UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Janel Canty |

|Patient Assessment Tool . |Assignment Date: 9-18-2012 |

| |Agency: BMC |

|Patient Initials: T.A. |Age: 58 |Admission Date: 8/21/2012 |

|Gender: F |Marital Status: Single |Primary Medical Diagnosis with ICD-10 code: K46 |

|Primary Language: English | |

|Level of Education: 12th grade |Other Medical Diagnoses: intestinal obstruction |

|Occupation (if retired, what from?): none | |

|Number/ages children/siblings: | |

|0 children/ 1 sister 56 years old | |

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| |Code Status: Full |

|Living Arrangements: with sister; patient does not have stairs and is able to take her |Advanced Directives: none |

|medication on her own. | |

| |Surgery Date: 9-17-12 Procedure: retroperitoneal |

|Culture/ Ethnicity /Nationality: African American | |

|Religion: non domination |Type of Insurance: Medicaid |

|( 2 CC: "I couldn't use the bathroom" |

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|( 3 HPI: (OLD CART) The patient came to the emergency room with difficulties having a bowel movement for one month and had a sharp pain in her lower left abdomen. |

|Patient stated that the pain would go in and out but for the past month she has trouble having a bowel movement. Patient stated that there was nothing that made |

|her pain feel better or made her pain feel worse. Patient used milk magnesia as treatment while she was at home. Patient had an abdominal x-ray on 8-21-12 and |

|x-ray should an abdominal obstruction. Patient had retroperitoneal surgery on 9-17-12 and patient was intubated. The patient was extubated on 8-21-12 and |

|transferred to post operative care until 9-17-12 and then transferred to 5N. |

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|( 2 PMH/PSH Hospitalizations for any medical illness or operation |

|Date |Operation or Illness |Management/Treatment |

|8/22/2012 |Bowel obstruction |Repair of inguinal hernia |

| | |Patient has a retroperitoneal drainage catheter to drain the extra |

| | |fluid in the abdominal. |

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|( 2 FMH |

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|( 1 immunization History |

| |Yes |No |

|Routine childhood vaccinations | | |

|Routine adult vaccinations for military or federal service | | |

|Adult Diphtheria (Date) | | |

|Adult Tetanus (Date) | | |

|Influenza (flu) (Date) | | |

|Pneumococcal (pneumonia) (Date) | | |

|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 |Patient stated NKA | |

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|Other (food, tape, dye, etc.) |Patient stated NKA | |

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|( 5 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis, prognosis or treatment) |

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|In the bowel there is an obstruction that causes distention and accumulation of fluid and gas in the lumen of the bowel. The obstruction is from a inguinal |

|hernia. There is an increase mobility and secretions from the mechanical obstructions, this results in a the intestines inability to reabsorb the fluid making |

|the bowel distention. With an increase in mobility and distention of fluid this causes the symptom of abdominal cramping. In a simple bowel obstruction, |

|intestinal secretions and gas have built up proximal to the obstruction and the bowel distal to the obstruction collapses. When this happens the inflammatory |

|response kicks in and the bowel wall becomes edematous and congested. This type of obstruction can cause decrease absorption which can result bowel ischemia and |

|necrosis. This can cause death in a patient. The treatment for the bowel obstruction is typically surgery, management of the fluids such as electrolytes and a |

|nasogastric tube will be inserted. |

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|Electronical reference (2009), web: pg.88, 4.02;software:p. 210-211, 7.08; electronic: p. 187-189, 6.31 and 189-192, 6.32 |

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|S.E. (2012). Understand pathophysiology. St. Louis: Elsevier mosby. |

