UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Emma Fleck |
|Patient Assessment Tool . |Assignment Date: 10/8/13 |
| ( 1 PATIENT INFORMATION |Agency: FHT |
|Patient Initials: P.S |Age: 81 |Admission Date: 10/3/13 |
|Gender: Female |Marital Status: Married |Primary Medical Diagnosis with ICD-10 code: J13 |
|Primary Language: English |Altered mental status, community-acquired pneumonia |
|Level of Education: some college |Other Medical Diagnoses: |
|Occupation: retired |COPD, UTI, lung cancer, GERD, hypothyroidism, depression |
|Number/ages children/siblings: 1 daughter 55 | |
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|Served/Veteran: No |Code Status: Full resuscitation |
|Living Arrangements: Patient and her husband lives at their daughter’s house, no stairs. |Advanced Directives: Yes |
| |Surgery Date: none Procedure: monitor patient, blood |
| |work, and chest x-ray October 9th |
|Culture/ Ethnicity /Nationality: Scotland | |
|Religion: Christian |Type of Insurance: Unknown, doesn’t remember |
|( 1 CHIEF COMPLAINT: |
|Patient has right sided community- acquired pneumonia |
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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |
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|Patient’s daughter noticed that P.S was not acting like herself and was confused. The patient was more short of breath than usual. Patient did not say she had |
|fever, chills, or pain but was feeling short of breath, weak and coughing. While at the hospital, that patient had a pleural fluid culture, and chest x-rays to |
|determine community-acquired pneumonia from Streptococcus bacteria and had a urinalysis to determine patient has a UTI. Patient is receiving broad span antibiotics|
|and normal saline to help with hyponatremia, UTI, and right sided pneumonia. Patient is now alert and orientated and complains of activity intolerance due to being|
|short of breath. Patient complains of always being short of breath when doing an activity. Her symptoms are relieved when stopping the activity and having her |
|oxygen at about 3L. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation
|Date |Operation or Illness |
|Unknown about age 50 |COPD |
|2007 |Depression |
|Unknown many years ago |Hypothyroidism |
|2010 |Macular denegation |
|August 2013 |Lung cancer |
|October 2013 |Thoracentesis |
|October 2013 |Pneumonia |
|October 2013 |UTI |
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|( 2|Age (in years) |
|FAM| |
|ILY| |
|MED| |
|ICA| |
|L | |
|HIS| |
|TOR| |
|Y | |
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|( 1 immunization History |
|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |
|Routine childhood vaccinations |X | |
|Routine adult vaccinations for military or federal service | |X |
|Adult Diphtheria (Date) | |X |
|Adult Tetanus (Date) | |X |
|Influenza (flu) (Date) 2013 |X | |
|Pneumococcal (pneumonia) (Date) 2013 |X | |
|Have you had any other vaccines given for international travel or occupational purposes? Please List | |X |
|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |
|REACTIONS |Causative Agent | |
|Medications |Aspirin |Redness on skin, hives |
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|Other (food, tape, latex, dye, |None | |
|etc.) | | |
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|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |
|genetic factors impacting the diagnosis, prognosis or treatment) |
|Pneumonia is an inflammatory condition caused by inhalation of bacteria, viruses, fungi, aspiration of water, and inhalation of smoke toxic gases. Pneumonia |
|affects the gas-exchanging portions of the lungs and can cause fluid in the alveoli and bronchioles causing lack of oxygen to the patient. “Pneumonia is the sixth |
|leading cause of death in the united states and the number one cause of death from an infectious disease” (Osborn, Wraa, & Watson, 2010). Community-acquired |
|pneumonia (CAP) is commonly caused by streptococcus pneumonias. Symptoms of pneumonia are fever, chills, an increased respiratory rate, sounds of crackles in the |
|lungs, rusty sputum, and x-ray abnormalities. However the elderly may not have some of the main symptoms and can show signs of confusion and weakness. Factors that|
|can increase the risk of developing CAP are advanced age, immunocompromised state, COPD, alcoholism, smoking, immobility, malnutrition, and crowded living |
|conditions. Some of the diagnostic tests to determine pneumonia are an abnormal chest x-ray, sputum gram stain culture, CBC that has presence of leukocytosis, and |
|thoracentesis with pleural fluid sample which has abnormal cells and bacteria. Antibiotics such as ofloxacin, levofloxacin, and sparfloxacinare are the main |
|treatment of CAP and if the CAP is bad, hospitalization is needed and broad-spectrum antibiotics are used. Using antibiotics greatly decreases the mortality rate |
|and improves prognosis of pneumonia. (Osborn, Wraa, & Watson, 2010). |
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( 5 Medications: References nursing central davis drug guide*
|Name: Duloxetine |Concentration (mg/ml) 30 mg |Dosage Amount (mg) 30mg 1 capsule |
