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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Tatyana Boytsan
Assignment Date: 3/11/2016
MSI & MSII PATIENT ASSESSMENT TOOL .
1 PATIENT INFORMATION Agency: SMH - UD
Patient Initials: MP Age: 68 Admission Date: 3/9/2016
Gender: Female Marital Status: Married Primary Medical Diagnosis: Pan Diverticulitis
Primary Language: English
Level of Education: Associate in Arts in Architectural Design Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Banker, Marketing, Sales Tumor found in the diverticula.
Number/ages children/siblings: A daughter (49), 3 sisters, a brother,
and a half-sister (78)

Served/Veteran: No Code Status: Full Code


If yes: Ever deployed? Yes or No
Living Arrangements: with husband, here in Florida Advanced Directives: Yes
If no, do they want to fill them out?
Surgery Date: 3/9/2016 Procedure: Bowel
Resection
Culture/ Ethnicity /Nationality: White
Religion: Christian Type of Insurance: Medicare and Bankers Life

1 CHIEF COMPLAINT:
Patient came to the hospital with an aching 10/10 abdominal pain and bloating that was slightly relieved with the use of
antibiotics and pain medication. This episode of diverticulitis occurred four days after a prior episode, this being the worst
one shes had thus far.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)

The patient had four or five episodes of diverticulitis since January, after which she started to consider surgical
intervention. Now that shes had another episode, she came to SMH for definitive surgical intervention. She always had
pain in the left lower quadrant, but now the pain is associated with complaints of abdominal bloating in the upper
abdomen. It is presumed that has sigmoid and likely distal descending colon as the source of her symptoms. Surgical
intervention, namely a robot left colectomy, on 3/9/2016.

University of South Florida College of Nursing Revision September 2014 1


2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
1985 Hysterectomy
1986 Gallbladder removal
2001 Right ankle fracture repair with hardware
5/3/2006 HART murmur apex found
2010 Left thumb surgery
2011 Right big toe surgery
5/4/2012 Occlusion and stenosis of carotid artery
2013 Cataracts removed

2003 Diverticulitis diagnosed


Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma

of

Cancer

Problems

Tumor
Stroke
Allergies

MI, DVT
Gout
MEDICAL Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Father 71
Mother 89
Brother
Sister 66
AUNT 93
relationship

relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? (2011)
Influenza (flu) (Date) Is within 1 years? (11/05/15)
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

University of South Florida College of Nursing Revision September 2014 2


1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Sulfa Itching, rash, prickly feeling
Tetracycline Itching, rash, prickly feeling
Medications

Environmental Sneezing, wheezing, coughing


Other (food, tape,
latex, dye, etc.)

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)

Diverticulitis is the inflammation of the diverticula, which is an abnormal saclike outpouching of the intestinal wall
and can occur in most places of the gastrointestinal tract. (Osborn, Wraa, Watson, & Holleran, 2013) One risk factor for it
is age, considering it is common after the age of 60 and uncommon in children. When it first develops it is typically
asymptomatic but when symptoms do occur, they are pain in the lower left quadrant, abdominal bloating, bowel changes,
nausea and vomiting. Complications include hemorrhage, peritonitis, bowel obstruction, and fistula formation. (Osborn et
al., 2013) A colonoscopy is usually enough to diagnose diverticular diseases. Treatment varies and can be dependent upon
how bad the symptoms are. If they are mild, a dietary change can be made to increase fiber in the diet. If it is severe,
surgical resection of the colon or intestines may be necessary. With surgical resection, a temporary or permanent
colostomy may be necessary.

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name Acetaminophen/Tylenol Concentration Dosage Amount 650mg

Route PO Frequency Q6H


Pharmaceutical class analgesic/antipyretic Home Hospital or Both
Indication Given in conjunction with PCA therapy, to control pain.
Adverse/ Side effects Liver failure, n/v, stomach pain, loss of appetite, jaundice
Nursing considerations/ Patient Teaching Dont give more than 4000mg a day.

Name Cefazolin Concentration 2gm/100mL Dosage Amount

Route IVPB Frequency Q8H

Pharmaceutical class Cephalosporin Home Hospital or Both

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Indication Antibiotic, per post-op orders.
Adverse/ Side effects Diarrhea, stomach pain, n/v, skin rash and itching, white patches or sores inside the mouth or lips (sign of a superinfection).
Nursing considerations/ Patient Teaching Okay to give if pt has an allergy to penicillin that is itching/rash or an upset stomach. Preferably give with
metronidazole.

