhoids FORMCHECKBOX Blood in the stool FORMCHECKBOX Lupus FORMCHECKBOX Psoriasis FORMCHECKBOX Yellow jaundice FORMCHECKBOX Hepatitis FORMCHECKBOX Rheumatoid Arthritis FORMCHECKBOX Hives or rashes FORMCHECKBOX Pancreatitis FORMCHECKBOX Sarcoidosis FORMCHECKBOX Skin infections Cellulitis LLE FORMCHECKBOX Colitis FORMCHECKBOX Tumor FORMCHECKBOX Use of sunscreen SPF: 30 FORMCHECKBOX Diverticulitis FORMCHECKBOX Life threatening allergic reactionBathing routine: Once nightly FORMCHECKBOX Appendicitis FORMCHECKBOX Enlarged lymph nodesOther: FORMCHECKBOX Abdominal AbscessOther: FORMCHECKBOX Last colonoscopy? 2012HEENTOther:Hematologic/Oncologic FORMCHECKBOX Difficulty seeing Genitourinary FORMCHECKBOX Anemia FORMCHECKBOX Cataracts or Glaucoma FORMCHECKBOX nocturia FORMCHECKBOX Bleeds easily FORMCHECKBOX Difficulty hearing FORMCHECKBOX dysuria FORMCHECKBOX Bruises easily FORMCHECKBOX Ear infections FORMCHECKBOX hematuria FORMCHECKBOX Cancer FORMCHECKBOX Sinus pain or infections FORMCHECKBOX polyuria FORMCHECKBOX Blood Transfusions FORMCHECKBOX Nose bleeds FORMCHECKBOX kidney stonesBlood type if known: A FORMCHECKBOX Post-nasal dripNormal frequency of urination: 5x/dayOther: FORMCHECKBOX Oral/pharyngeal infection FORMCHECKBOX Bladder or kidney infections FORMCHECKBOX Dental problemsMetabolic/Endocrine FORMCHECKBOX Routine brushing of teeth 2x/day FORMCHECKBOX Diabetes Type: FORMCHECKBOX Routine dentist visits 2x/year FORMCHECKBOX Hypothyroid /Hyperthyroid FORMCHECKBOX Vision screening FORMCHECKBOX Intolerance to hot or coldOther: FORMCHECKBOX OsteoporosisOther:Pulmonary FORMCHECKBOX Difficulty BreathingCentral Nervous System FORMCHECKBOX Cough - dry or productiveWomen Only (DOES NOT APPLY) FORMCHECKBOX CVA FORMCHECKBOX Asthma FORMCHECKBOX Infection of the female genitalia FORMCHECKBOX Dizziness FORMCHECKBOX Bronchitis FORMCHECKBOX Monthly self breast exam FORMCHECKBOX Severe Headaches FORMCHECKBOX Emphysema FORMCHECKBOX Frequency of pap/pelvic exam FORMCHECKBOX Migraines FORMCHECKBOX Pneumonia Date of last gyn exam? FORMCHECKBOX Seizures FORMCHECKBOX Tuberculosis FORMCHECKBOX menstrual cycle regular irregular FORMCHECKBOX Ticks or Tremors FORMCHECKBOX Environmental allergies FORMCHECKBOX menarche age? FORMCHECKBOX Encephalitis FORMCHECKBOX last CXR? 2013 FORMCHECKBOX menopause age? FORMCHECKBOX MeningitisOther:Date of last Mammogram &Result:Other:Date of DEXA Bone Density & Result:CardiovascularMen OnlyMental Illness FORMCHECKBOX Hypertension FORMCHECKBOX Infection of male genitalia/prostate? FORMCHECKBOX Depression FORMCHECKBOX Hyperlipidemia FORMCHECKBOX Frequency of prostate exam? NEVER FORMCHECKBOX Schizophrenia FORMCHECKBOX Chest pain / Angina Date of last prostate exam? NEVER FORMCHECKBOX Anxiety FORMCHECKBOX Myocardial Infarction FORMCHECKBOX BPH FORMCHECKBOX Bipolar FORMCHECKBOX CAD/PVD FORMCHECKBOX Urinary RetentionOther: FORMCHECKBOX CHFMusculoskeletal FORMCHECKBOX Murmur FORMCHECKBOX Injuries or FracturesChildhood Diseases FORMCHECKBOX Thrombus (DVT 2013) FORMCHECKBOX Weakness FORMCHECKBOX Measles FORMCHECKBOX Rheumatic Fever FORMCHECKBOX Pain FORMCHECKBOX Mumps FORMCHECKBOX Myocarditis FORMCHECKBOX Gout FORMCHECKBOX Polio FORMCHECKBOX Arrhythmias FORMCHECKBOX Osteomyelitis FORMCHECKBOX Scarlet Fever FORMCHECKBOX Last EKG screening, when? 2013 FORMCHECKBOX Arthritis FORMCHECKBOX Chicken PoxOther:Other:Other:General Constitution FORMCHECKBOX Recent weight loss or gainHow many lbs?Time frame?Intentional?How do you view your overall health? “Healthy, except my legs.”Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No, none.Any other questions or comments that your patient would like you to know?Patient does not report any other questions or comments.