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( 5 Medications: (Include both prescription and OTC)

|Name Nystatin |Concentration 500,000 unitd per 5 ML |Dosage Amount |

|Route PO |Frequency Q6hr |

|Pharmaceutical class antifungal |Home Hospital or Both |

|Indication prevent fungal infections from happening near the wound. |

|Side/adverse effects: irritation, sensitization |

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|Name acetaminophen |Concentration |Dosage Amount 2 tabs= 650 mg |

|Route PO |Frequency Q4h PRN |

|Pharmaceutical class antipyretics |Home Hospital or Both |

|Indication reduction of fever |

|Side/adverse effects: agitation, anxiety, headache, fatigue, insomnia, atelectasis, dyspnea, hepatotoxicity, constipation, increased liver enzymes, nausea, |

|vomiting, pruritus, hypokalemia, muscle spasms, trismus |

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|Name aquaphor |Concentration |Dosage Amount 1 APP |

|Route topical |Frequency Q8H |

|Pharmaceutical class oil based lubricant |Home Hospital or Both |

|Indication dry skin |

|Side/adverse effects: irritation and sensitization |

|Name Metronidazole |Concentration |Dosage Amount 500 mg |

|Route PO |Frequency Q8h |

|Pharmaceutical class anti infective |Home Hospital or Both |

|Indication treatment of anaerobic infection |

|Side/adverse effects: seizures, dizziness, headache, optic neuropathy, abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant |

|taste, vomiting, steven-johnson syndrome, rash, urticaria, leukopenia, peripheral neuropathy, superinfection |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

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|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

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Electronical reference (2009), web: pg.88, 4.02;software:p. 210-211, 7.08; electronic: p. 187-189, 6.31 and 189-192, 6.32

|( 4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis) |

|Diet ordered in hospital? Changed to Full on 9/18/2012 |Analysis of home diet (Compare to food pyramid and |

| |Consider co-morbidities and cultural considerations): |

|Diet pt follows at home? |From the patients 24 diet recall, the patient does not take in enough food to |

| |meet the food pyramids requirements. Patient intakes enough grains for the day |

| |by eating 1 cup of rice a day. The daily recommendation is 6 ounces and the |

| |patient intakes 8 ounces. The patient does not eat any vegetables or fruits. For|

| |the patient to improve their nutritional status to the recommendation, she would |

| |need to intake 2.5 cups of vegetables and 2 cups of fruits. Patient does eat an |

| |adequate number of meats with two eggs and 1 cup of chicken. She meets the |

| |recommendation of 5.5 ounces of meats a day. The patient also does not eat |

| |milk, yogurt, or cheese. She needs to increase the amount of low fat dairy |

| |products to 3 cups per day. Patient ate more fats and oils then moderation. |

| |Patient stated that she had not drank any water. The recommended amount of water|

| |is 8 cups per day. |

|Breakfast: scrambled eggs (2 eggs) and 1 cup of apple juice | |

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|Lunch: nothing | |

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|Dinner: 1 cup of chicken, 1 cup of rice, 1 cup of soda |Jenson, S. (2011). Nursing health assessment. Philadelphia: Lippincott Williams |

| |and Wilkins. |

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|Snacks: 1 cup of cheese puffs, 1 bag of laze potatoes chips | |

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|[pic] | |

|(2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? the patient stated that she lives with her sister |

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|How do you generally cope with stress? or What do you do when you are upset? |

|Patient stated that she prays when she feels stressed |

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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |

|Patient stated that she has not had any difficulties with depression, anxiety, feeling overwhelmed, relationships, friends, or social life. |

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|+2 DOMESTIC VIOLENCE ASSESSMENT |

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|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |

|am going to ask some questions that help me to make sure that you are safe.” |

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|Have you ever felt unsafe in a close relationship? _____no__________________________________________________ |

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|Have you ever been talked down to?_____no__________ Have you ever been hit punched or slapped?  ___yes________ |

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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?  |

|_________no_________________________________ If yes, have you sought help for this?  ____N/A_____________ |

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|Are you currently in a safe relationship? Patient is not in a relationship |

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|( 5 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 |

|Give the textbook definition of both parts of Erickson’s developmental stage for your patient’s age group: |

|The patient was in Erikson's stage of Generativity versus stagenation. Generativity is when a person is concerned about the next generation and attempts to help |

|them. Stagnation is when a person does not have anything offer to the next generation. |

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|Describe the characteristics that the patient exhibits that led you to your determination: |

|The patient is in the stagnation stage because she does not show any concern for the next generation. She does not have children and wanted nothing to do with |

|them. She is not involved with anything to do with the community. She was only concerned with what she was going to do when she left the hospital. She only |

|thought of others when it came to talking about her sister coming home, and that was only because she wanted to know when she was going to help her pay for |

|hospital bill. |

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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |

|This has put the patient further into the stage of stagnation because now she is only thinking about how she is going to take care of herself and take care of her |

|bills. |

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|Jenson, S. (2011). Nursing health assessment. Philadelphia: Lippincott Williams and Wilkins. |