|Route: p.o |Frequency 1 cap daily |
|Pharmaceutical class: antidepressants |Both |
|Indication: major depressive disorder, chronic musculoskeletal pain |
|Side effects/Nursing considerations: SE: neuroleptic malignant syndrome, seizures, suicidal thoughts, serotonin syndrome, and hepatotoxicity. Monitor blood |
|pressure, monitor appetite, suicidal thoughts |
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|Name: Lorazepam |Concentration 0.5 mg |Dosage Amount 1 Capsule |
|Route: p.o |Frequency: 1tab daily |
|Pharmaceutical class: benzodiazepines |hospital |
|Indication: decreases anxiety, depresses CNS |
|Side effects/Nursing considerations |
|Dizziness, drowsiness, respiratory depression, cardiac arrest |
|Assess anxiety, CNS reactions, fall risk |
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|Name: Budesonide |Concentration Amount 0.5mg |Dosage 0.5 mg NEB |
|Route: Inhalant |Frequency: BID |
|Pharmaceutical class: corticosteroids | both |
|Indication: potent locally acting anti-inflammatory and immune modifier. Decreases in symptoms of allergic rhinitis |
|Side effects/Nursing considerations: cough, bronchospasm, cough, dry mouth, nasal burning, infection |
|Monitor degree of nasal stuffiness, amount of color and nasal discharge, periodic adrenal function tests |
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|Name: levothyroxine |Concentration 0.1 mg |Dosage Amount 0.1 mg, 1 tab |
|Route: p.o |Frequency: BID |
|Pharmaceutical class: hormones | both |
|Indication: thyroid supplementation in hypothyroidism to restore normal hormonal balance |
|Side effects/Nursing considerations: SE: headache, tachycardic, weight loss, assess apical pulse and bp and chest pain, monitor thyroid function |
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|Name: guaifenesin |Concentration 1 tab 600 mg |Dosage: tab total 1,200 mg |
|Route: p.o |Frequency: 1 daily |
|Pharmaceutical class: cold and cough remedies expectorant | Both |
|Indication: mobilization and subsequent expectoration of mucus |
|Side effects/Nursing considerations: SE:dizziness, diarrhea, stomach pain, headache |
|Assess lung sounds, frequency and type of cough, bronchial secretions. |
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|Name meropenem |Concentration 500 mg iv |Dosage Amount: 500 mg iv |
|Route: IV |Frequency q6h |
|Pharmaceutical class: anti-infectives, carbapenems | Hospital |
|Indication: bactericidal action against susceptible bacteria such as pneumonia, UTI |
|Side effects/Nursing considerations SE: seizures, apnea, diarrhea, inflammation, allergic reactions |
|Assess for infection, observe signs for allergic reaction, monitor renal function |
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|Name: pantoprazole |Concentration 40 mg |Dosage Amount 1 Tab |
|Route p.o |Frequency: daily |
|Pharmaceutical class: proton pump inhibitors | both |
|Indication: binds to an enzyme in the presence of acidic gastric pH, treatment of ulcers, GERD |
|Side effects/Nursing considerations: hyperglycemia, headache, diarrhea, bone fracture |
|Assess for epigastric or abdominal pain, blood in stool. |
|Name: prednisone |Concentration 10 mg |Dosage Amount 40mg 4 tab |
|Route p.o |Frequency: daily |
|Pharmaceutical class: anti-inflammatories | both |
|Indication: suppression of inflammation and modification of the normal immune response |
|Side effects/Nursing considerations: depression, headache, hypertension, nausea, adrenal suppression |
|Assess intake and output, adrenal insufficiency, weakness, and confusion |
|Name: tiotropium |Concentration 18 mcg |Dosage Amount 18mcg |
|Route inhale |Frequency: daily |
|Pharmaceutical class: anticholinergic, bronchodilators | both |
|Indication: long term maintenance treatment of bronchospasm due to COPD |
|Side effects/Nursing considerations: headache, glaucoma, dry mouth, urinary retention |
|Assess respiratory status, wheezing withhold medication |
|Name: trazodone |Concentration 100 mg |Dosage 50 mg, 1/2 Tab |
|Route p.o |Frequency: qhs |
|Pharmaceutical class: antidepressant | Both |
|Indication: major depression, anxiety, alters the effects of serotonin in the CNS |
|Side effects/Nursing considerations: suicidal thoughts, drowsiness, hypotension, dry mouth, tremor, altered taste |
|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |
|Diet ordered in hospital? Regular |Analysis of home diet (Compare to “My Plate” and |
|Diet pt follows at home? Regular |Consider co-morbidities and cultural considerations): |
|24 HR average home diet: | |
|Breakfast: Patient says she usually just eats oatmeal or cereal in the morning. |The patient needs to eat a healthier diet eating and making sure she is getting |
| |enough electrolytes, vitamins (B and D), and calories. From what she said, she |
| |does eat at home but I do not think she is getting enough calories/protein to |
| |prevent illnesses. Eating a better diet with whole grains, higher protein, |
| |healthy fats, and fruits and vegetables will help my patient with more energy and|
| |better management of her health problems. The patient will benefit with good fats|