±10 PHYSICAL EXAMINATION:General Survey: A&O x4Height: 6’9”Weight: 215 lbs.BMIPain: 5/10 in left foot and in head from headache.Pulse: 61Blood Pressure: 115/76 (Right arm)Respirations: 19Temperature: 97.5 F (Oral)SpO2: 100%Is the patient on Room Air or O2: Room AirOverall Appearance: [Dress/grooming/physical handicaps/eye contact] FORMCHECKBOX clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicapsOverall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] FORMCHECKBOX awake, calm, relaxed, interacts well with others, judgment intactSpeech: [e.g.: clear/mumbles /rapid /slurred/silent/other] FORMCHECKBOX clear, crisp dictionMood and Affect: FORMCHECKBOX pleasant FORMCHECKBOX cooperative FORMCHECKBOX cheerful FORMCHECKBOX talkative FORMCHECKBOX quiet FORMCHECKBOX boisterous FORMCHECKBOX flat FORMCHECKBOX apathetic FORMCHECKBOX bizarre FORMCHECKBOX agitated FORMCHECKBOX anxious FORMCHECKBOX tearful FORMCHECKBOX withdrawn FORMCHECKBOX aggressive FORMCHECKBOX hostile FORMCHECKBOX loud Other:Integumentary FORMCHECKBOX Skin is warm, dry, and intact FORMCHECKBOX Skin turgor elastic FORMCHECKBOX No rashes, lesions, or deformities FORMCHECKBOX Nails without clubbing FORMCHECKBOX Capillary refill < 3 seconds FORMCHECKBOX Hair evenly distributed, clean, without verminSuperficial thrombophlebitis apparent with a darkened skin tone on LLE.Cellulitis localized to the patient’s left foot. FORMCHECKBOX Central access device Type: Peripheral IV 20 gauge 1 ? length Location: Right AC Date inserted: 01/27/15 Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what? 0.9% NaCl with 100mg Vibramycin IVPB Q 12 hours and 1,000mg Vancomycin Q 8 hours at different times. HEENT: FORMCHECKBOX Facial features symmetric FORMCHECKBOX No pain in sinus region FORMCHECKBOX No pain, clicking of TMJ FORMCHECKBOX Trachea midline FORMCHECKBOX Thyroid not enlarged FORMCHECKBOX No palpable lymph nodes FORMCHECKBOX sclera white and conjunctiva clear; without discharge FORMCHECKBOX Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness FORMCHECKBOX PERRLA pupil size 3/3 mm FORMCHECKBOX Peripheral vision intact FORMCHECKBOX EOM intact through 6 cardinal fields without nystagmus FORMCHECKBOX Ears symmetric without lesions or discharge FORMCHECKBOX Whisper test heard: right ear- 15 inches & left ear- 15 inches FORMCHECKBOX Nose without lesions or discharge FORMCHECKBOX Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesionsDentition: No present problems with DentitionComments:Pulmonary/Thorax: FORMCHECKBOX Respirations regular and unlabored FORMCHECKBOX Transverse to AP ratio 2:1 FORMCHECKBOX Chest expansion symmetric FORMCHECKBOX Percussion resonant throughout all lung fields, dull towards posterior bases FORMCHECKBOX Sputum production: thick thin Amount: scant small moderate large Color: white pale yellow yellow dark yellow green gray light tan brown red No sputum productionLung sounds: RUL CL LUL CLRML CL LLL CLRLL CLCL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - AbsentCardiovascular: FORMCHECKBOX No lifts, heaves, or thrills Heart sounds: FORMCHECKBOX S1 S2 audible FORMCHECKBOX Regular FORMCHECKBOX Irregular FORMCHECKBOX No murmurs, clicks, or adventitious heart sounds FORMCHECKBOX No JVDRhythm (for patients with ECG tracing – tape 6 second strip below and analyze)7429538735Patient’s ECG tracing showed a Sinus Rhythm. FORMCHECKBOX Calf pain bilaterally negative FORMCHECKBOX Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3 FORMCHECKBOX No temporal or carotid bruits Edema: +1 LLE [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]Location of edema: LLE localized to the left foot pitting non-pitting FORMCHECKBOX Extremities warm with capillary refill less than 3 seconds Warm, red, and swollen left footGI FORMCHECKBOX Bowel sounds active x 4 quadrants; no bruits auscultated FORMCHECKBOX No organomegaly FORMCHECKBOX Percussion dull over liver and spleen and tympanic over stomach and intestine FORMCHECKBOX Abdomen non-tender to palpationLast BM: (date 01 / 28 / 15 ) Formed Semi-formed Unformed Soft Hard Liquid Watery Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red FORMCHECKBOX Nausea FORMCHECKBOX Emesis Describe if present: NONEGenitalia: FORMCHECKBOX Clean, moist, without discharge, lesions or odor FORMCHECKBOX Not assessed, patient alert, oriented, denies problems Other – Describe:GU Urine output: FORMCHECKBOX Clear FORMCHECKBOX Cloudy Color: Light yellow Previous 24 hour output: 2,480mLs FORMCHECKBOX Foley