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|+3 Cultural Assessment: |

|“What do you think is the causes of your illness?” |

|Patient stated that she believes that her diet has caused her to have this illness. |

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|What does your illness mean to you? |

|Patient stated that this illness means to her that she needs to be more careful with what she eats and to eat more vegetables. |

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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? ____N/A________________________________________________ |

|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___________________ |

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|How long have you been with  your current partner?______N/A____________________________________________ |

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|Have any medical or surgical conditions changed your ability to have sexual activity?  ____no___________________ |

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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?no |

|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |

| If so, what? |How much? |For how many years? |

| |2 packs per week |(age13 thru 58 ) |

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| | |If applicable, when did the patient quit? 1 |

| | |month ago |

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|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? no|Has the patient ever tried to quit? yes |

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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |

| What? Beer |How much?1/2 pint once a week |For how many years? |

| | |(age 13 thru 48 ) |

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| If applicable, when did the patient quit?10 years ago | | |

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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |

| If so, what? |

|Crack cocaine |How much? twice |For how many years? |

| | |(age 56 thru 56 ) |

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| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? 2 years | |

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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 | Chills with severe shaking |

|Integumentary | Constipation Irritable Bowel | Night sweats |

| Changes in appearance of skin | GERD Cholecystitis | Fever |

| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |

| Dandruff | Hemorrhoids Blood in the stool | Lupus |

| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |

| Hives or rashes | Pancreatitis | Sarcoidosis |

| Skin infections | Colitis | Tumor |

| Use of sunscreen no SPF: | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: Shower 3 times a week |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? no | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing |Genitourinary | Anemia |

| Cataracts or Glaucoma | nocturia | Bleeds easily |

| Difficulty hearing | dysuria | Bruises easily |

| Ear infections | hematuria | Cancer |

| Sinus pain or infections | polyuria | Blood Transfusions |

|Nose bleeds | kidney stones |Blood type if known: O positive |

| Post-nasal drip |Normal frequency of urination: 4 x/day |Other: |

| Oral/pharyngeal infection | Bladder or kidney infections | |

| Dental problems | |Metabolic/Endocrine |

| Routine brushing of teeth 1 x/day | | Diabetes Type: |

| Routine dentist visits no x/year | | Hypothyroid /Hyperthyroid |

|Vision screening1 year | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

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|Pulmonary | | |

| Difficulty Breathing | |Central Nervous System |

| Cough - dry or productive |Women Only | CVA |

| Asthma | Infection of the female genitalia | Dizziness |

| Bronchitis | Monthly self breast exam no | Severe Headaches |

| Emphysema | Frequency of pap/pelvic exam no | Migraines |

| Pneumonia | Date of last gyn exam? | Seizures |

| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |

| Environmental allergies | menarche age? | Encephalitis |

|last CXR? none | menopause age? 1999 | Meningitis |

|Other: |Date of last Mammogram &Result: |Other: |

| |Date of DEXA Bone Density & Result: | |

|Cardiovascular |Men Only |Mental Illness |

|Hypertension | Infection of male genitalia/prostate? | Depression |

| Hyperlipidemia | Frequency of prostate exam? | Schizophrenia |

| Chest pain / Angina | Date of last prostate exam? | Anxiety |

|Myocardial Infarction | BPH | Bipolar |

| CAD/PVD |Urinary Retention |Other: |

|CHF |Musculoskeletal | |

|Murmur | Injuries or Fractures |Childhood Diseases |

| Thrombus | Weakness | Measles |

|Rheumatic Fever | Pain | Mumps |

| Myocarditis | Gout | Polio |

| Arrhythmias | Osteomyelitis | Scarlet Fever |

| Last EKG screening, when? no |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

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Review of Systems Narrative

|General Constitution |

|Pt’s perception of health: |

|My patient stated that she believes that she is in good health. She said other than having this bowel obstruction she has not had any other health problems. She |

|does believe that she needs to watch what she eats more because that could potentially turn in to another problem. |