Name Famotidine/ Pepcid Concentration Dosage Amount 20mg

Route PO Frequency BID


Pharmaceutical class antacid/antihistamine Home Hospital or Both
Indication Treats and prevents ulcers and GERD, decreasing excess stomach acid.
Adverse/ Side effects Possible allergic reaction, dark colored urine, unusual bleeding, jaundice
Nursing considerations/ Patient Teaching Avoid taking with alcohol.

Name Heparin Concentration 10000units/1mL Dosage Amount 5000 units

Route Subcutaneous injection Frequency Q12H


Pharmaceutical class heparinoid Home Hospital or Both
Indication Given to decrease the ability of the blood to clot, in this case prophylactically.
Adverse/ Side effects Bruising, bleeding, hemorrhage, chest pain, trouble breathing, dizziness
Nursing considerations/ Patient Teaching Hold for platelet count less than 100,000 due to risk of bleeding.

Name Fentanyl/Duragesic Concentration 10mcg/1mL Dosage Amount

Route PCA Frequency PRN


Pharmaceutical class Opioid Home Hospital or Both
Indication Use for the reduction of pain
Adverse/ Side effects Respiratory distress, blurred vision, n/v, shaking or shivering
Nursing considerations/ Patient Teaching Dont take with alcohol, can cause respiratory distress, high risk for addiction and dependency.

Name Fluoxetine/Prozac Concentration Dosage Amount 40mg

Route PO Frequency Daily


Pharmaceutical class SSRI Home Hospital or Both
Indication Treats depression, OCD, bulimia nervosa, and panic disorder.
Adverse/ Side effects restlessness, chills, fever, itching, anxiety, headache
Nursing considerations/ Patient Teaching Dont take with MAO inhibitors, watch for hypertension and possible serotonin syndrome.

University of South Florida College of Nursing Revision September 2014 4


5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Full liquid Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Cardiac diet Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Toast, peanut butter, and fresh fruit

Lunch: Tuna salad, green beans, boiled egg

Dinner: Soup, meat and potatoes, vegetables

Snacks: Chips, pickles, sometimes cookies.

Liquids (include alcohol): Water, unsweetened tea

Use this link for the nutritional analysis by comparing the


patients 24 HR average home diet to the recommended
portions, and use My Plate as a reference.

MPs diet reaches the mark in some parts, for example she gets
enough vegetables, fruits, and protein in her diet. She consumes
enough calories, and although shes a little over the recommended
sodium amount, shes still under when it comes to added sugars
and saturated fats. One concern is that she isnt consuming
enough dairy in her diet, peaking at a mere five percent of the
recommended amount. And while she consumes more refined
grains, shes still under 50% of the recommended amount. There
are definitely other foods that she could incorporate into her diet
for a more rounded meal.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
Family! Her husband, her daughter, and her sisters are all there for her when needed.
How do you generally cope with stress? or What do you do when you are upset?
Pray and try to relax by taking her mind off it by doing things like reading books and watching movies. If things
get really bad, she goes to see her therapist.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Depressed in general, but seem to be doing more okay than depressed these days. While she wasnt expecting to
have surgery so suddenly, but she tolerated the unexpected well.

+2 DOMESTIC VIOLENCE ASSESSMENT

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.
Have you ever felt unsafe in a close relationship? _____________________NO_____________________________

Have you ever been talked down to?_____NO_______ Have you ever been hit punched or slapped? ____NO______

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

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
Since MP is 68, she falls into the integrity versus despair stage of Eriksons eight stages of development. It is in
around this age, 65 and older, that people start looking back over their and life and either coming to satisfied terms
with it or being disappointment and denying that death is more or less approaching. (Halter, 2014)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
MP is evidently in the Ego Integrity stage. She speaks about her memories with ease and fulfillment, in a way that
shows that even though those were great times she is enjoying the stage of life that she is currently in. She even
brings it straight up that she is getting older, and her health not being as good as it used to is a part of that. She
understands that as she is getting older, she is nearing her death, and she isnt afraid of that .

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
As aforementioned, it hasnt affected the patient much. While surgical intervention was unexpected, the patient is
familiar with her disease and her outlook on life hasnt been changed by it.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The patient says shes always had GI issues of sorts, so shes not really sure what the cause is. She thinks her eating
habits may have contributed to it as well.

What does your illness mean to you?


It is a bit of an obstacle for the patient, but it doesnt usually get in the way much. Im getting old so its just
another part of life!

+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

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__________________________

Are you currently sexually active? _____NO___________ If yes, are you in a monogamous relationship?
__YES____________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _____CONDOM_____________

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How long have you been with your current partner?_______51 years_________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? _Yes, no sex after surgeries for a
while._

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

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
__ Some what of importance, because I am spiritual but not religious. _________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
__ It is just a part of life, so not really. I dont see it as a big deal. __________________________
______________________________________________________________________________________________________

+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?(specify daily amount) For how many years? X years
(age thru )

If applicable, when did the


Pack Years:
patient quit?