Catheter FORMCHECKBOX Urinal or Bedpan FORMCHECKBOX Bathroom Privileges without assistance or with assistance FORMCHECKBOX CVA punch without rebound tenderness Musculoskeletal: FORMCHECKBOX Full ROM intact in all extremities without crepitus FORMCHECKBOX Strength bilaterally equal at ___5/5____ RUE ____5/5___ LUE ___5/5____ RLE & ___3/5____ 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] FORMCHECKBOX Vertebral column without kyphosis or scoliosis FORMCHECKBOX Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesiaNeurological: FORMCHECKBOX Patient awake, alert, oriented to person, place, time, and date FORMCHECKBOX Confused; if confused attach mini mental exam FORMCHECKBOX CN 2-12 grossly intact FORMCHECKBOX Sensation intact to touch, pain, and vibration FORMCHECKBOX Romberg’s Negative FORMCHECKBOX Stereognosis, graphesthesia, and proprioception intact FORMCHECKBOX Gait smooth, regular with symmetric length of the strideDTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]Triceps: 2 Biceps: 2 Brachioradial: 2 Patellar: 2 Achilles: 2 Ankle clonus: positive negative Babinski: positive negative ±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):LabDatesTrendAnalysisCBCWBCNormal (4.6-10.2 k/ul)On Admission: 13.43 (HIGH)Current: 9.32RBCNormal (4.69-6.13 m/ul)On Admission: 4.86Current: 4.50 (LOW)HemoglobinNormal (14.1-18.1 g/dl)On Admission: 14.2Current: 13.4 (LOW)HematocritNormal (43.5-53.7%)On Admission: 41.3 (LOW)Current: 38.6 (LOW)Platelet CountNormal (142-424 k/ul)On Admission: 180Current: 159(01/26/15)(01/30/15)(01/26/15)(01/30/15)(01/26/15)(01/30/15)(01/26/15)(01/30/15)(01/26/15)(01/30/15)Upon reviewing the results of the patient’s lab values in reference to the CBC, the patient’s WBC was significantly higher than the normal range upon admission. However, the patient’s WBC is trending downward throughout his hospitalization as seen by his current value of 9.32, being within defined limits. The patient’s hematocrit levels were lower than the normal range both at the time of admission and in his current hospitalization date, showing no real trend. However, both the patient’s RBC and hemoglobin levels trended downward with hospitalization as they were both within normal limits at the time of admission. The platelet count is also within normal limits both currently and at the time of admission, again showing no real trend.When the patient was admitted to the hospital, his WBC was significantly higher than the normal range. The patient was admitted with redness, swelling, and pain associated with his left foot. These objective findings, along with an elevated WBC, are indicative of an infection or inflammatory process. The patient was diagnosed with cellulitis, a bacterial infection of the skin, further explaining his elevated WBC upon admission. However his current WBC has trended downward due to the nursing interventions put to work including the usage of antibiotics, antipyretics, and ACE bandage wraps to aid in the eradication of the infection and associated swelling. The patient’s RBC, hemoglobin, and hematocrit levels were all trending downward to a value lowered than defined limits. There are many possibilities and factors that affect these values. In this patient, these decreased levels can be indicative of decreased oxygenation tissue perfusion in relative to his cellulitis infection. Another plausible cause of decreased RBC, hemoglobin, and hematocrit could be related to nutrition deficiency or anemia. This patient has a relatively healthy diet, but was missing some essential nutrients in his diet according to “My Plate.” The patient’s platelet count is within normal range indicating that he has sufficient clotting factors. It is important to always monitor platelet count in case of an emergency surgery that may need to take place.Metabolic PanelSodiumNormal (135-145 meq/L)On Admission: 138Current: 140PotassiumNormal (3.5-5.3 mmol/L)On Admission: 3.7Current: 3.8ChlorideNormal (98-107 meq/L)On Admission: 103Current: 106BUNNormal (6.0-20 mg/dl)On Admission: 12Current: 7CreatinineNormal (0.72-1.25)On Admission: 