| |and proteins to reduce the risk of infection. Examples of fats and protein |
| |include: chicken, eggs, fish, beans, nuts, and avocado and seeds (pumpkin, |
| |sesame). The patient and her daughter should have a dietician come talk to them |
| |about small frequent meals at home that can help with a good calorie intake. |
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|Lunch: soup, crackers | |
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|Dinner: usually meat, a side of vegetables and rice or some other carb. | |
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|Snacks: fruit, yogurt | |
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|Liquids (include alcohol): water and tea | |
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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 reference. |
|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |
|Who helps you when you are ill? “My daughter, she does so much for me and her father.” |
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|How do you generally cope with stress? or What do you do when you are upset? |
|Patient told a lot of jokes and tried to hide her true feelings, but this observation she keeps her stress and feelings to herself. |
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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |
|Even though patient was sarcastic and told jokes, you could tell the patient is overwhelmed with her illness and being old. Her husband has dementia and feels bad |
|that her daughter has to take care of both of them. |
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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. XSelf absorption/Stagnation XEgo 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: “Ego intergrity vs. despair occurs during late adulthood from age 65 through the end of life. During this period of time, people reflect back |
|on the life they have lived and come away with either a sense of fulfillment from a life well lived or a sense of regret and despair over a life |
|misspent”(Cherry,2013). |
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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 shows signs of ego integrity because she was very friendly and looked back on her life with happiness, although she has some regrets like not being able|
|to care for herself and her husband anymore, She doesn’t show any signs bitterness. Although she is sad at times, she is happy that she’s been married for over 50 |
|years and has a wonderful daughter and grandchildren. |
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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: Her recent hospitalization has the patient |
|relieve that she is old and could die sooner now since she has COPD lung cancer and now pneumonia. This makes her realize if she has had a good life or a life full|
|of many regrets and bitterness towards herself and others. She has had a good life and just a few regrets. |
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|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” Being old and having bad lungs from smoking. |
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|What does your illness mean to you? To her, her illness means that she should have made better decisions when she was younger. |
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|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |
|Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |
|usually related to either infection, changes with aging and/or quality of life. All of these questions are confidential and protected in your medical record” |
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|Have you ever been sexually active?____Yes________________________________________________________________ |
|Do you prefer women, men or both genders? _____Men____________________________________________________ |
|Are you aware of ever having a sexually transmitted infection? ____No_______________________________________ |
|Have you or a partner ever had an abnormal pap smear?______No_________________________________________ Have you or your partner received the Gardasil (HPV) |
|vaccination? _No______________________________________ |
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|Are you currently sexually active? ___________No________________When sexually active, what measures do you take to prevent acquiring a sexually transmitted |
|disease or an unintended pregnancy? ___________Condom_______________________ |
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|How long have you been with your current partner?_____ 56 years__________________ |
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|Have any medical or surgical conditions changed your ability to have sexual activity? No____________________ |
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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |
|No |
±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Patient does believes in God and God is important to her.________________________________________________________________________
Do your religious beliefs influence your current condition?
