UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Janel Canty |

|Patient Assessment Tool . |Assignment Date: 1/11/13 |

| |Agency: BMC |

|Patient Initials: S.G |Age:73 |Admission Date:1/4/13 |

|Gender: f |Marital Status: single |Primary Medical Diagnosis with ICD-10 code: |

|Primary Language: English | |

|Level of Education: 2 years of college |Other Medical Diagnoses: Myelodysplastic syndrome, anemia, |

| |hypertension |

|Occupation (if retired, what from?): bookkeeper | |

|Number/ages children/siblings:3 sisters- 72,70,63 3 children- 53,50,49 | |

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| |Code Status: Full |

|Living Arrangements: lives with her 63 year old sister at a house with no stairs and is able|Advanced Directives: a will that her sister keeps in her desk. |

|to take her medication on her own. | |

| |Surgery Date: 1/8 Procedure: Colonoscopy |

|Culture/ Ethnicity /Nationality: White | |

|Religion: Baptist |Type of Insurance: Medicare |

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|( 2 CC: “I was diagnosed with Myeloplastic syndrome and I started to feel dizzy and short of breath so I came in” |

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|( 3 HPI: (OLD CART) The patient is a 73 year old female who was diagnosed with Myleodysplastic syndrome in November 2012 and also has hypertension. She has been |

|following up with Hematology. She presented to the hematologist on 1/4/2012 with symptoms of feeling tired, dizzy, short of breath, and chest pain. She was also |

|complaining of some increasing abdominal pain over the last few days. Patient stated that she has not had an appetite for the past few days. The patient was sent|

|to the hospital for further evaluation of multiple problems. The patient has seen the hematologist for the past two weeks regularly and has received four units of|

|blood transfusion for acute fall in hematocrit and hemoglobin. The patient had a chest X-ray on 1/4/2013, which resulted in no acute cardiopulmonary disease. The |

|patient had a CT of the abdomen on 1/5/2013 and the CT showed within defined limit results and no changes in inflammatory. The patient also had an MRI on 1/5/2013 |

|which resulted in age related cerebral atrophy. The patient also had loss of normal fatty bone marrow of the vivarium and upper cervical spine which is related to|

|the diagnosis of myleodysplastic syndrome. The patient then had a MRI of the spine on 1/6/2013 that showed abnormal dark marrow on both the T1 and T2 sequence |

|throughout the thoracic and lumbar sections, this is consistent with myleodysplastic syndrome. The patient had a Colonoscopy on 1/8/2013 which resulted in |

|diverticulosis and hemorrhoids but no bleeding was present. The patient has a myelogram scheduled for 1/8/2013. |

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

|Date |Operation or Illness |Management/Treatment |

|1998 |Lung cancer |Left lobectomy |

|2012 |Myelodysplastic syndrome | |

|2013 |Anemia |Blood transfusion |

|2010 |Colonoscopy | |

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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) 2010 | | |

|Adult Tetanus (Date) 2010 | | |

|Influenza (flu) (Date) 2012 | | |

|Pneumococcal (pneumonia) (Date) 2012 | | |

|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 |NKA | |

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

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

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|Anemia is when there is a deficit in the number of erythrocyte in the body. The volume of erythrocytes is measured the hemoglobin protein, hematocrit, and the red|

|blood cell count. The erythrocytes are mainly responsible for transportation of oxygen on the hemoglobin molecule. When anemia occurs the body is unable to |

|maintain sufficient oxygen to the tissues. There are many different causes of anemia such as vitamin deficiency, excessive bleeding, decrease in red blood cell |

|production, increases in red blood cell destruction, increase in red blood cell sequestration by the spleen, and toxic drugs. In this particular patient the |

|decrease in red blood cell production is the cause of the anemia. The patient has myelodysplastic syndrome which causes bone marrow failure. Risk factors |

|myelodysplastic syndrome includes old age, occupational exposure to petroleum solvents, smoking, and radiotherapy. Upon examination a patient that has |