1.0Current: 0.8(01/26/15)(01/30/15)(01/26/15)(01/30/15)(01/26/15)(01/30/15)(01/26/15)(01/30/15)(01/26/15)(01/30/15)There is no relevant trend among the patient’s sodium, potassium, chloride, BUN, and creatinine levels. Both currently and upon admission, these lab values were within normal limits. No changes The patient has normal levels of sodium, chloride, and potassium, indicating that this patient has balanced electrolytes with no identifiable insufficiencies. This panel also showed the patient’s BUN and creatinine levels as being within defined limits, relaying proper and adequate kidney function. It is always important to monitor electrolytes and kidney function to ensure there are no complications either related to the patient’s medications or plan of care.Liver UltrasoundAST (SGOT)Normal (5-34 IU/L)On Admission: 62 (HIGH)Current: 81 (HIGH)ALT (SGPT)Normal (5-55 IU/L)On Admission: 91 (HIGH)Current: 135 (HIGH)(01/30/15)(01/26/15)(01/30/15)(01/26/15)(01/30/15)During my shift the patient was ordered to receive a liver ultrasound relative to his significantly high liver function tests. Both currently and upon admission, the patient’s AST and ALT levels were higher than the normal range. Likewise, both of these levels have trended upward throughout the patient’s hospital stay. An increase in the levels of AST and ALT can be related to liver damage or liver injury. Although, elevated AST and ALT levels often are indicative of this, there are a number of other plausible causes, including adverse effects from certain medications, or the over-usage of certain medications. This patient is currently prescribed Lovenox and acetaminophen, both of which have adverse and side effects of increased liver enzymes. The patient reported that he has been taking 250mg of acetaminophen for the past two weeks (01/11/15). Continual usage of these medications can possibly give cause to the reasoning behind an elevated AST and ALT level. This patient’s liver ultrasound was ordered during my shift (01/30/15) and the results were had not yet been received. If the results had come during my shift, I would conclude that this patient’s elevated AST and ALT levels are related to the over-usage of medications affecting the liver. +2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: Patient is currently on a regular diet. A liver ultrasound has been scheduled to determine the reasoning behind his elevated liver function tests. Patient is limited to decreased mobility and needs assistance with voidance (ambulation to the restroom or assistance getting to the bed-side urinal). Patient is currently receiving prescribed antibiotic therapy regimen. Vitals are stable: BP: 115/76 Pulse: 61 Respirations: 19 Temperature: 97.5 F (oral) SpO2: 100% and current pain score is 5/10 localized to the LLE. 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)1. Ineffective peripheral tissue perfusion related to cellulitis as evidenced by edema, redness without blanching, swelling, and pain to the patient’s left lower extremity.2. Limited mobility related to left lower extremity cellulitis as evidenced by decreased movement and reported worsening pain upon ambulation.3. Acute pain related to irritation of the skin related to cellulitis as evidenced by patient’s subjective 5/10 pain score.4. 5.± 15 CARE PLANNursing Diagnosis: Ineffective peripheral tissue perfusion related to cellulitis as evidenced by edema, redness without blanching, swelling, and pain to the patient’s left lower extremity.Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Goal on Day Care is ProvidedPatient will show decreased signs and symptoms of cellulitis including edema, swelling, and redness during my shift (0645-1530).Throughout entire shift (0645-1530), administer both antibiotics (Vancomycin and Vibramycin) to the patient as prescribed by the physician.Patient’s affected with any type of infection are at an increased risk of developing secondary complications. Among these complications may include necrosis, amputation, sepsis, and even death. For patients with cellulitis, or any spectrum of bacterial infection, it is highly recommended to immediately get started on an antibiotic therapy regimen. Antibiotics work to eliminate bacterial cells in the body to decrease the reproduction of any further bacterial cells, resulting in an elimination of an infection. It is crucial to always ensure that the patient is receiving his/or her antibiotic therapy as appropriately scheduled in order to adequately attack the infection.Throughout my entire shift (0645-1530), the patient received all scheduled antibiotic therapy regimens as prescribed. The nurse and I ensured that the patient understood why he was receiving these antibiotics and for how long they would be infusing into his bloodstream. Patient was compliant in receiving all antibiotic medications throughout my shift. The patient’s swelling, edema, and redness had not significantly decreased during my shift. However, the goal is on-going and will continue to be assessed.Wrap ACE bandage around affected lower left extremity and ensure the patient’s affected leg remains comfortably elevated to decrease swelling while promoting venous return. The usage of ACE bandages promotes venous return, which allows affected tissue’s swelling to decrease. Compression is often used to prevent venous stasis and promote venous flow to other areas of the body. Likewise, implementing the action of elevating the affected extremity also plays a role in enabling venous return to the systemic circulation. By allowing the vasculature in the affected extremity to “rest” through elevation, the systemic circulation has the opportunity to receive venous flow, further promoting decreased swelling.Throughout my shift (0645-1530) the ACE bandage remained intact on the patient’s lower left extremity. It was removed twice by physicians so they were able to assess the extremity in full detail. The nurse and I ensured that it was properly attached throughout my shift. The patient’s lower left extremity remained elevated throughout my shift with the implementation of pillows. This goal was not achieved during my shift but remains on-going.Continually monitor and note the presence of, or fluctuation in, edema, swelling and redness through nursing assessments. Nursing assessments are a crucial role in the job of a nurse. Assessments give baselines, show fluctuations, and enable the patient to understand his/or her plan of care. By monitoring for any changes in edema, swelling, and redness, the nurse can further structure the patient’s plan of care with the physician to determine a best possible outcome for decreasing symptoms and eradicating his infection. Through treatment, should come positive fluctuations in the patient’s cellulitis symptoms. During my entire shift (0645-1530), the nurse and I continually assessed the patient for any plausible fluctuations in his state of infection. We assessed for changes in edema, swelling, and redness without blanching. This goal was not met during my shift, however still remains on-going.Patient will demonstrate understanding of the signs and symptoms of an infection to prevent recurrence of cellulitis prior to discharge.Educate the patient about the cardinal signs and symptoms of an infection: redness, fever, swelling, pain, and often chills.*Patient education is an important aspect of care. If the patient is taught, and can demonstrate the multiple different signs and symptoms associated with an infection, there is a greater likelihood that the patient will be able to differentiate what an infection may look like in the future. Through teaching and demonstration come not only patient education, but patient comfort as well. If the patient feels worried about having a recurrent cellulitis infection, education can make him/or her feel more comfortable with knowing the cardinal signs of an infection, and plausibly preventing another worsening infection from occurring.During my shift (0645-1530), the nurse and I explained to the patient what the cardinal signs and symptoms of an infection were and what they identified themselves as. The patient was compliant in learning about the cardinal signs with the wife at the bedside. He showed understanding in regards to what a future infection may look like. The patient is expected to receive further detailed paperwork on these cardinal signs prior to discharge, however the patient’s discharge date has not yet been set.Ensure the patient has adequate information about the usage of antibiotics, how to retrieve care in outpatient clinics, and what to do in case of a recurrent infection.