_No__________________________________________________________________________________________________
______________________________________________________________________________________________________
|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |
|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes |
| If so, what? |How much?(specify daily amount) |For how many years? |
|Used to smoke cigarettes |½ pack a day |(age 25 thru 81 ) |
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|Pack Years: 50 | |If applicable, when did the patient quit? 5 |
| | |weeks 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? No |
| What? |How much? (give specific volume) |For how many years? many |
| | |(age thru ) |
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| If applicable, when did the patient quit? | | |
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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No |
| If so, what? |
| |How much? |For how many years? |
| | |(age thru ) |
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| Is the patient currently using these drugs? No |If not, when did he/she quit? | |
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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |
|No |
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( 10 Review of Systems
|General Constitution |Gastrointestinal |Immunologic |
| Recent weight loss or gain | Nausea, vomiting, or diarrhea | Chills with severe shaking |
|Integumentary |X Constipation Irritable Bowel | Night sweats |
|X 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 None SPF: | Diverticulitis | Life threatening allergic reaction |
|Bathing routine: every other day |Appendicitis | Enlarged lymph nodes |
|Other: | Abdominal Abscess |Other: |
| | Last colonoscopy? Never had one | |
|HEENT |Other: |Hematologic/Oncologic |
|X Difficulty seeing |Genitourinary | Anemia |
| Cataracts or Glaucoma | nocturia |X Bleeds easily |
|X Difficulty hearing | dysuria |X Bruises easily |
| Ear infections | hematuria |X Cancer |
| Sinus pain or infections (with his allergies) | polyuria | Blood Transfusions |
|Nose bleeds | kidney stones |Blood type if known: |
| Post-nasal drip |Normal frequency of urination: 5/day |Other: |
| Oral/pharyngeal infection |X Bladder or kidney infections UTI | |
| Dental problems | |Metabolic/Endocrine |
|X Routine brushing of teeth 2/day | | Diabetes Type: |
|X Routine dentist visits twice ayear | |X Hypothyroid /Hyperthyroid |
|X Vision screening | | Intolerance to hot or cold |
|Other: | | Osteoporosis |
| | |Other: |
|Pulmonary | | |
|X Difficulty Breathing | |Central Nervous System |
|X Cough - productive |Women Only | CVA |
| Asthma |X Infection of the female genitalia UTI |X Dizziness |
|X Bronchitis | Monthly self breast exam | Severe Headaches |
| Emphysema | Frequency of pap/pelvic exam | Migraines |
|X Pneumonia | Date of last gyn exam? She does not know | Seizures |
| Tuberculosis | menstrual cycle regular | Ticks or Tremors |
| Environmental allergies |Xmenarche age? 13 | Encephalitis |
|Xlast CXR? 10/6 |X menopause age? 54 | Meningitis |
|Other: former smoker, COPD, lung cancer |Date of last Mammogram &Result: she does not know if |Other: |
| |she had one. | |
| |Date of DEXA Bone Density & Result:unknown | |
|Cardiovascular |Men Only |Mental Illness |
|Hypertension | Infection of male genitalia/prostate? |X Depression |
|Hyperlipidemia | Frequency of prostate exam? 1 year | Schizophrenia |
| Chest pain / Angina | Date of last prostate exam? |X Anxiety |
|Myocardial Infarction | BPH | Bipolar |
| CAD/PVD | Urinary Retention |Other: |
|CHF |Musculoskeletal | |
|Murmur | Injuries or Fractures |Childhood Diseases |
| Thrombus |X Weakness | Measles |
|Rheumatic Fever |X Pain | Mumps |
| Myocarditis | Gout | Polio |
| Arrhythmias | Osteomyelitis | Scarlet Fever |
|X Last EKG screening, when? Hospitalization 10/2 |Arthritis |X Chicken Pox |
|Other: |Other: |Other: |
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|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |
|No |
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|Any other questions or comments that your patient would like you to know? |
|No |
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|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |
|General Survey: |Height: 5’2 |Weight: 50kg BMI: 20.1 |Pain: (include rating & location) |
| | | |2 pain around thoracentesis cite on right|
| | | |posterior chest |
| |Pulse: 88 |Blood | |
| | |Pressure: 106/78 arm | |
| | |(include location) | |
|Temperature: (route taken?) |Respirations: 20 | | |
|Oral 98.1 | | | |
| |SpO2 94 |Is the patient on Room Air or O2: NC 3liters O2 |
|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |
|X 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] |
|X awake, calm, relaxed, interacts well with others, judgment intact |
