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    Janelle Gosch Pat ms2 Feedback

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    UNIVERSITY OF SOUTH FLORIDA a COLLEGE OF NURSING ‘Student: Janelle Gosch MSII PATIENT ASSESSMENT TOOL | ASE" Dee! Apel 2015 LA PATIENT INFORMATION Agency: LRMC | | Patient Initials: V.HLR. ‘Age: SI “Admission Date: March 18, 2015 Gender: Female ‘Marital Status: Widowed Primary Medical Diagnosis | [Primary tanguage:Enaish | Get pala | Level of Education: Some college ‘Other Medical Diagnoses: (new on this admission) ‘Occupation (if retired, what fom?): Unemployed | epetionia | uiaberiageschiden/sibings: Vounger sister 50 years od, Two | Dyspnea children, daughter age 24, son age 22. 4 grandchildren. Seer Ee vere CseeeeeeCC seer i Served/Veteran: No Code Status: Full Code | If yes: Ever deployed? No Liying Arrangements: Patient lives in one story four-bedroom ‘Advanced Directives: i | use, Patient lives with mother, son and son’s wife and two Ifno, do they want to fil them out? children, There are two steps in leading to the front door. ‘Surgery Date: N/a Procedure: chest xray Culture/ Ethnicity (Nationality: Caucasian ae a ‘Religion; Cathal “Type of Insurance: Patient is unsure of insurance type. af cuir COMPLAINT: © I started feeling chest pain yesterday aftemoon and my mother took me to the emergency department this moming.” vii ESS: (Be sure to OLDCART the symptoms in addition to the hospital course of fay) — ee : Yesterday around 3 0 clock in the afternoon; V-HLR. started experiencing a sharp pain in her chest, She was siti her living room watching TV when it occurred, The pain she states isin the upper and lower part of her chest Aid does not account any radiating pain, The pain has been consistent since yesterday afternoon and has not gone away. é pain is worsened with coughing and breathing, and relieved by sleeping and shallow breaths. She has not tried ‘anything for her pain other then trying to distract herself from it. This morning her mother drove her to the emergency department because the pain was not subsiding. Upon admission a chest X-ray was done which revealed pospigis Bilatera, pneumonia. A treatment plen is now being decided an, : mae Rely ERE? Coenen wonky aquired te University of South Florida College of Nursing - Revision September 2014 1 £2PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical iness or operation; include treatment/management of disease Date Operation or Hiness_f w014 ‘Arrived to ED with chest pain. joe 10/2013, Arrived to ED with shortness of breath, t 4/2013 Arrived to ED with abdominal pain. A 1/2012 “Arrived to ED with chest pain and shortness of breath For’on« pulgbhary hyferflation, COPD. 8/2011 ‘Arrived to ED with severe headaches x gf a 12/2010 Arrived to ED with headache and Bruisingyover ‘the right eye. 1992 ‘Tubal ligation. 1980s Bell’s palsy 2 7 2 6 MILY |Z Z 2 gils| |g 8 vMepicaL 2 | owe 8/2) | | | 3 2] 283) gd 4/3 wisrory £ | pam 2 /25/2/2/2/2| 8/2 E|. 53] el/eele3| 2) 2) | 2 ry Gf S)ea/S)2/ 8/2] alalalgiabSlgzlee $|a\ 8) 2 = | applicabley | <2 | = <\|8 e+ 6. d)2 see a] a) So 6 (Father (65__|Canoer x{/O jojo, ojo} O/x«(Olofo;xjo/oojojo|o [Mother (69 O} x |jO)0)x|O}O;oO 0/0) 0 /O}0|0/O ;0O/0 (0 {Sister ‘50 OOO O;O OOO; OlO)0/O/0 | O/O/o}0 (0 [Daughter O] x (Oo O/O/OjO oO OO) OjO/O\o o/o/o0/o0 Son DOO O(O,O}O O/OjO)O}x/oO ojo o;o|o ‘Comments: V.ALR. states that her father used alcohol heavily throughout her childhood and was diagnoses with diabetes around his 50s. Mother has had allergies since childhood, as well as her daughter, Son was recently told he has high blood pressure. All other dates of onset are unknown to patient. {A IMMUNIZATION HISTORY (May state “U” for unknown, except for Tetanus, Flu, and Pna) Rout nati te) Ts within 5 yea “Have you had any ot ‘given for international travel or ? Please List (mast -occupational purposes? Please I. a see _ If yes: give date, ean state “U” for the patient not knowing date received “x ins University of South Florida College of Nursing — Revision September 2014 2 1 ALLERGIES ‘NAME of or ADVERSE Grice Ae “Type of Reaction (describe explicitly) REACTIONS | The patient states she is allergic to Medications Cipro, Keflex, Levaquin, and penicillin, | The patient is unable to differentiate a specific reaction for each medication, She states they all make her itching and sick, Patient denies being | N/A Other (food, tape, | allergic to any other latex, dye, ete.) things such as food, tape, latex, dye, ete. a PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanies of disease, risk factors, how to diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or ‘tpatment) Seeteeseeaaenac is : > Levi have algo done plasvibienennnt pain] nentardiag. 