|myelodysplastic syndrome with anemia will present with fatigue, shortness of breath, lightheadedness, and angina. To diagnosis the anemia the labs will show low |

|hemoglobin, hematocrit, and red blood cell count. To treat anemia from myelodysplastic syndrome a red blood cell transfusion will take place. If the patient is |

|bleeding or about to go to surgery then a platelet transfusion will also take place. The prognosis for someone with myelodysplastic syndrome is about 5 years, |

|with 50% of those patients dying from excessive bleeding. |

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( 5 Medications: (Include both prescription and OTC)

|Name Carvedilol |Concentration |Dosage Amount 12.5 mg |

|Route PO |Frequency BID |

|Pharmaceutical class beta blocker |Home Hospital or Both |

|Indication Used for the patients hypertension |

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|Name Cetirizine (zyrtec) |Concentration |Dosage Amount 10 mg |

|Route PO |Frequency Daily |

|Pharmaceutical class piperzines peripherally selective |Home Hospital or Both |

|Indication relief of allergic symptoms caused by histamine release |

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|Name cholecalciferol |Concentration |Dosage Amount 1000 IU |

|Route PO |Frequency daily |

|Pharmaceutical class fat soluble vitamins |Home Hospital or Both |

|Indication prevention of vitamin D deficiency from myelodysplastic syndrome |

|Side effects: headache, irritability, somnolence, weakness, conjunctivitis, photophobia, arrhythmias, hypertension, anorexia, constipation, dry mouth, increased |

|liver enzymes, metallic taste, nausea, pancreatitis, polydipsia, vomiting, weight loss, albuminuria, azotemia, polyuria, pruritus, hypercalcemia, bone pain, muscle|

|pain. |

|Name esomeprazole |Concentration |Dosage Amount 40 mg |

|Route PO |Frequency daily |

|Pharmaceutical class proton pump inhibitor |Home Hospital or Both |

|Indication decreases risk of gastric ulcer |

|Side effects: headache, abdominal pain, constipation, diarrhea, dry mouth, flatulence, nausea, bone fracture |

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|Name Fenofibrate |Concentration |Dosage Amount 600 mg |

|Route po |Frequency daily |

|Pharmaceutical class fibric acid derivatives |Home Hospital or Both |

|Indication decreases LDL cholesterol |

|Side effects: fatigue, headache, pulmonary embolism, arrhythmias, dvt, cholelithiasis, pancreatitis, rash, urticarial, rhabdomyolysis, hypersensitivity reactions |

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|Name Guaifenesin |Concentration |Dosage Amount 600 mg |

|Route po |Frequency Hs |

|Pharmaceutical class allergy, cold, and cough remedies |Home Hospital or Both |

|Indication to decrease coughs |

|Side effect: dizziness, headache, nausea, vomiting, diarrhea, stomach pain, rashes, urticaria |

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|Name levothyroxine |Concentration |Dosage Amount 50 mcg |

|Route po |Frequency daily |

|Pharmaceutical class thyroid preparation |Home Hospital or Both |

|Indication thyroid supplement |

|Side effects: headache, insomnia, irritability, angina pectoris, arrhythmias, tachycardia, abdominal cramps, diarrhea, vomiting, sweating, hyperthyroidism, |

|menstrual irregularities, heat intolerance, weight loss, accelerated bone maturation in children |

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|Name potassium chloride |Concentration |Dosage Amount 20 mEq |

|Route po |Frequency daily |

|Pharmaceutical class mineral electrolyte replacement supplement |Home Hospital or Both |

|Indication for potassium depletion |

|Side effect: confusion, restlessness, weakness, arrhythmias, ecg changes, abdominal pain, diarrhea, flatulence, nausea, vomiting, gi ulceration, stemotic lesions |