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|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |
|X clear, crisp diction |
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|Mood and Affect: X pleasant X cooperative X cheerful X talkative quiet boisterous flat |
| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |
|Other: |
|Integumentary | |
|X Skin is warm, dry, and intact | |
|X Skin turgor elastic | |
|X No rashes, lesions, or deformities | |
|X Nails without clubbing | |
|X Capillary refill < 3 seconds | |
|X Hair evenly distributed, clean, without vermin | |
|*Serous drainage from wound | |
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|X Peripheral IV site Type: 20g Location: left hand Date inserted: 10/3 |
| X no redness, edema, or discharge |
| Fluids infusing? no X yes – what? Normal Saline, antibiotics |
| 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? |
| |
|HEENT: X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ X Trachea midline |
|X Thyroid not enlarged X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge |
|X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |
|X PERRLA pupil size / 3 mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmus |
|X Ears symmetric without lesions or discharge X Whisper test heard: right ear- 5 inches & left ear- 5 inches |
| X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |
|Dentition: |
|Comments: |
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|Pulmonary/Thorax: X Respirations regular and unlabored X Transverse to AP ratio 2:1 X 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 |XSputum production: thick thin Amount: scant small X moderate large |
| |CR – Crackles | Color: white Xpale yellow yellow dark yellow green gray light tan brown red |
| |RH – Rhonchi | |
| |D – Diminished |Did not see original sputum but she said that she now coughs up rusty color sputum and from her chart, now|
| | |she has clear/yellow sputum |
| |S – Stridor |*right upper and lower lobe anterior slight crackles, left side all clear, lungs are diminished. |
| |Ab – Absent | |
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|Cardiovascular: X No lifts, heaves, or thrills PMI felt at: 5 ICS |
|Heart sounds: X S1 S2 Regular X No murmurs, clicks, or adventitious heart sounds X No JVD |
|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |
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|X Calf pain bilaterally negative X 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 |
|X 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: none pitting non-pitting |
|X Extremities warm with capillary refill less than 3 seconds |
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|GI/GU: X Bowel sounds active x 4 quadrants; no bruits auscultated X No organomegaly |
|X Percussion dull over liver and spleen and tympanic over stomach and intestine X Abdomen non-tender to palpation |
|Urine output: X Clear Cloudy Color: yellow Previous 24 hour output: N/A |
|X Foley Catheter Urinal or Bedpan Bathroom Privileges |
|X CVA punch without rebound tenderness |
|Last BM: (date 10 / 4 / 2013 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |
|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |
|Hemoccult positive / negative (leave blank if not done) |
|Genitalia: X Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |
| Other – Describe: |
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|Musculoskeletal: X Full ROM intact in all extremities without crepitus |
|X Strength bilaterally equal at ____3___ RUE __3_____ LUE ___3____ RLE & ___3____ 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] |
|X vertebral column without kyphosis or scoliosis |
|X Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias |
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|Neurological: X Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |
|X CN 2-12 grossly intact X Sensation intact to touch, pain, and vibration X Romberg’s Negative |
|X Stereognosis, graphesthesia, and proprioception intact Gait is not smooth |
|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |
|Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: |
|negative |
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|*Did not have tools to perform DTR test, but assuming that all DTR are +1 or 2 |
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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormal, include rationale and analysis. List dates with all labs and |
|diagnostic tests): |
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|Lab |
|Dates |
|Trend |
|Analysis |
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|Chest x-ray |
|October 3rd, October 6th |
|3rd:Left infusion port, Volume loss of right lung fibrotic scar, right upper lobe mass in superior mediastinum consolidation, scattered granulomas in left lung |