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|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |

|No the patient stated that this is the only time that she has seeked medical attention |

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|Any other questions or comments that your patient would like you to know? |

|No the patient was in touch with her medical care. |

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|±10 PHYSICAL EXAMINATION: |

|Orientation and level of Consciousness: alert and oriented times 3 |

|General Survey: Pleasant African American|Height: 5'3 |Weight: 170 BMI: 31.1 |Pain: (include rating & location) 0 |

|women | | | |

| |Pulse: 97 |Blood | |

| | |Pressure: 116/73 | |

| | |(include location) | |

|Temperature: (route taken?) |Respirations: 18 | | |

|98.3 oral | | | |

| |SpO2 95 |Is the patient on Room Air or O2: Room |

|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 | |

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| 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: PICC Location: Left arm Date inserted: 8-25-2012 |

| 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: Location: Date inserted: |

|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 |

|Functional vision: right eye - left eye - without corrective lenses |right eye - left eye - with corrective lenses|

|Functional vision both eyes together: with corrective lenses or NA |

| PERRLA pupil size / 4 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |

| Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches |

| Weber test, heard equally both ears Rinne test, air time(s) longer than bone |

| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |

|Dentition: Patient has poor hygiene in the mouth. |

|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 |Tactile fremitus bilaterally equal without overt vibration |

| |CR - Crackles |Sputum production: thick thin Amount: scant small moderate large |

| |RH – Rhonchi | Color: white pale yellow yellow dark yellow green gray light tan brown red |

| |D – Diminished | |

| |S – Stridor | |

| |Ab - Absent | |

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|Cardiovascular: No lifts, heaves, or thrills PMI felt at: 5th intercoastal space midclavicular line |

|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: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3 |

|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 Liver span cm |

|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation |

|Urine output: Clear Cloudy Color: yellow Previous 24 hour output: 960 mLs N/A |

|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |

|CVA punch without rebound tenderness |

|Last BM: (date 9 /9 / 2012 ) 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 |

|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_____ in UE & ____5___ in LE |

|[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 |

|Repair of inguinal hernia 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: 2 Biceps: 2 Brachioradial: 2 Patellar: 2 Achilles: 2 Ankle clonus: positive negative Babinski: |

|positive negative |

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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |

|diagnostic tests): |

|Patient white blood cell count was in normal range with 9.4 |

|done on 9-18-12 |

|To check for sign of infection |

|Patient had low chloride with a value of 96 |

|done on 9-18-12 |

|patient had surgery so we want to check electrolyte levels |

|Patient had a low BUN level with 1 |

|done 9-18-12 |

|patient had surgery the day prior so we would want to know how the renal system is functioning |

|Patient had low creatine level with .5 |

|done 9-18-12 |

|patient had surgery the day prior, we would want to know how the renal system is functioning. |

|Patient's has a low BUN and creatine because of increased extracellular fluid. |

|Patients urine specific gravity was normal at 1.027 |

|done 9-18-12 |

|This test to see the concentration of the urine |

|Patient had a abdominal X-ray |

|on 8-21-12 |

|This proved that their way an abdominal obstruction |

|distended loops of bowel |

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|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: |

|Patient has medium continuous suction on drain and the nurse records the amount every Q8h |

|Patient will have skin prep around abdominal wound every dressing change which is down Q8h |

|Patient has physical therapy once per day to walk down the hall way and back. |

|Patient will receive their antifungal medication when indicated to prevent infection. |

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|( 2 Medical Diagnoses |( 8 Nursing Diagnoses |

|(as listed on the chart) |(actual and potential - listed in order of priority) |

|1. inguinal hernia |1. disturbed body image R/t retroperitoneal drain AEB patient stating "walking |

| |around with this drain will be uncomfortable if people stare at me" |

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|2. |2. risk for infection R/t open wound |

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|3. |3. ineffective tissue perfusion R/T Surgery |

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|4. |4. |

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|5. |5. |

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± 15 for Care Plan

Nursing Diagnosis: disturbed body image R/t retroperitoneal drain AEB patient stating "walking around with this drain will be uncomfortable if people stare at me"

