UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Kolten Bush |

|MSI & MSII Patient Assessment Tool . |Assignment Date: 9/18/2015 |

| ( 1 PATIENT INFORMATION |Agency: SMH |

|Patient Initials: HR |Age: 89 |Admission Date: 9/16/2015 |

|Gender: Male |Marital Status: Married |Primary Medical Diagnosis: Pneumothorax -Collapsed lung |

|Primary Language: English | |

|Level of Education: Some college |Other Medical Diagnoses: (new on this admission) |

| |None |

|Occupation (if retired, what from?): Retired, builder, developer | |

|Number/ages children/siblings: 2 girls, ages 60 and 63 | |

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|Served/Veteran: Veteran, Army Infantry |Code Status: Full code |

|If yes: Ever deployed? Yes or No | |

|Living Arrangements: Lives at home with his wife, in a single story house, and she helps out|Advanced Directives: Yes |

|with any of his medical needs. |If no, do they want to fill them out? |

| |Surgery Date: 9/16/2015 Procedure:LVATS, L bronch, lysis of adhesions |

|Culture/ Ethnicity /Nationality: Caucasian | |

|Religion: Jewish |Type of Insurance: Liability, Medicare, AARP |

|( 1 CHIEF COMPLAINT: “I came to the doctor for pneumonia, and they did a chest xray and found that I had a partially collapsed lung (Pneumothorax) |

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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay) Patient came to his primary care doctor for suspected |

|pneumonia, after doing a Chest Xray, they found his left lung to be partially collapsed (Pneumothorax). The patient stated he felt a little weaker than normal for |

|the past few days, but wasn’t in any respiratory distress or pain. When he would feel weak, he would sit down and the symptoms would resolve. Patient was admitted |

|on 9/18 after receiving the chest x-ray, and they scheduled surgery for a LVATS, L bronch and lysis of adhesions in his left lung. |

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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of disease

|Date |Operation or Illness |

|Doesn’t remember dates of |Transurethral resection of the prostrate (TURP) |

|surgeries | |

| |Hernia repair- didn’t remember location |

| |Spine repair- wouldn’t elaborate but it involved L3 & L4 |

| |Shoulder surgery to repair torn rotator cuff |

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| |HTN, COPD, Asthma |

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|( 2 FAMILY MEDICAL HISTORY |

|( 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) U | | |

|Adult Tetanus (Date) Is within 10 years? U | | |

|Influenza (flu) (Date) Is within 1 years? | | |

|Pneumococcal (pneumonia) (Date) Is within 5 years? U | | |

|Have you had any other vaccines given for international travel or occupational purposes? Please List | | |

If yes: give date, can state “U” for the patient not knowing date received

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |Sulfas |Itching, rash |

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|Other (food, tape, latex, dye, | | |

|etc.) | | |

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|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |

|genetic factors impacting the diagnosis, prognosis or treatment) “A Pneumothorax is defined as air the pleural space that prevents the lung from fully expanding |

|and results in partial or complete collapse of the lung. If this pressure continues to build without intervention, it will develop into a tension pneumothorax in |

|which the pressure pushes the airway and cardiovascular structures to the opposite side of the chest, causing cardiovascular collapse and if untreated, death” |

|(Osborne, et al. 2014, p-671). The treatment of a pneumothorax involves a needle thoracostomy and then placing a chest tube. Those that are tall, thin and who |

|smoke are at a higher risk of having a pneumothorax. Some diseases can also increase your chances of having a pneumothorax such as, asthma (which he had), COPD, |

|Cystic fibrosis, Tuberculosis and whooping cough. A pneumothorax can be diagnosed by auscultating the lungs and hearing decreased or no breath sounds on the |

|affected side. (Heller, 2013) |

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( 5 Medications: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN medication . Give trade and generic name.]

|Name Bisakoedill, Dulcolax |Concentration |Dosage Amount 15 mg X3 |

|Route PO |Frequency 3 tabs, 3 times a day |

|Pharmaceutical class stimulant laxatives |Home Hospital or Both |

|Indication Treatment of Constipation |

|Adverse/ Side effects abdominal cramping, nausea, diarrhea, hypokalemia, muscle weakness |

|Nursing considerations/ Patient Teaching- Patient- should only be used for short term, increase fluid intake |

|Name Cefazolin, Ancef |Concentration |Dosage Amount 1 g |

|Route IVPB |Frequency Once a day, infusing over 30 min |

|Pharmaceutical class first generation cephalosporins |Home Hospital or Both |

|Indication Perioperative prophylaxis, upper respiratory procedures |

|Adverse/ Side effects Seizures, Pseudomembranous colitis, Steven Johnson syndrome, thrombocytopenia |