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|Name raloxifene |Concentration |Dosage Amount 60mg |

|Route po |Frequency daily |

|Pharmaceutical class selective estrogen receptor modulators |Home Hospital or Both |

|Indication treatment of osteoporosis |

|Side effects: stroke, dvt, pe, retinal vein thrombosis, leg cramps, hot flashes |

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|Name acetaminophen |Concentration |Dosage Amount 500 mg |

|Route po |Frequency Q4h Prn |

|Pharmaceutical class antipyretics nonopioid analgesics |Home Hospital or Both |

|Indication for mild fever |

|Side effects: hepatic failure, hepatoxicity, renal failure, neutropenia, pancytopenia, leukopenia, rash, urticardia |

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

|Diet ordered in hospital? Regular diet with counting calories for|Analysis of home diet (Compare to food pyramid and |

|type 2 diabetic | |

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

|Diet pt follows at home? | |

|Breakfast: 1/2 cup of oatmeal with 1 scrambled egg and 1 piece of toast. 2 cups |This patient has a pretty well balanced diet. She is achieving the required |

|of black coffee |amount of 6 ounces of grains during a day by taking in ½ cup of oatmeal, 1 piece |

| |of toast and 1.5 cups of rice. The patient also gets adequate amount of 2 ½ cups|

| |of vegetables in a day by eating a cup of salad and 1 ½ cups of vegetables for |

| |dinner. Though the patient does need to add fruit into her diet. The patient |

| |does not get the recommended amount of 3 cups of milk by only eating 1 egg of 2 |

| |ounces. The patient did meet the recommended amount of 5 ounces of meat during |

| |the day by eating 1 ounce of chicken, 3 ounces of meat for dinner and 1 ounce of |

| |peanut butter crackers. The patient intakes the daily recommended amount of water|

| |of 6 cups per day by drinking at least 7 cups of water a day. |

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|Lunch: 1 ounce chicken sandwich with a grilled chicken salad that is a cup. 2 | |

|cups of water | |

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|Dinner: 4 ounces of meat, 1 ½ cups of rice, 1 ½ cup of vegetables, 2 cups of | |

|water | |

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|Snacks: drinks 3 cups of water throughout the day, peanut butter crackers | |

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

|Who helps you when you are ill? |

|The patient’s 63 year old sister who lives with her helps her when she is ill. |

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

|The patient stated that first she cries then puts herself together and prays a lot. |

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

|Yes, the patient has had difficulty with feeling overwhelmed because she is working two jobs, her son has rectal cancer and she is taking care of him, and her |

|illness on top of it. |

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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? ___________yes____________________________________________ |

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|Have you ever been talked down to?_____yes__________ 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?  |

|______yes____________________________________ If yes, have you sought help for this?  _______yes__________ |

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|Are you currently in a safe relationship? no |

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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: |

|Ego integrity is when an older adult has come to terms with the live that they have lived. They know the choices they made were the only possible life that could |

|have lived. While patients that have despair will feel regret to the live that they lived. This patient will fear death because they do not understand that this |

|is the one and only life cycle. This patient will think that there is not enough time for them to change any of the choices that they made is now permanent. |

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

|While interview my patient she described the decisions that she made in her life are what brought her to where she is today. We talked about her first husband and|

|how he was abusive and she told me that if she had not went through that in her life then she would not have realized that she can be happy without a man in her |

|life. That and other decisions help the patient find her way back to her religion. My patient described how happy she was with her life and everything she has |

|done in it. |

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

|My patient’s illness has helped her come to reality of her life. The patients illness did not make her have despair about her life. |

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|+3 Cultural Assessment: |

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

|The patient stated that she has no idea what caused her illness and the doctors do not know either. |

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|What does your illness mean to you? |

|The patient stated that she is still trying to get a grasp on it but she knows that she needs to slow down her lifestyle because she can’t keep up with everything |

|she use to do. |

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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?  _________yes_______________________ |

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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? |

|Smoked cigarettes |3 packs a week |(age 13 thru 38 ) |

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| | |If applicable, when did the patient quit? 35 |