*Teaching the patient about what his medications do, how they affect him, and where he can go to get them administered to him is another important aspect of preventing a recurrent infection. Printing out information of people and places to go can give the patient the opportunity to seek an increased positive effect related to self-health. This gives the patient the opportunity to envelop his home health will good and safe resources to decrease the changes of a recurrent infection.Throughout my shift, the nurse and I explained to the patient why he was receiving each antibiotic, what they were doing, and how they would affect his plan of care. The patient expressed understanding upon our explanation. However, the patient will receive more information about discharge planning and how to find outpatient settings closer to his discharge date.Advocate for the patient to ensure he feels comfortable with new infection-based knowledge.*A main characteristic that a nurse should have is the ability to be a patient advocator. It is the nurses’ job to ensure that the patient feels comfortable and safe in the knowledge that he has been given about his health care. If the patient seems anxious or hesitant about any of the information, it would be the nurses’ job to inform the physician that other implementations may need to be brought to attention. During my shift (0645-1530), the nurse and I ensured that we were listening and advocating for anything that the patient may have wanted to know. As an example, during my shift the patient was scheduled to receive a liver ultrasound. The patient was unaware of this procedure and asked to receive more information from the physician. The nurse and I established patient advocacy and brought the physician to the floor.Patient will regain mobility with safety and comfort with a decrease in swelling and pain associated with cellulitis. (Long Term)Implement plan of care instructions and guidelines to the patient on how to adequately and safely improve his infection.*If the patient is given the instructions and properly follows all prescribed instructions to improve his cellulitis infection, he will be able to fully heal and implement adequate mobility back into his daily living. Currently, the patient’s cellulitis infection has not yet been fully controlled. This is a long-term goal and is suitable to be met in the future after the patient’s plan of care has been finished.±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—The patient may need a consult/meeting with PT/OT to establish and regain full mobility.□Pastoral Care □Durable Medical Needs □F/U appointments—The patient will need follow-up appointments to check on the status of the infection.□Med Instruction/Prescription—The patient will need prescriptions and instructions as to where he may receive his antibiotic therapy.□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No □Rehab/ HH—The patient will need home health in regards to his antibiotic therapy regimen. □Palliative Care ReferencesVan Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2015). Unbound Medicine, Inc. [Software].Davis’s Laboratory and Diagnostic Tests (Ativan, Claritin, Coreg, Cozaar, Microzide, Nifedipine).?Nursing CentralHuether, S. (1996) Understanding Pathophysiology. Chapter 39, Page 1053. St. Louis, Missouri: Wilson"Erikson's Psychosocial Development in Psychology 101." Erikson's Psychosocial Development in Psychology101 at AllPsych Online. Web. 5 February 2015."." . Web. 5 February 2015 ................
................

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

Google Online Preview   Download