|Nursing considerations/ Patient Teaching Nurse- assess for infection (vitals) obtain cultures before initiating therapy, observe patient for anaphylaxis, patient- |

|report signs of super infection- furry overgrowth on tongue, itching, foul smelling stools, instruct patient of rash, fever, or if diarrhea develops |

|Name Docusate, Colace |Concentration |Dosage Amount 100mg |

|Route PO |Frequency once daily 1 cap |

|Pharmaceutical class stool softener |Home Hospital or Both |

|Indication prevention of constipation |

|Adverse/ Side effects throat irritation, mild cramps, diarrhea, rashes |

|Nursing considerations/ Patient Teaching Patient- should take only for a short amount of time, encourage increasing bulk in the diet, increasing fluid intake |

|Name famotidine, Pepcid |Concentration |Dosage Amount 20mg |

|Route PO |Frequency Q12 hr tab |

|Pharmaceutical class histamine h2 antagonist |Home Hospital or Both |

|Indication- Short term treatment of active duodenal ulcers |

|Adverse/ Side effects Arrhythmias, Agranulocytosis, Aplastic anemia, thrombocytopenia |

|Nursing considerations/ Patient Teaching- Nurse- assess for epigastirc or abdominal pain, monitor CBC periodically. Patient- take as directed, don’t take max dose |

|for more than 2 weeks, smoking interferes with the action of histamine antagonists |

|Name lubiprostone, Amitiza |Concentration |Dosage Amount 2 24mcg caps |

|Route PO |Frequency BID |

|Pharmaceutical class Chloride channel activators |Home Hospital or Both |

|Indication Chronic idiopathic constipation |

|Adverse/ Side effects dizziness, headache, peripheral edema, dyspnea, diarrhea, arthralgia |

|Nursing considerations/ Patient Teaching Assess for abdominal distention, presence of bowel sounds, color, consistency and amount of stool produced. |

|Patient/family- take as directed, inform that they might have dyspnea within 1 hr of first dose. |

|Name piperacillin/tazobactam Zosyn |Concentration |Dosage Amount 3.375 g |

|Route IVPB |Frequency Q6h |

|Pharmaceutical class extended spectrum penicillins |Home Hospital or Both |

|Indication Community-acquired and nosocomial pneumonia caused by piperacillin resistant, beta-lactamase-producing bacteria |

|Adverse/ Side effects Seizures, Pseudomembranous colitis, Steven Johnson Syndrome, Toxic Epidermal Necrolysis, Anaphylaxis Serum sickness |

|Nursing considerations/ Patient Teaching Nurse- assess for infection, observe for anaphylaxis, monitor bowel function, Patient/family- advise patient to report |

|rash and sign’s of infection, notify health care provider of fever and diarrhea especially if blood is in the stool |

|Name psylliuym powder |Concentration |Dosage Amount 3.3-3.5 g/ 1 packet |

|Route PO |Frequency BID |

|Pharmaceutical class Bulk forming agents |Home Hospital or Both |

|Indication Management of simple or chronic constipation, particularly if associated with a low fiber diet |

|Adverse/ Side effects Bronchospasm, cramps, intestinal or esophageal obstruction, N/V |

|Nursing considerations/ Patient Teaching Assess for abdominal distention, presence of bowel sounds, assess color consistency and amount of stool produced. Patient/|

|family- Increase bulk forming foods, increase fluid intake, and increase mobility. |

|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Adverse/ Side effects |

|Nursing considerations/ Patient Teaching |

|Name |Concentration |Dosage Amount |

|Route |Frequency |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Adverse/ Side effects |

|Nursing considerations/ Patient Teaching |

|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |

|Diet ordered in hospital? Regular |The patient only consumes 1 1/2 cup of fruit, which is about one banana. |

| |According to my plate the patient needs to double this amount to have the proper |

| |amount of fruit for one day. |

|Diet patient follows at home? “Healthy” |The patient is consuming about 3-4 cups of vegetables a day, which is beneficial |

| |for his age and is very appropriate for a healthy diet. |

|24 HR average home diet: |Due to the patient being older than 51, he should consume about 3 ounce |

| |equivalents for his daily consumption of grains. He consumes 3 ounce equivalent |

| |in his bowel of steel cut oats. |

|Breakfast: Fruit, steel cut oats,milk, black coffee |The patient is eating about 7 oz of meat, which is a proper amount of protein for|

| |his age. |

| |For someone over 51 years of age, he consumes 2-3 cups of dairy each day, which |

| |is the proper amount to have per day. He consumes this with his milk in the steel|

| |cut oats and his frozen yogurt. |

|Lunch: salad with cut up chicken |He limits the amount of oils he consumes, which is good, because having too much |

| |oil can be unhealthy. |

| |One teaching point that I instructed him was to continue down the path of eating |

| |healthy and exercising properly once he is healed form surgery. I explained the |

| |complications with carrying more weight and how eating poorly can lead to being |

| |diagnosed with diabetes. |

|Dinner: Light salad, fish or some kind of meat, veggies | |

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|Snacks: choc frozen yogurt | |