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

|Whiskey |Once a month |(age 28 thru 33 ) |

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

|At the age of 33. |

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

| If so, what? |

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

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

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

|The patient stated that she has not been exposed. |

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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 SPF: 15-30 | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: showers every morning |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? 1/8/13 | |

|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: A- |

| Post-nasal drip |Normal frequency of urination: 7day |Other: |

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

| Dental problems | |Metabolic/Endocrine |

| Routine brushing of teeth 1 x/day | | Diabetes Type: 2 |

| Routine dentist visits 0x/year | | Hypothyroid /Hyperthyroid |

|Vision screening | | 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 | Severe Headaches |

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

| Pneumonia | Date of last gyn exam? 2012 | Seizures |

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

| Environmental allergies | menarche age? | Encephalitis |

|last CXR? 1/4/2013 | menopause age? 50 | Meningitis |

|Other: |Date of last Mammogram &Result: 2012 |Other: |

| |Date of DEXA Bone Density & Result:2012 | |

|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? |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

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Review of Systems Narrative

|General Constitution |

|Pt’s perception of health: |

|Patient stated that she understands that her health is not what it used to be and that she needs to slow down her lifestyle. She believes that the amount of blood |

|that she makes just cannot keep up with her. |

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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: |

|Orientation and level of Consciousness: |

|General Survey: Patient is a pleasant |Height: 65 inches |Weight: 183 BMI:30.45 |Pain: (include rating & location) |

|white female | | |7 out of 10 headache |

| |Pulse: 93 |Blood | |

| | |Pressure: 133/73 right arm | |

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|Temperature: (route taken?) |Respirations: 16 | | |

|97.1 oral | | | |

| |SpO2 97 |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: IV Location: Left anticubidal Date inserted: 1/4/13 |

| 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 dentures |

|Comments: patient stated that she does not go to the dentist |

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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 intercostal 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: light yellow Previous 24 hour output: mLs N/A |

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

|CVA punch without rebound tenderness |

|Last BM: (date 1 / 8 /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 |

|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 |

|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): |

|Patients RBC were low at 2.39, this is down from 1/6 when they were 2.87 |

|Patients Hgb was low with 8.8, this is also down from 1/6 when it was 10.2 |

|Patient’s platelet count was 362 but was high on 1/6 when it was 402. This could indicate the body is bleeding out somewhere. |

|Patient had a chest x-ray on 1/4 /2013 that showed there was no evidence of acute cardiopulmonary disease |

|Patient had a CT of the abdomen on 1/5/2013 which showed normal results with no inflammatory changes |

|Patient had an MRI of the brain on 1/5/2013 which showed age related cerebral atrophy. It also showed loss of normal fatty bone marrow of the carvarium and upper |

|cervical spine. This is related to the patient having myelodysplastic syndrome. |

|Patient had an MRI of the spine on 1/6/2013 which showed abnormal dark marrow on both the T1 and T2 sequence throughout the thoracic and lumbar region. This is |

|related to the patient having myelodysplastic syndrome. |

|The patient had a Colonoscopy on 1/8/2013 which resulted in diverticulosis and hemorrhoids but no bleeding was present. |

|The patient has a myelogram scheduled for 1/8/2013. |

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|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: |

|The patient is currently being treated with vitamin replacements and pervious blood transfusions. The patient is undergoing procedures such as a colonoscopy and |

|myelogram to check for internal bleeding. |

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|( 2 Medical Diagnoses |( 8 Nursing Diagnoses |

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

|1.Anemia |1. Pain r/t myelodysplastic syndrome AEB patient stated that her head pain was 7 |

| |out of 10. |

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|2.myelodysplastic syndrome |2. Anxiety r/t cause of disease AEB patient stating not knowing why she has this |

| |disease |

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|3. |3. Risk of bleeding r/t myelodysplastic syndrome. |

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|4. |4. Fatigue r/t decrease oxygen supply to the body AEB decrease red blood cell |

| |count. |

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|5. |5. |

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± 15 for Care Plan

Nursing Diagnosis: Pain r/t myelodysplastic syndrome AEB patient stated that her head pain was 7 out of 10.