6 fechani¢ of disease: Pneumonia is an infectiqp that inflames the air sacs\in onebr both lungs. The air sacs may Till with uid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing, A variety of organisms, including bacteria, viruses and fungi, ean cause pneumonia. Symptoms of pneumenia inclu cough, sputum may be rst or geen or tinged with blood, fever, chills chest paint tachycardia, nausea, vomiting, diarrhea, Symptoms caused by viruses are the same as those caused by bacteria. But they may come on slowly and often are not as obvious or as bad. Risk factors; Pneumonia can affect anyone. You may be more likely to get the disease afler having a cold or the flu, These illnesses make it hard for your lungs to fight infection, so itis easier to got pneumonia, Having a long-term, or chronic, disease like asthma, heart disease, cancer, or diabetes also makes you more likely to get pneumonia. the two age groups at highest risk are children who are 2 years old or younger developing and people who ate age 65 or older “How fo diagnose: Upon admission you'll be asked about your medical history and doing a physical exam, including listening to your lungs with a stethoscope to check for abnormal bubbling or crackling sounds that indicate the presence of secretions, If pneumonia is suspected you may get a chest X-ray to determine the extent and location, CBC blood test to confirm infection, sputum test to pinpoint the cause of infection. Other test include rapid urine test to identify bacteria, HIV test for people with impaired immune system, Some doctors may suggest an HIV test if they think that Pneumocystis Jiroveci is causing the pneumonia, Treatment: For most people, pneumonia can be treated at home with medication. It often clears up in 2 to 3 weeks. But older adults, babies, and people with other diseases can become very ill. They may need to be in the hospital. Medications include antibiotics to treat bacterial pneumonia, fever reducers, which include aspirin, ibuprofen, and acetaminophen, cough medicine to calm your eough to promote rest. You may also receive respiratory therapy to remove mucus from the lungs. Getting plenty of rest, staying hydrated, and taking your medication as prescribed which includes taking the entire course of antibiotics can ensure a quick recovery and decresse your tisk of complication. To help prevent pneumonia, get vaccinated, practice good hygiene, don’t smoke, and keep your immune system strong. Prognosis: The mortality (death) rate is up to 30% for patients with severe pneumonia who require treatment in an intensive-care unit. Overall, around 5%-10% of patients who are treated in a hospital setting die from the disease. Pneumonia can be treated successfully with medication, However, some people, especially those in higherisk groups, may ‘experience complications, including lung abscess, fluid accumulation around lungs (pleural effusion), difficulty breathing, bacteria in the bloodstream (bacteremia). Genetic factors: There are not many resource that link genetic Factors fo pneumonia, Many genetic links fo other chronic University of South Florida College of Nursing — Revision September 2014 3 lisease like asthma, heart disease, cancer, or diabetes also makes you diseases such as Having a long-term, oF chronic more likely to get pneumonia. FERENCES: HTTP:/WWW.MAYOCLINIC.ORG/DISEASE! CONDITIONS/PNEUMONIA/BASICS/DEFINITION/CON-200200322 4A MEDICATIONS: [include both prescription and OTC; hospital (include TVF) , home (reconciliation), routine, and PRN ‘medication . Give trade and generic name.) Name ATbueol Inbar [Concentration Sng Dosage Amouat 2m Route NEB/inkaaton [Frequency ape Pharmaccoal cs bronchodilator Teo 1 ow ed "averaeSe eft: Poa dvlal bronthospan, chest pal, pi {iypergirceml, typoatemia,and tremors, 2 [Nursing consldeaton’ Paden Teaching: THs medcton rane alvay month mle: Avs Tung suo, ple, and Wool prasar ere [siminisiato, Monitor pulmonary funtion tt before tating therapy and erg, Sake tater wal andi teat Lm betwee nals rine Iveore se For eilaren nay we spacerEscets Inbal ase may lent foolrance aad pratonelbrebaspasn, ober for whee and oy pare. Use Spree ry TRIG NH Wy COPD. Uae a Te oH Tr nT TTS oases, restesnes, headache nausea, Vong, hypertesion arrhythmias, Tedicaion: Used nth MAO tahibitors may led to hypertensive cris . (ame apn ew [Concatration S2ama=T abs sage Aron abe our FO [Freaneny one ine : Pharmaceotia eases [Howat | inaction epg ae proteooe [eves Side effects nits, i Blcding, dyapepan planar itrws, nausea, abdomioal pals, on0r€ln,vontng, anemia, hemolji, rash wicaia (hives), yas, laryageal edema [Nursing considerations Patient Teachings This mediation produces snalgcla and Feduvesintummation avd fever by Inhibiting te prvtion of prestaglandns. Asses for hypersensitive reetion, pai, kinitation of movement, fever. Monitor nb values. Adlnister with food or antacid to reduce gastic Hevtaton. Take with fal glass of mater and remain upright for 30 mins, Avoid in patients with chronic alcobol we. Asplrin may need tobe witheld] week ruery iClong term nse. Tae ony preverbed dose. [Nanne erixone (Rocepiin) [Concentration Toddmy [Dosage Amowwe 1000 ‘Route injection —— regensy oe tine [Pharanaceutical class antbiot3™ gen. cephalosporin Mospian nos ey gP TC id aca co Wa eR aig STIS Aversa Side eee: eure, peeodomembranout COWS, darrhea, chalets (@ulsone) aia ie aap tans. . ‘Nursing considerations Patent Teachings assess for inection, vas aga, appearance, ari, and sol, WBC: Before Therapy obtain Wstory of any previous ‘reactions with penicilin or cephalosporin. Obtain specimen culture before iiating therapy. Observe fir aller reaction, monitor bowel function Instruct [patient to ootify healthcare provider if fever and dlarica develop. ier sodng, rash, ureaval, Bleeding emai oem [Rane sathraaye [Concentration Sv0mg/ DEW 25m [Besnge Amoont Sime Route IVP BINT Frequency one Wwe 330m Pivariaceatica last macralides sia ~ Fi : neato teatent of respiratory War@ectons Bet suiceptbe organise [Aavers! Side fects; dziness, sans, drewsincs, fatigue, torsade de palate, chest pals, bypowaston, QT Inierval prolongation, hepafotonieiy, abdominal pain, darrhes, nausea, melens oral candidiasis, pylori steno, anemia, lekopeni, throm bocytopenk, sevens jahason syndrome ash, photoseastvity, [sftoxiity, hyperkalemia, angioedema ‘Norsingconsierationy Patient Teaching: Aes patient Tor fet Vials sigas, appearance, wile aed soa, WHC, Observe for signs af anaphylixis rash, [rari whcesingy and edema. Monitor ab values. Take medication ae drested and Naish the drag completly. lstruct patient not take with fod. Inform [patient aout drowniness and dizzinese do nat drive while taking aidwronyein [Name ertapenem sodium ehlorde [Concentration Tema DDasige Amon Tam [Frequency Pah, Tome ‘University of South Florida College of Nursing — Revision September 2014 4 [Pharmaceutical Gags cavbapeneas liawt iso Tor mderate ove > "Adverse Side efecs eaures, headaches, darthea, nase, vowing, | Ruan on catn ate Teaching Assess pate Yr Tem WT igs, appeaaRE, IE. a Wl WAC. Observe Tir varius, wheszing, and edema, Mitra values Obtain specimen clare efore nating therapy Observe for allie ecto, moater bowel farcton its, phlbitis and pain TV ste, wnapas Inesruet patent ty health ere provider i fever nnd diarrbea develop ‘Name Fpraroptane 00256 Te ocentraon Smeg Sm ——osage Amount SOE [Rowe NEB Freaaeney athe [Pharaaceutcal dass Toone [indications Maintenance therapy of reversible wiway obsiruction due to COPD, [Aaverse Side ees dizziness, Headache, burred ison, are thr, bronchospast, cough, hypoteaton, reaction | [Nursing conseration’ Patent Teaching: nes respiratory atu (ate, breath sounds, degree of djspnen, pulse) before adiion,Tatract pale proper use mdf ake medication as directed. Do not double dose. Advise patent that rinsing mouth after using inhaler, z00d ora ae dry mouth. lations, GTTaton, ra, waasea, eae jotiuhaler, nebulizer, or nasal spray. lnytene sd sugartess gum may al Aone other heme medi cari ong Z University of South Florida College of Nursing — Revision September 2014 5 Diet patient follows at home 24 HR average home diet: ee Breakfast: 2 scrambled eggs (milk added cooked with butter), 3 strips of bacon , and 3 links of sausage. . Lunch: fried chicken sandwich, fries with ketchup Dinner: porkehops, mashed potatoes and gravy and canned green beans. Shacks: bananas, powder sugar donuts. Liquids (inelude alcohol): 1 cup of orange juice, water. typical diet at home is shown above and is not up to the recommended diet as suggested by Choossemyplate. gov. Here the patient’s average diet exceeded the recommended amount of calories by 103 calories. When broken down into daily food group targets the patient exceeds her consumption of protein by twice the recommended amount of SI/2 02. 1 would recommend cutting down to only one protein for breakfast instead of three. Her diet is lacking dairy, only in taking % of the recommended 3 cups. Adding a cup of milk throughout the day or ‘cup of yogurt can be a good alternative snack compared to donuts, She was just shy of the recommended amount of grains and fruits in a daily diet. I would suggest adding a side of rice instead of French fries and try a grilled chicken sandwich with @ {uit of choice such as a peach or pear fo meet both her recommend grain and fruit target. This also isa healthier choice for lunch and climinates unnecessary fat and oil from her diet ‘which can cause heart problems and contribute to this patients initial complaint of chest pain, Vegetable food group target was exactly were we would like fo see it. L would suggest trying to substitute canned green beans for fresh green bars; this would cut down on sodium, Other suggestions would be to increase water intake to promote hydration as well as incorporate at least 150 minutes of exercise per week. (Compare to “My Plate” and ies and cult ural considerations) Beane) fap) Sas) OF Mane) Whew) Keene) ton OK OK Under Owe J cits 25% a5 Tata Porcantage Tors Graph Fels inks; tet ne Rapa Vinw By Maa aly Limits Total calories Ester: 2103 da 1 Empty Calories’ Eaton: st0de eee Empty Calories? Limit 258 ‘otal Umi: 2000, oils 1 Saturated Fat hm Sodium? db. oor Eaten 29 Eien tian Init 6p. It 