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |

| | |Provide References | |

|Patient will demonstrate adaption to changes in |Incorporate psychosocial questions through out the |Assessment of psychosocial issues can help to |Client walked down the hallway holding the drainage |

|physical appearance or body function as evidence by |day, related to body image as part of nursing |identify clients at risk for body image concerns as a|bag and stated that she did not feel uncomfortable |

|adjustment to lifestyle change. |assessment to identify clients at risk for body image|result of a disfiguring condition |anymore, that it just felt great to get out of bed. |

| |disturbance. | | |

| |Use a tool such as the Body Image Quality of Life |Using a body image scale can help nurses to identify | |

| |inventory. This will quantify both the positive and |possible body image disturbances and to plan | |

| |negative effects of body image on one's psychosocial |individual nursing interventions. | |

| |quality of life. | | |

| |If nursing assessment reveals body image concerns |Many clients with disfiguring conditions are | |

| |related to a disfiguring condition, assist client |concerned about and may avoid exposing the | |

| |invoicing her concerns and if appropriate, coaching |disfigurement to others' gaze and displays of | |

| |the client in how to respond to questions from others|ignorance and negative comments by others. o | |

| |in social situations. | | |

| |Refer clients to a social skill training if indicated|Social skill training help clients learn new mental | |

| | |scripts for interacting with others, challenge | |

| | |negative thoughts, and replacing these with new | |

| | |thoughts, and applying new behaviors and thoughts in | |

| | |a social situation | |

| |Acknowledge denial, angry, or depression as normal |The influence of emotion-forcing coping on distress | |

| |feelings when adjusting to changes in body and |following disfigurement following disfiguring injury | |

| |lifestyle. However, allow client to share emotiuons |was associated with less body image disturbance. | |

| |when they are ready, rather then rushing them | | |

| |Encourage the client to discuss interpersonal and |Changes in physical appearance and function | |

| |social conflicts that may arise. |associated with disease process need to be integrated| |

| | |into the interaction that occurs between clients and | |

| | |lay caregivers. | |

| |Encourage the client to write a narrative description|Expressive writing has therapeutic benefits with | |

| |of their changes. |feelings of greater psychological well-being and | |

| | |fewer post-traumatic intrusion and avoidance | |

| | |symptoms. | |

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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 |

± 15 for Care Plan

Nursing Diagnosis: risk for infection R/t open wound

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |

| | |Provide References | |

|Patient will remain free from symptoms of infection. |Observe and report signs of infection such as |Prospective surveillance study for health care |Patients wound was a beefy red color with no warmth |

| |redness, warmth, discharge, and increase body |acquired infection on hematology oncology units |or sign of discharge. The patient was afebrile with |

| |temperature every hour. |should include origin as the single most common and |no sign of infection. |

| | |clinically important entity. | |

| |Wash hands before and after dealing with patients |Washing hands in-between patients is the number one | |

| | |reducer of infections in the hospital. | |

| |Note and report any laboratory values. |The White blood cell count and the automated absolute| |

| | |neutrophil count are better diagnostic tests for | |

| | |adults. | |

| |Assess skin for color, moisture, texture, and turgor.|The skin is the body's first line of defense in | |

| |Keep accurate ongoing documentation of changes |protecting the body from infection | |

| |Carefully wash and pat dry skin, including skin fold |Atopic dermatitis is a common, chronic skin condition| |

| |area. use hydration and moisturization on all at |that can be managed in most clients by prescribing | |

| |risk surfaces. |avoidance measures, good skin care, antihistamines, | |

| | |and conservation tropical medication. | |

| |Encourage fluid intake |Fluid intake helps thin secretions and replace fluid | |

| | |lost during fever | |

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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 |

Ackley, B.J. (2011). Nursing Diagnosis Handbook. St. Louis: Mosby Elservier

± 15 for Care Plan

Nursing Diagnosis:

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |

| | |Provide References | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|± 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 |

Work cited:

Ackley, B.J. (2011). Nursing Diagnosis Handbook. St. Louis: Mosby Elservier

Huether, S.E. (2012). Understanding Pathophysiology. St. Louis: Elsevier Mosby.

Jensen, S. (2011). Nursing Health Assessment. Philadeplphia: Lippincott Williams and Wilkins. Nusing Central. (2012,05).

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