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|6th: Obscuration of the right hemi diaphragm and right heart border, consolidation and increased interstitial marking in right upper lung, layering right pleural |
|effusion ,left side clear |
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|The results show that the patient has pneumonia with the consolidation of the right upper lung. |
|Worse on the right side and better for the left side. Since prior x-ray, patient is going to receive another x-ray on the 9th |
| |
|NA+ |
|10/3, 10/6 |
|128 to 130 |
|Patient’s NA+ is moving up |
|Pneumonia is associated with hyponatremia. Patient’s NA+ levels have gone up from before. Normal NA+ levels are 135-145mEq/L |
| |
|Thoracentesis |
|10/3 |
|Normally the pleural cavity contains only a very small amount of fluid, the patient has more and gram stain was used. pH less than 7.4 and neutrophils |
|Results show that patient has bacterial pneumonia, Streptococcus pneumonia. Normally there is not a buildup of fluid in the lungs. |
| |
|RBC 3.35, 3.55 |
|10/3,10/6 |
|Trending up |
|3.71 to 5.31 million cells/mm3 in females. Patient has low RBC but seems to be moving up. |
| |
| |
| |
| |
| |
| |
|WBC 11.5, 8.3 |
|10/3, 10/6 |
|Her white count has trended down |
|Normal lab values(4,500 to 10,500 cells/mcL) Patient is within normal range, when she came in, the WBC showed that she had an infection and now it has gone down to |
|show that the medication is working or her body is not in the acute phase anymore. |
| |
|Urine culture |
|10/3 |
|Increased WBC, cloudy microbiological culture of urine samples, |
|Patient has a urinary tract infection, there should not be any WBC in urine |
| |
| |
|(Nursing Central, 2012) |
| |
| |
| |
|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: |
| |
|Diet: Patient is on regular diet |
|Scheduled diagnostic tests: Chest X-ray |
|Vitals: patient’s vitals were monitored to make sure because she is at risk for infection and to monitor patient’s pneumonia. She is hooked up to a tele to monitor |
|change in sinus rhythm and monitor heart rate. |
|Patient is on antibiotics and receiving medications to control pneumonia and secretions. |
|Dressing changes are as needed. |
| |
|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
|Ineffective airway clearance r/t presence of secretions |
|Risk of infection |
|Activity intolerance r/t imbalance between oxygen supply and demand |
| |
| |
| |
| |
| |
± 15 CARE PLAN
Nursing Diagnosis: Ineffective airway clearance r/t presence of secretions
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |
| | |Provide References | |
|Maintain a patent airway at all times. |1.Administer oxygen |1.Oxygen shown to correct hypoxia |Patient’s oxygen saturation was a 94 at rest but when|
| |2.Postion client to optimize respiration (head of bed|2. Upright position allows for maximal lung |when moving and trying to wash herself oxygen |
| |elevated 30-45 degrees and repositioned every 2 hours|expansion, lying flat makes it harder for patient to |saturation when down to a 90. Patient was on 3L of |
| |3.Monitor oxygen saturation levels at least greater |breathe. |oxygen to maintain airway. Patient remained in a |
| |than 88 when resting (COPD) |3. Oxygen saturation levels can help determine |upright position to have a better airway. |
| | |patients oxygen needs | |
| | | | |
|Explain methods useful to enhance secretion removal. |1. Demonstrate effective breathing exercises inhale |1. Coughing helps to maintain a patent airway. |Patient was able to understand at least 2 different |
|Patient will be able to name at least two ways to |deeply; hold breath for a couple of seconds and cough| |ways to help remove secretions. Patient now knows |
|remove secretions. |two or three times with mouth open. |2. Giving fluids mobilizes and help remove secretions|that drinking water helps with secretions. |
| |2. Reduce secretions by drinking fluids. | | |
| |3. Patient will take medications to reduce | | |
| |secretions. | | |
| |. | | |
| | | | |
| | | | |
| | | | |
|(Ackley& Ladwig, 2011). | | | |
| | | | |
| | | | |
|±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 |
|XDietary Consult Patient needs teaching on foods that provide calories and protein and foods that patient’s daughter can make. |
|XPT/ OT due to the patient’s weakness I would recommend a PT to my patient to build strength and possible teaching on how to use a walker. Also a respiratory therapist to help with decreases patient’s secretions and |
|manage COPD. |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appts |
|XMed Instruction/Prescription |
|□ are any of the patient’s medications available at a discount pharmacy? XYes □ No |
|□Rehab/ HH |
|□Palliative Care |
± 15 CARE PLAN
Nursing Diagnosis: Risk of infection
|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 of infection during 10 hour |1) Assess vitals (normal WBC count, temp < 100 F, |Patient is at increased risk for infection due to |Patient remained free of infection |