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|Liquids (include alcohol): water, wine, prune juice | |

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|[pic] |Use this link for the nutritional analysis by comparing the patients 24 HR |

| |average home diet to the recommended portions, and use “My Plate” as a reference.|

|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? My wife |

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

|“ AS a younger man I went crazy, rant and rave, now I handle it differently by expressing my stress to my wife” |

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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______________________________________________________ |

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|Have you ever been talked down to?____no___________ Have you ever been hit punched or slapped?  __no____________ |

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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?  ______________________ |

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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: Patients who are in the Ego integrity stage are those that feel like their life had been successful and they have few to no regrets in their |

|life. Patients who are in Despaired stage feel that their life has been a waste and they have many regrets that they wish they could change. They are unhappy and |

|dissatisfied with their life. (Cherry, 2005) |

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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 because he is happy with his life. He does not have any regrets and he has a loving supportive family that cares about him|

|during his time of need. |

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

|His current condition has him slightly worried for his overall health, but he is ready to be home and recover with his supportive wife and loved ones. |

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|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” “ not quite sure” patient states he was diagnosed with a disease as a child, can’t remember the name of it, may |

|have caused this as well. Said it was something to do with lungs but not his asthma. |

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|What does your illness mean to you?” it may eventually get me” |

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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? _____women________________________________________________________ |

|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?   __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?  _none_________________________________ |

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|How long have you been with your current partner?___66 years_____________________________________________________ |

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|Have any medical or surgical conditions changed your ability to have sexual activity?  _yes current surgery__________________________ |

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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?

No but the tenants of your religion do _____________________________________________________________________________________________________

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Do your religious beliefs influence your current condition?

no______________________________________________________________________________________________________

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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? cigarettes. |How much?(specify daily amount) |For how many years? 5 X years |

| |Very few. |(age thru ) doesn’t|

| | |remember, smoked a long time ago but now quit |

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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? No|Has the patient ever tried to quit? |

| |If yes, what did they use to try to quit? |

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

| What? Wine |How much? 1-2 glasses |For how many years? |

| |Volume: standard wine glass |(age 35 thru now ) |

| |Frequency: maybe 4 times a week | |

| 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? Marijuana |

| |How much? Couple tokes |For how many years? |

| | |(age thru ) |

| | |Smoked in his 50s |

| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? 30-40 years | |

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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |

|Very little- since he was a builder/developer he had minimal exposure when building houses |

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|5. For Veterans: Have you had any kind of service related exposure? |

|Traveling- possible malaria |

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( 10 Review of Systems Narrative

| |Gastrointestinal |Immunologic |

| | Nausea, vomiting, or diarrhea | Chills with severe shaking |

|Integumentary | Constipation Irritable Bowel | Night sweats |

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

| Problems with nails- toe nail fungus | 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- benign skin cancer |

| Use of sunscreen SPF:50 | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: at least once a day |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

|Be sure to answer the highlighted area | Last colonoscopy? 6 years ago | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing |Genitourinary | Anemia |

| Cataracts or Glaucoma | nocturia | Bleeds easily |

| Difficulty hearing | dysuria | Bruises easily |

| Ear infections | hematuria | Cancer- skin, benign |

| Sinus pain or infections | polyuria | Blood Transfusions |

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

| Post-nasal drip |Normal frequency of urination:10 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 2x/year | | Hypothyroid /Hyperthyroid |

|Vision screening- every 4 months | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

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|Pulmonary | | |

| Difficulty Breathing | |Central Nervous System |

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

| Asthma | Infection of the female genitalia | Dizziness |

| Bronchitis | Monthly self breast exam | Severe Headaches |

| Emphysema | Frequency of pap/pelvic exam | Migraines |

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

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

| Environmental allergies | menarche age? | Encephalitis |

|last CXR? After surgery 9/16/2015 | menopause age? | 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? 1 year ago | 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? 9/16/2015 |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