209 Lint 2900m— ‘Who helps you when you are ill? ‘The patient stated resting helps her when she is WL “I usuall How do you generally cope with stress? or What do you do when you are upset? University of South Florida College of Nursing ~ Revision September 2014 6 “Stay in bed when Idon’t feel well” When V.HLR. feels stressed she likes go-aitigiing, she'll go to thrift siops-and look for anything interes enjoys fishing. ——" ing. She als 1 paesntt tow tntiquinges Ft é 2 Recent difficulties (Feelings of depression, anxiely, being overwhelmed, relationships, friends, social Hite) ‘The patient denies any feeling of major depression or anxiety, but does state she does get over whelmed sometimes and this can make alittle sed. 2 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. J am going to ask some questions that help me to make sure that you are safe.” | bs JMESTIC VIOLENCE ASSESSMENT | Have you ever felt unsafe in a close relationship? __Patient states she has felt unsafe in one previous relationship but that ‘was a long time ago. é Have you ever been talked down to?___The patient states she has before not recently. Have you ever been hit punched or slapped? ___the patient denies being hit or punched or slapped. | Have you been emotionally or physically harmed in other ways by & person in a close relationship with you? ‘The patient denies any emotional or physical harm in other ways by a person close fo i, If'yes, have you sought help for this? LNA. Are you currently in a safe relationship? 4 DEVELOPMENTAL CONSIDERATION: Erikson’s stage of psychosocial development: Ditratvs OMisrost _ClAutonomy vs. Doubt & Shame Cntsive vs OGuit Clindasty ws [erioriy identity ve, ORole Confusion Difusion Clntimscy vs. isolation CGeneratvity vs. Self sbsorton’tagnation _X Ego atari vs, Despai ‘Check one box and give the textbook definition (with citation and reference) of both parts of Frickson’s developmental stage for yout patient's age grou; F.GO INTEGRITY: - the last of eight stages of psychosocial development, and used by to representa post-nareissistie love of the hhuman,ego...as an experience which conveys some world order and spiritual sense, no matter how deatly paid for (Erikson,1973), Refefence: Pik H. Krikson, Childhood and Society (Penguin 1973) pp. 259-260 Describe the stage your patient is in and give the characteristics thatthe patient exhib that Ted you to your detennin “This patient exhibits the last or eighth stage of psychosocial development; she talks about her children and her ‘grandchildren and hopes they have easy and happy lives. She love to play with her grandchildren and looks back on her cov life with no regrets except for smoking because she could have set a better example for them, Describe what impact of disease/condition or hospitalization has had on your petient’s developmental stage of lie as ‘Since the patient is in her last stage of development, she has accepted her condition and she is not surprised by it. She frequently comes to the hospital now and knows that it is beeause of previous lifestyle ch = +3-CULTURAL ASSESSMENT: “What do you think is the cause of your illness?” The patient states that being inactive and unhealthy has caused her illnesses. University of South Florida College of Nursing — Revision September 2014 7 ‘What does your Hliness mean to you? moa The patient states that her iliness is a lesson to be learned. She hopes that her grandchildren do not follow her example. XUALITY ASSESSMENT; (the following prompts may help to guide your discussion Consider beginning with: “Tam 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 ie. Al of these questions are confidential and protected in your medical record” _ ne Have you ever been sexually active? Patient states she has been sexually active eee Do you prefer women, men or both genders? __ The patient states she is interested in men. ‘Are you aware of ever having a sexually transmitted infection? The patient states she is not aware of having a sexually transmitted infectic Have you or a partner ever had an abnormal pap smeer?____Patient denies have an abnormal pap smear. Have you or your partner received the Gardasil (HPV) vaccination? __ Patient has not received the Gardasil HPV vaccination, Z ‘Are you currently sexually active? __Patient states she has not been sexually active since her husband died Ifyes, are you in a monogamous relationship? ___ patient states she is widowed, — When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? NA. = if How long have you been with your current partner?__She states she was in her most recent relationship for 25 years. Have any medical or surgical conditions changed your ability to have sexual activity? __Pationt states she had her tubes tied in 92. Do you have any concerns about sexual health or how to prevent sexually transtnitted disease or unintended pregnancy? Patient does not have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnane) University of South Florida College of Nursing — Revision September 2014 8 41 SPIRITUALITY ASSESSMENT: (including but nt limited tthe following questions ‘What importance dos selgion or spina have in your hie? “__Patient states she is not a very religious person, Di Patient states she does not believe her belief influence her condition MOKING, 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?