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

| | |Provide References | |

|Use a self-report pain tool to identify current pain |While interviewing the patient, check the patient to |If the patient is in pain when you are interviewing |The patient was given Tylenol when the pain was 7 out|

|level and establish a comfort function goal |see if they are in pain. If pain is present, conduct|them, then they will not be able to pay attention. |of 10. When I checked back on her 20 minutes later, |

| |a pain assessment and implement pain management. |By relieving there pain, they will be able to |the headache was lowered to 3 out of 10. Which is the|

| | |participate in their care. |pain scale she said was her tolerated pain level. |

| |Ask about the pain, location, quality, onset, |Determining these characteristics will help find the | |

| |duration, temporal profile, intensity, aggravation, |underlying cause. | |

| |alleviating factors, and effects on pain on function | | |

| |and quality of life. | | |

| |When assessing the patient for their level of pain |This scale will show the pain intensity by using a | |

| |use a self-report pain tool, such as the scale 0-10 |valid and reliable self-report tool. | |

| |numerical pain rating scale. | | |

| |Assess the patient’s pain presence routinely at |Pain is known as the 5th vital sign. Pain needs to be| |

| |frequent intervals, often at the same time as vital |assessed frequent to make sure the patient’s pain has| |

| |signs are taken. |not come back and to help declare the underlying | |

| | |cause of the pain. | |

| |While interviewing the patient, ask the patient if |This can help you determine what has relieved this | |

| |they have other experienced this pain before |pain before. This also helps determine the patient’s | |

| | |response to pain. | |

| |When talking with the patient about their pain, |This has the patient be a part of their care plan, | |

| |assess what is their comfort functioning pain goal |while also determining what their functioning pain | |

| |using the pain scale? |level is. | |

| |Determine the medications the patient has on their |Accurate medication reconciliation can precent errors| |

| |current medication use and what they have already |associated with incorrect medications and dosage. | |

| |taken for that pain. | | |

| |Administer an opioid analgesic if indicated |Opioid are indicated for moderate to severe pain. | |

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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: Anxiety r/t cause of disease AEB patient stating not knowing why she has this disease

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

| | |Provide References | |

|Identify, verbalize, and demonstrate techniques to |When assessing the patient determine how the level of|To determine if the anxiety is having an effect on |After the patient came back from her colonoscopy, she|

|control anxiety |anxiety is effecting the patient physical reaction to|the patients physical health. |felt less anxiety. The patient still had a bit of |

| |the anxiety. | |anxiety about her actual syndrome and why she has |

| | | |this disease. |

| |When speaking with the patient use empathy to |The way a nurse interacts with a client influences | |

| |encourage the client to interpret the anxiety |the patient quality of life. | |

| |symptoms as normal. | | |

| |Encourage the patient to use positive self-talk such |Cognitive therapies focus on changing behaviors and | |

| |as “anxiety won’t kill me.” This will be taught to |feelings by changing thoughts. | |

| |the patient when they are not feeling any anxiety for| | |

| |the patient to use when they start feeling a sign of | | |

| |anxiety. | | |

| |When the patient starts to feel anxiety talk to them.|Help the patient understand the things they are | |

| | |feeling anxiety about. Such as a patient not being | |

| | |able to understand why they have a disease, talk to | |

| | |them about the disease. | |

| |When the patient is going to have a procedure or |This will ease the client’s anxiety and help the | |

| |activities, explain to them what is going to happen |nurse-client communication. | |

| |without using medical terms | | |

| |Ask the patient during the interview process what |What has helped previously, will help determine what | |

| |they have done previously to relieve their anxiety. |will help again. | |

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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) |

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|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:

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

| | |Provide References | |

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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) |

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|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:

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

| | |Provide References | |

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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) |

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|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 |

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