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|General Constitution |

|Recent weight loss or gain |

|How many lbs? |

|Time frame? |

|Intentional? |

|How do you view your overall health? Good, but “Doctor says I should gain 10 pounds. |

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

|No |

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

|No |

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|±10 PHYSICAL EXAMINATION: |

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|General Survey: Patient is a pleasant elderly gentleman who appears to not be in any stress. |

|Height 5ft 10 |

|Weight 145 |

|BMI 20.8 |

|Pain: (include rating and location) patient states a )-10 |

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|Pulse 75 |

|Blood Pressure: (include location) |

|135/74 RA |

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|Respirations 18 |

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|Temperature: (route taken?) 97.7 oral |

|SpO2 99 |

|Is the patient on Room Air or O2 |

|2 L O2 |

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|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |

| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |

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|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |

| awake, calm, relaxed, interacts well with others, judgment intact |

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|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |

| clear, crisp diction |

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|Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat |

| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |

|Other: |

|Integumentary |

| Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities |

| Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin |

|If anything is not checked, then use the blank spaces to |

|describe what was assessed in the physical exam that |

|was not WNL (within normal limits) |

| Central access device Type: Peripheral IV Location: 18LFA, 18RFA Date inserted:9/16/2015 |

|Fluids infusing? no yes - what? NS and an epidural |

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|HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline |

| Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge |

| Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |

| PERRLA pupil size 2 and 2 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |

| Ears symmetric without lesions or discharge Whisper test heard: right ear- 8 inches & left ear- 4 inches |

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

|Dentition: |

|Comments: |

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|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |

|Percussion resonant throughout all lung fields, dull towards posterior bases |

|Sputum production: thick thin Amount: scant small moderate large |

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

|Lung sounds: Lung sounds diminished throughout all lobes bilaterally |

|RUL LUL |

|RML LLL |

|RLL |

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|CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent |

|Cardiovascular: No lifts, heaves, or thrills |

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|Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |

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|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |

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|Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |

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

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|No temporal or carotid bruits Edema: +2 in bilateral lower legs [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), |

|+4(7-8mm) ] |

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|Location of edema: pitting non-pitting |

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|Extremities warm with capillary refill less than 3 seconds |

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|GI Bowel sounds active x 4 quadrants; no bruits auscultated- Patients bowel sounds hypoactive No organomegaly |

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

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|Last BM: (date 09 / 17 / 2015 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

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|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |

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|Nausea emesis Describe if present: |

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|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |

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|Other – Describe: |

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|GU Urine output: Clear Cloudy Color: amber Previous 24 hour output: 500mls mLs N/A |

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

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|CVA punch without rebound tenderness |

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|Musculoskeletal: Full ROM intact in all extremities without crepitus |

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|Strength bilaterally equal at ____4___ RUE ____4___ LUE ___4____ RLE & ___4____ in LLE |

|[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] |

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|vertebral column without kyphosis or scoliosis |

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|Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia |

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|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |

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|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |

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|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride- Not assessed, patient remained in bed. |

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|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |

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|Triceps: +2 Biceps: +2 Brachioradial:+2 Patellar: +2 Achilles: +2 Ankle clonus: positive negative |

|Babinski: positive negative |

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

|diagnostic tests): |

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|Lab |

|Dates |

|Trend |

|Analysis |

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|Glucose-94 |

|Glucose-126 |

|Normal (60-100) |

|9/16 |

|9/17 |

|Elevated upward |

|Blood Glucose levels can fluctuate, however, his glucose is within pre diabetic range but he has not been diagnosed. He has been advised to eat healthy and have an |

|exercise routine. |

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|WBC:7,800 |

|HCT: 47 |

|HGB:14 |

|Platelets:305,000 |

|9/16 |

|No significant trend noted |

|All lab values are within normal limits. |

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|Na: 142 |

|K: 3.9 |

|CL: 98 |

|HCO3: 21 |

|BUN: 17 |

|Creatinine: .9 |

|9/16 |

|No significant trend noted |

|All lab values are within normal limits. |

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|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: |

|Patient has a chest tube that is draining fluid from his surgery of his collapsed lung. He has a foley catheter still in place, advised to use his incentive |

|spirometer 10X an hour. He is advised to get up and ambulate and when the chest tube is removed, he will be ambulating even more. Activity and using the incentive |

|spirometer will help to prevent atelectasis. He has been advised to eat a proper healthy diet and make an exercise plan. |

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|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |

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|1. Ineffective airway clearance related to surgery (thoracotomy), as evidenced by diminished throughout booth lobes bilaterally. |

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|2. Risk for infection related to chest tube placement. |

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|3. Activity intolerance related to Risk for DVT as evidenced by bed rest. |

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|4. Anxiety related to difficulty breathing and having a chest tube in place. |

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|5. |

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± 15 CARE PLAN

Nursing Diagnosis: Ineffective airway clearance related to surgery (thoracotomy), as evidenced by diminished throughout booth lobes bilaterally.