_4 years Pi states she smokes cigarettes ‘A pack a day (age 10 tha St) Ifapplicable, when did the 7 patient quit? Patient has tried to pe toe quit multiple times but has not been able to. Flas the patient ever tried to quit? Multiple times. Does anyone inthe patient's household smoke tobacco? If | Thee ha dd they use to ty to qui? Patient states she 50, what, and how much? boas not tried anything to quit. 2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes What? Just beer How much? 3 beers For how many years? ‘Volume: a bottle or can of beer. (ge tm SI Frequency: once a week Trapplicable, when did the patient quit? Patient does not plan on quitting. 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? (oge___thru nl Ts the patient urrenly using these G85? 15.54 when did helshe quit? ‘Yes No 4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks Patient states she is not exposed to any occupational or environmental hazards 5, For Veterans: Have you had any kind of service related exposure? NIA University of South Florida College of Nursing — Revision September 2014 9 30 REVIEW OF SYSTEMS NARRATIVE Gastrointestinal Immunologie Tr Nausea, vomiting, or Tames Ll chile with severe shaking Integumentary [Constipation [Tiritable Bowel — | [C] Night sweats ‘Changes in appearance of skin (GERD [Cholecystitis Fever [EProbiems with nals Indigestion Gestris/ Ulcers | E) HIV oF ADDS X Dandruff Hemorrhoids _) Blood inte stoi | (7) Lupus [Psoriasis Yellow jaundice [-) Hepatitis ‘Rncumatoid Arr ‘T Hives or rashes i Sarcoidosis [LSkia infections Tumor X Use of sunscreen SPF: 15 Life threatening allergic resction ‘Bathing routine: once a day JAppendicts Enlarged lymph nodes Other: ‘Abdominal Abscess Other ‘Be sure to answer the highlighted area_| [7] Last colonoscopy? Never HEENT Other Hemuatologic/Oncologie [Difficulty seeing Genitourinary (Anemia ‘Cataracts or Glaucoma, Ty nocturia Bleeds easily Difficulty heari Di aysuria Bruises easil Ear infe Cl hematuria Cancer ‘Sinus Ci polyuria Blood Transfusions ose bleeds [kidney stones Blood type if own: not known Post-nasal crip ‘Normal frequency of urination: 4 x/day | Other: ‘Oral/pharyngeal infection Ti Bladder or Kidney infections X Dental problems “Metabolicindocrine Routine brushing oftesth 2 x/day Cy Diabetes Type: Routine dentist visits Tdyear Co Bypothyroid Hypertnyroid [Evision sereening [inioierance to hot or cold ‘Other: D1 Osteoporosis ther: Pulmonary ‘X Difficulty Breathing ‘Central Nervous System WoMEN ONLY. Ocva. [iniéetion ofthe female genitalia Cdizziness Monthly self breast exam ‘X Severe Headaches 2 Emphysema ‘Frequency of pappeivie exam Migraines X Pneumonia Date of last gyn exam? 5 years ago Sizures Tubereulosis TJ mensirua cycle regular Ticks or Tremors Environmental allergies menarche ga? 16 Encephalitis Last CXR? 3/18/15 menopause ‘Meningitis, Date of last Maramogram &iesut: 5 years en ago and good Other Date of DEXA Bone Density & Result: 5 Cardiovascular MEN ONLY. Mental Tiiness [Hypertension Tnfection of male gentalalprostate? Depression Hyperlipidemia Frequency of prostate exam? Schizophrenia % Chest pain / Angina Date of last prostate exam? ‘Anxiety [LiMyocardial Infarction ‘BPLL Bipolar Cicappvp irinary Retention Other Our Musculoskeletal (Murmur Li Injuries or Fractures: Childhood Diseases Thrombus X Weakness ‘Measles [Rheumatic Fever Pain Mumps Myocarcitis Gout Polio Bi smiytnmias ‘Osteomyelitis ‘Scarlet Fever Yast EKG serecning, when? 3718/15 larthritis X Chicken Pox Other Gther: ‘Other: University of South Florida College of Nursing — Revision September 2014 10 |General Constitution Recent weight loss or gain N/A How many Ibs? Time frame? Intentional? How do you view your overall health? Patient views her health as moderately healthy but could be better. Is there any problem that is not mentioned that your patient sought medical attention for with anyone? Patient states there are no problems that are not mentioned that your patient sought medical attention for with anyone. ‘Any other questions or comments that your patient would like you to know? Patient states she does not have any question or comments. University of South Florida College of Nursing ~ Revision September 2014 ul £1 PHYSICAL EXAMINATION: General Survey: Patient | Height 183em Weight 84.6kg BMI Pain: (include rating and is calm and cooperative, | Pulse 81 Blood Pressure: (include location) | location) clean and well groomed, Respirations 105/63 in left upper arm 8 out of 16 She is very tired and slips | 20 In chest out of conversation at time to close her eyes. “Temperature: (route taken?) 