|shift. |confusion) |having a urinary foley, incision, and patient came in|WBC count, temperature, patient remained alert, clear|
| |2) Assess absence of purulent drainage from incision |with pneumonia. Assessing the vitals will determine |drainage from incision site, urine clear/yellow and |
| |3) Perineum care, try to get patient from a foley to |if patient is developing an infection, purulent |not cloudy. Patient did not want to remove foley |
| |a bed pan |drainage determines that there is an infection at the|though. |
| | |site, and perineum care to decrease risk of | |
| | |developing another UTI/help get rid of original. | |
| | | | |
|Patient will eat at least 50% of food to decrease | |Monitoring the patient’s intake can help determine |Patient ate 25% of breakfast and ate 50% of lunch. |
|risk of infection |1) Monitor patient’s food intake and record |patterns of eating, risk of poor nutrition, and |Patient did not eat that much of her meals. |
| |percentages of food served |examine foods she likes to eat. | |
| |2) Provide companionship at mealtime to encourage |Providing companionship since during mealtime usually| |
| |nutritional intake |people are present and can encourage eating | |
| | | | |
| | | | |
| | | |. |
|(Ackley& Ladwig, 2011). | | | |
| | | | |
|± 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 |
|XDietary Consult Patient needs teaching on foods that provide calories and protein and foods that patient’s daughter can make. |
|XPT/ OT due to the patient’s weakness I would recommend a PT to my patient to build strength and possible teaching on how to use a walker. Also a respiratory therapist to help with decreases patient’s secretions and |
|manage COPD. |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appts |
|XMed Instruction/Prescription |
|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
± 15 CARE PLAN
Nursing Diagnosis: Activity intolerance r/t imbalance between oxygen supply and demand AEB patient says she’s short of breath
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |
| | |Provide References | |
|Will increase activity level by discharge and be able|1)Have patient participate in bathing |1)Activity will improve physical and well-being of |Patient needed assistance with walking to chair, |
|to (do at least two activities, walk 10 feet) |2)Have patient walk to chair and sit in chair with |the patient. |patient felt too weak to walk any further than 5 |
| |oxygen (10 feet) |2)If patient is able to tolerate activity without |feet. |
| | |oxygen saturation dropping, she will more likely get |Patient was able to wash face and needed help with |
| | |to go home sooner |the rest of her body, oxygen saturation dropped to |
| | | |about a 90. |
| | | | |
|Client will verbalize understanding of need to |1) Teach patient to alternate periods of rest and |1) Teaching the patient at least two ways to decrease|1) Patient was able to verbally say two ways to |
|increase activity level gradually and name two ways |activity to reduce the body’s oxygen demand (Sitting |oxygen commands with benefit the patient. |conserve energy with an understanding. |
|to conserve energy while performing ADLs. |in a chair while dressing, wearing slip-on shoes.) |2) Teaching patient alternative exercises can help |2) Patient was able to demonstrate ROM exercises to |
| |2) Teach patient ROM exercises to build strength if |conserve energy but also protect patient from losing |increase activity level |
| |patient is unable to tolerate regular activity. |strength. | |
| |Patient will know alternative was to increase | | |
| |activity level. | | |
| | | | |
| | | | |
| | | | |
|(Ackley& Ladwig, 2011). | | | |
| | | | |
| | | | |
|±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 |
|XDietary Consult Patient needs teaching on foods that provide calories and protein and foods that patient’s daughter can make. |
|XPT/ OT due to the patient’s weakness I would recommend a PT to my patient to build strength and possible teaching on how to use a walker. Also a respiratory therapist to help with decreases patients secretions and |
|manage COPD. |
|□Pastoral Care |
|□Durable Medical Needs |
|□F/U appts |
|XMed Instruction/Prescription |
|□ are any of the patient’s medications available at a discount pharmacy? XYes □ No |
| |
|□Rehab/ HH |
|□Palliative Care |
References
Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidence-based guide to
planning care. (9th ed.). St.Louis,Missouri: Mosby Elsevier.
Cherry, K. (2013). Integrity Versus Despair. Retrieved from
Nursing Central Unbound Medicine, Davis’s Drug Guide 2012
Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical-surgical nursing: preparation for practice. Upper
Saddle River, N.J.: Pearson Prentice Hall.
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