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

| | |Provide References | |

|Airway Patency |Listen to breath sounds q4 and listen for normally |Keeping the airway patent will allow the patient to |While listening to his lungs, his lungs were |

| |cleared or only scattered crackles or wheezing |breath more easily. |diminished throughout both lobes, however according |

| | | |to the nurse, they were slowly improving. Will |

| | | |continue to monitor breath sounds as the fluid comes |

| | | |off the pleural space from the chest tube. |

|Demonstrate Turn Cough Deep Breath (TCDB) |Teach the patient how to (TCDB), and then ask for |TCDB will help the patient to get rid of any lung |The patient repeated demonstration of TCDB properly. |

| |repeated demonstration back. Have the patient sit up |secretions and it will help to maintain a more patent| |

| |and Turn cough deep breath properly. |airway | |

|Preventing Pneumonia or atelectasis |Use of Incentive Spirometer (I.S) X10 an hour |Using an I.S will help open up the airway and prevent|Patient returns demonstration using the I.S 10 times |

| | |the formation of Pneumonia or atelectasis. |for me appropriately. |

| |Rotating and repositioning every two hours while | | |

| |laying in bed | | |

|Free from infection with chest tube placement |Will monitor for s/s of infection and monitor for |A chest tube that is placed is susceptible to |Patient is not experiencing any signs of infection |

| |infection around the insertion site of the chest tube|infection. |and the insertion site is clean without any erythema.|

| | | |Will continue to monitor patient for infection |

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|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

|Consider the following needs: |

|□SS Consult |

|□Dietary Consult |

|□PT/ OT |

|□Pastoral Care |

|□Durable Medical Needs |

|□ X F/U appointments |

|□ X Med Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □X No |

|□Rehab/ HH |

|□Palliative Care |

± 15 CARE PLAN

Nursing Diagnosis: Activity intolerance related to risk for DVT as evidenced by bed rest.

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

| | |Provide References | |

|Ambulating with assistance, building up to without |Ambulating with assistance, building up to without |Getting up and walking will help with lung expansion |The patient ambulated down the hall twice during my |

|assistance |assistance. Patient will become more independent with|and will help with the recovery from the surgery. |shift with the PCT, with the second time going |

| |ambulation. |This will help to prevent pneumonia and atelectasis. |farther than the first time. |

|Patient demonstrated understanding of the need or |Patient demonstrating why the need for SCDs or Ted |Right after surgery, most patients are not able to |When walking into the patients throughout the day, he|

|SCDs or Ted Hose. |Hose, and compliance with keeping them on. |get up and walk yet so we want to place these devices|had the SCDs and Ted hose on at all times. |

| | |on their legs to help with blood circulation to | |

| | |prevent a DVT. | |

|Patient will have warm dry skin, and consistent |Monitor patients skin color and also their breathing |After surgery we want the patient to get up and |While observing the patient ambulating he did not |

|regular breathes with activity. |during activity |ambulate as soon as possible, but we also don’t want |have any trouble breathing nor did he become flush or|

| | |to over do it. This is important to monitor their |clammy. |

| | |skin to make sure they aren’t become to diaphoretic, | |

| | |or clammy. We also don’t want their breathing to | |

| | |become tachypnea. | |

|Patient will demonstrate increased activity |The nurse, the PCT or I will be there to guide the |Increased activity tolerance with only little to |When observing the patient with the PCT ambulating |

|intolerance before discharge. |patient while ambulating, but for the most part we |moderate assistance will only make his transition |down the hallway, he seemed like the activity was |

| |want the increased activity to be as independent as |home more easier |becoming easier, especially on his second walk of the|

| |possible. | |day. Once his Foley and chest tube have been removed,|

| | | |more independent ambulation will be expected. |

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References

Ackley, Betty J., and Gail B. Ladwig. Nursing Diagnosis Handbook: An Evidence-based Guide to Planning

Care. Maryland Heights, MO: Mosby, 2010. Print.

Cherry, K.A (2005). Erik Erikson's Stages of Development. Retrieved November 10, 2015, from



. (n.d.). Retrieved November 10, 2015, from

Heller, J. (2013, July 20). Collapsed lung (Pneumothorax): MedlinePlus Medical Encyclopedia. Retrieved November 10, 2015, from

Unbound Medicine Nursing Central

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