36.8 C Oral SpOr 98% Overall Appearance: [Dress/grooming/physical handicaps/eye contact] X clean, hair combed, dress appropriate for setting and temperature, maintains dye contact, no obvious handicaps Ts the patient on Room Air ‘Overall Behavior: patient is calm and cooperative but isa litle fred and closes eyes frequenily throughout conversation Dawake, calm, relaxed, interacts well with others, judgment intact Speech: [e.g clear/inumbles /rapid /slurred/silenvother] X clear, crisp diction ‘Wood and Affect, X pleasant _X cooperative [J cheerful [I talkative quit boisterous athetic LJ bizare [Jagitated [Janxious _{_Jtearful Caw Eh lagaressive _[_Jhostile oud Tired Ufategumentary XX Skin is warm, dry, and intact X Skin turgor elastic _X No rashes, lesions, or deformities XNails without clubbing —_X Capillgy# refill <3 seconds ___X Hair evenly distributed, clean, without vermin [i Central access device Type: UPGripherel IV 18 gauge Location: upperright arm Date inserted: 3/18/15 Fluids infusing? Xno_ [yes - what? JHEENT: X Facial features symmoirie _X No pain in sinus region X No pain, clicking of TMI_X Trachea midline “Thyroid not enlarged __X'No palpabie [ymph nodes __X sclera white and conjunctiva clear, without discharge X Eyebrows, eyelids, orbital arog eyelashes, and lacrimal glands symmetric without edema or tenderness SPERRLA pupil size /3 mb“X Peripheral vision intact_X EOM intact through 6 cardinal fields without nystagmus X Ears symmetric without lesions or discha isper test heard: rightew- inches & leficar- inches X Nose without lesions or discharge _X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions Pufmonary/Thorax: Respirations regular and labored _X Transverse to AP ratio 2:1_X Chest expansion symmetric Percussion resonant throughout all lung fields, dull towards posterior bases “DiSputum production: Wie Amount none. Lung sounds: diminished throughout RUL diminished LUL_ dim RML diminished TLL di RLL diminished hed (CL =flear, WH= Wheenes: CR — Graavles RH — Rhonehig D ~ Diminished: S— Siidor; Ab Absent Lardiovascalar: (fis, heaves, or thrills Heart sounds: XS; $; audible X Regular L] Irregular X No murmurs, clicks, or adventitious heart sounds _X No JVD University of South Florida College of Nursing — Revision September 2014 12 's Rhythm strip reveals normal sinus rhythm, | eden (for patients with ECG tracing — tape 6 second strip below and analyze) at | Le ‘e-ha-208 cnn i University of South Florida College of Nursing — Revision September 2014 13 LI Calf pain bilaterally negative _X Pulses bilaterally equal (rang scale: O-absom, |-barcly palpable, 2-weak, 3-normal, 4-bounding) | Apical pulse:3 Carotid: 3 Brachial: 4 Radial: 3 Femoral: 3 Popliteal: 3 -DP:___PT: X No temporal or carotid bruit Edemate (eg OL (I eee rE Location of edema: ping —_momiting X Extremities warm with capillary refill less than 3 seconds (at 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 Tast BM: (te 3/18/15) Formed Color: Medium Brown To Nausea Tlemesis Describe if present: Genitalia: [JClean, moist, without discharge, lesions or odor __X_Not assessed, patient alert, oriented, denies problems i Other — Deseribe: GU Urine output: _X Clear [JClouds ‘Color:_yellow Previous 24 hour output; N/A _LiFoley Catheter [Urinal or Bedpan _X Bathroom Privileges with assistance, patient complains of weakness XX CVA punch without rebound tenderness LBtKGculoskeletal: X Full ROM intact in all extremities without crepitus {strength bilaterally equalst 5 RUE § LUE__4 RUB & 4 in LLE [ting see D-abseny, Irae, 2st agin avi caine gravy Bu ot asi re some esse, Sagat fl resistance] X vertebral column without kyphosis or scoliosi X Neurovascular status intact: peripheral pul palpable, no pain, pallor, paralysis or paresthesia Neurological: X Patient oriented to person, place, time, and date [_Confused; iteontusea X CN 2-12 grossly intact X Sensation intact to touch, pain, and vibration X Romberg’s Negative X Stereognosis, eraphesthesia, and proprioception intact __X Gait smooth, regular with symmetric length of the siride DTR: [rating scale: Q-absent, +1 sluggish/diminished, +2 nctive/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] Triceps: 2 Biceps: 2 Brachloradial: 2 Patella 2 Achilles 2 Ankle clonusnegaive Babinski- negative oe short hand Gummacy wae ae of purl at 40 3% £10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normal as well as ‘bnormals, include rationale and analysis. List dates with all labs and diagnostic tests) University of South Florida College of Nursing ~ Revision September 2014 14 Lab Dates Trend Analysis WBC (Normal 3.5-10.5) This patient's white blood | A low white blood cell 9.7 K/mel, 3/18/15 cell count stay with in count (leukopenia) may 5.9 K/meL 3/19/15 normal range throughout | be caused by a medical 4.8 KimeL 3/20/15 her stay at the hospital condition, such as an but do trend downward | autoimmune disorder that, toward the lower end of | destroys white blood normal range. cells, bone marrow problems or cancer, Certain medications also can cause white blood cell counts to drop. If your white blood cell ‘count is higher than normal, you may have an infection or inflammation. A high white blood cell count can also be a reaction to medication. This patients WBC remained in normal range so none of these conditions apply. RBC (Nonmal 47-6.1) Upon admission this | RBCs contain 4.42 million/meL snisnis patients red blood cell | hemoglobin, which 3.80 million/meL 3nl9is ‘count was within normal | carries oxygen. How 3.80 million/meL. 3/20/15 range, throughout her | much oxygen your body stay her RBC value began | tissues get depends on to drop to 3.80 how many RBCs you million/meL on the 19" | have and how well they and the 20" work. Lower RBCs may be due to bleeding, malnutrition, and drugs that decrease rbe, gb (Normal 12-14) Fe ‘Much like this patient's | Hemoglobin is a protein 13.6 gmidL. 3/18/15 RBC count, her in red blood cells that 11.5 gmidL, 3/19/15 hemoglobin follows a | carries oxygen. So it 114 gmidl, 3/20/15 similar pattern. This makes sense that when patient's hemoglobin _| RBC are low, Hgb and value starts off in the | Hmt values may also be normal range but then low. Low Hgb values decreases to below may be due to anemia, normal limits on the bleeding, poor nutrition, following days. or chronic iliness. Het (Normal 36%-46%) ‘Similarly to this patient's | The hematocrit is the 41.5% 3/18/15 hemoglobin her proportion, by volume, of 35.9% 3/19/15 hematocrit levels are also | the blood that consists of 35.7% 3/20/15 trending downward as her | red blood cells, expressed University of South Florida College of Nursing ~ Revision September 2014 15 stay increases. Upon admission her hematocrit is within normal range then drops below the normal range limit on the following days. as a percentage. A person who has a low hematocrit is referred to as being anemic, Common reasons of loss of blood, traumatic injury, surgery, b12 deficiency, and cancer. Platelet (Normal 150- 450) 218 K/meL. 183 K/mel. 197 K/mel. 3/18/15 B/9/S 3/20/15 The patient's platelet count stayed with the normal range of 150-450. There was little variation in the values throughout the length of stay. This patient’ platelet count slightly lowered to 183 then rose back up to 197. ‘A platelet count that’s lower than normal (thrombocytopenia) or higher than normal (thrombocytosis) is often a sign of an underlying medical condition, or it may be a side effect from medication, If your platelet count is outside the normal range, you'll likely need additional tests to diagnose the cause. Since this patient's platelet values are within normal range no additional test were done. Glucose (Normal 70-100) 109 mg/dL. 93 mg/dL, 90 mg/dL, 3/18/15 B/19/15 3/20/15 Upon admission this patient’s glucose levels were a little elevated at 109 but soon after remained within normal range upon the following days of stay. Normally, your blood glucose levels increase slightly after you eet. This increase causes your pancreas to release insulin so that your blood glucose levels do not get too high. Blood glucose levels that remain high over time can damage your eyes, kidneys, nerves, and blood vessels, BUN (Normal 6-20) 12mg/aL. 14mg/dL. 14mg/dL 3/18/15, 3/19/15 3/20/15 This patient's Blood urea nitrogen remained within normal values throughout the stay at the hospital. Variations between the values were very little only rising fiom 12 to 14 post admission, Blood urea nitrogen is an indication of renal health High BUN levels suggest renal failure. Low BUN. levels are not common and are not usually a cause for concer, They may be seen in severe liver disease malnutrition, and sometimes when a person is overhydrated. Creatinine (Normal 0.6- This patient’s creatinine Creatinine is a chemical University of South Florida College of Nursing ~ Revision September 2014 16 13) levels were just barely | waste molecule that is 0.7 mga. 3/18/15 within normal range upon | generated from muscle 0.4 mg/dL 3/19/15 admission, The next day | metabolism. Low 0.6 mg/dL. 320/15 we see that her creatinine | Creatinine level in the | dropped from 0.7 to .04 | blood can be a sign of | below normal range. certain diseases which Following that day the | cause decreased muscle creatinine was elevated | mass. Increased back up to 0.6 still creatinine levels in the borderline within normal | blood suggest diseases or limits. conditions that affect kidney function. Sodium (Normal 135- This patients sodium | Sodium is a substance 145) levels stay within normal_| that the body needs to 135 3/18vis range throughout the work properly. Your 139 anos entire length of stay at the | blood sodium level 141 3/20/15 | hospital. A slight represents a balance clevation in values occurs } between the sodium and throughout the stay but | water in the food and still remain in normal —_| drinks you consume and | Tange. the amount in your urine, Lower than normal sodium level is called hyponatremia. It may be due to dehydration, ketonuria, SIADH, or i i medications. Potassium (Normal | This patient’s Potassium | Potassium (K+) helps 5.0) evels were lowered upon | nerves and muscles, 3/18/15 admission, which could — | communicate. It also 3.2 mmol/l. 3/19/15 ‘explain the chest pain she | helps move nutrients into 42 mmoVL 3/20/15 ‘was experiencing. During | cells and waste products 4.3 mmol/L the next days her out of cells. Low levels of potassium level was potassium (hypokalemia) raised back into normal | may be due to diarrhea, range throughout the diuretics, remainder of her stay. _ | hyperaldosteronism, not | enough potassium in the diet, renal artery stenosis, and vomiting. Chloride (Normal 96- This patient's chloride | Chloride is a type of 106) levels were within normal | electrolyte. It works with 100mmol/L 3/18/15 range upon admission but | other electrolytes such as 107 mmol/L 3/19/15 ‘seem to have clevated potassium, sodium, and 107 mmol/, 3/20/15 throughout the next days. | carbon dioxide (CO2).. Although just barely These substances help above normal limit at 107 ‘on the 19" and the 20". keep the proper balance of body fluids and maintain the body's acid- University of South Florida College of Nursing — Revision September 2014 7 base balance. A greater- than-normal level of chloride is called hyperchloremia. It may be due to diarrhea, metabolic acidosis, respiratory alkalosis, and | renal tubuilar acidosis, Hypochloremia may be due to Addison's disease, | burns, congestive heart failure, dehydration, excessive sweating, or gastric suction. Calcium (Normal &.5t0 10.2 mg/d. 3/18/15 3/19/15 3/2015 Upon admission this patient’s calcium levels were under normal range and remain below the normal limit throughout the stay at the hospital. Although her calcium levels were consistently on the rise ending with 8.4 just below the normal limit of 8.5 upon discharge. More than 99% of the body’s total amount of calcium is found in the bones; most of the remaining calcium is in the blood. Hypocalcemia, very low levels can lead to dysthythmias, severe seizures and muscle spasms, hypotension, tetany, and bone fractures. Hypercalcemia, very high levels can lead to kidney stones or kidney failure, dysrhythmias, dementia, and coma, Neutrophils (Normal 13- 8.0, $4%-62%) TAT, 11.2% 3.96 , 66.8% 2.90 , 60.6% 3/18/15 3/19/15 3/20/15 Upon admission this patients absolute neutrophil count ANC vwas within normal range but her percentage of neutrophils were elevated, Throughout her stay her ANC remained in normal range but her percentage slowly decreased into normal range upon her last day of stay, Neutrophils are key components in the system of defense against infection, An absence or scarcity of neutrophils (a condition called neutropenia) makes a person vulnerable to infection. After chemotherapy, radiation, or a blood or marrow transplant, the ANC is usually depressed and then slowly rises, reflecting the fact that the bone marrow is recovering and new blood University of South Florida College of Nursing - Revision September 2014 18 [ cells are beginning to grow and mature. Increase in bacterial | infection, hemorrhage, and diabetic acidosis. ‘CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: Chest x-ray: ordered for chest pain, Results revealed pneumonia, # #pt Constant cardiac monitoring: ordered for chest pain, to be worn throughout stay at hospital Chest pain protocol: patient received aspirin as chest pain management protocol. = Mas& Lab draws: CBC and well as chemistry ordered daily to observe for abnormalities and trends. tAatibioti s treatment from found infection. ; A Antative Spirrmetry (1S) + TEDg exerci ses - Z8 NURSING DIAGNOSES (actual and potential - listed in order of priority’ E related to alyeolay capillary membrane changes secondary to inflammation as evidence by dyspnea, wert. pravervle ine fective breathing pa Ur Sint B27 1% COoM BAT. 7. Risk fovNnfection spread due to inadequate primary defense as Slee by decreased ciliary action, stasis of respiratory secretions. 3. Acute pain related to inl os flung parenchyma, cellular reactions to cirulating toxps, persistent coughing as evidence of reported chest pain'SRU Warding of affected area. a0 evidence by reports of fatigue, 7. Aeaivity intolerance related to generalized weakness and excessive dyspne een and tachycardia in response to activity. isk for ineffective airway clearance related to pneumonia disease process and possible presence of secretions University of South Florida College of Nursing ~ Revision September 2014 19 rd p10z soquaxdas uoistaay — Buisanyy Jo aBo]I0- vpuOLT Nog Jo AusroNTUQ, “uoyo poziseydwo pmnoys ouatAy rodoxd cress Rego Se yo wonuonaid | yuaned ayedgonued 01 yp 40} [803 t19}-Buoy ay], ;panumuos 2a Pyros suonHeAOL SA91 paureurar jared auf -poastyoe ‘atom juoned stp 10y sjeo% autog BttaRAXO E|NI[99 siayfe pue uoridumsos ua8ixo ue sputetap a1oqerout sasvaxout Speer (ezuangur pure eroumaud JeLa}9eq uy woUTUIOD) 1oAay STH, aqui [O09 0 pidoh aATHIOTTIaI se ‘aanyeroduray

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