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? NO If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? 1 or 2 drinks a week For how many years?
Red or white wine, and beer. Volume: Standard (5 oz) (age 21 thru now )
Frequency: Once or twice a month
If applicable, when did the patient quit?

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?
(age thru )

Is the patient currently using these drugs?


If not, when did he/she quit?
Yes No

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
NO

5. For Veterans: Have you had any kind of service related exposure?
NOT APPLICABLE

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10 REVIEW OF SYSTEMS NARRATIVE

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: Diverticulitis Life threatening allergic reaction
Bathing routine: Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy? (3/2/16)
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:
Post-nasal drip Normal frequency of urination: 5 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2 x/day Diabetes Type: 2
Routine dentist visits 2 x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
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? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? 12 Encephalitis
last CXR? menopause age? 30 Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 2012 Arthritis Chicken Pox
Other: Echo -2014 Other: Other:

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General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health?

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
NO

Any other questions or comments that your patient would like you to know?
NO

University of South Florida College of Nursing Revision September 2014 10


10 PHYSICAL EXAMINATION:

General Survey: Height 62 inches Weight 88.2 kg BMI 35.6 Pain: (include rating and
Pulse 64 Blood Pressure: 174/82 brachial location)
Respirations 17
Temperature: (route SpO2 98 Is the patient on Room Air or O2 2/10 aching abdomen
taken?) 97.9F
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

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


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

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


clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: 20g + 22g Location: R hand, L hand Date inserted: 3/9/2016
Fluids infusing? no yes - what? Normal saline

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / 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
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL: CL LUL: CL
RML: CL LLL: D
RLL: D

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

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Cardiovascular: No lifts, heaves, or thrills
Heart sounds: S1 S2 audible 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: [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

GI Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly


Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 3 / 11 / 16 ) Formed Semi-formed Unformed Soft Hard Liquid Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe:

GU Urine output: Clear Cloudy Color: 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

Musculoskeletal: X Full ROM intact in all extremities without crepitus


Strength bilaterally equal at _5___ RUE __5__ LUE _5__ RLE & _5__ 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]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

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 Rombergs 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

University of South Florida College of Nursing Revision September 2014 12


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):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis


Glucose Serum The patients blood sugar goes It is of no surprise that the
125^ 3/03/2016 up and down, so it doesnt patient has high glucose lab
necessarily trend upward, values, as the patient is a type
140^ 3/09/2016 however it does tend to stay at two diabetic. It may also be
150^ 3/10/2016 above average rates every time important to note that the
130^ 3/11/2016 her blood sugar is taken. patient does not use insulin or
Normal (60-100mg/dL) metformin at home.
Platelet While continuing to say Since the patient is on
350 3/03/2016 within normal range, there is heparin therapy it is
a downward trend. This important to watch platelet
348 3/10/2016 could be indicative of the levels, since heparin cannot
302 3/11/2016 heparin working. be given when platelets are
below 100. These lab values
show that the heparin is
Normal (150-400 10x3/uL) working in the body, and it is
safe to continue to administer
it.
BUN The BUN is trending A BUN test is used as one
11 3/03/2016 downwards, with a way to test kidney function,
testing how well the kidneys
6 3/10/2016 significant drop post are able to remove urea from
5 3/11/2016 operatively. the blood. A low BUN value
Normal (8-23mg/dL) can be indicative of liver
damage or a diet too low in
protein. However,
overhydrating, or drinking
too many liquids, can also
cause a low BUN value. This
may be in part to the patient
being NPO before surgery
and then being on a clear
liquid diet throughout the
blood work being done.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,


multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
There was a CT scan and a colonoscopy done in the beginning to confirm the diagnosis of extensive
diverticular disease. Treatment was then robotic left colectomy with TD of splenic flexure. Throughout the
patients stay, blood work was done, daily after surgery. Accuchecks were also done because the patient is a
type two diabetic. The patient was on a clear liquid diet and then progressed to full liquid, with plans of a
University of South Florida College of Nursing Revision September 2014 13
soft diet and then regular diet as tolerated because of the normal progression of post-op diets.

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


1. Acute pain related to surgical procedure as evidenced by verbal explanation of pain with the use of pain scale, guarding
of surgical site, moaning, and facial grimacing.

2. Risk for infection related to surgical incisions.

3. Risk for deficient fluid volume related to diarrhea.

4. Diarrhea related to increased intestinal motility caused by inflammation.

University of South Florida College of Nursing Revision September 2014 14


15 CARE PLAN
Nursing Diagnosis: Acute pain related to surgical procedure as evidenced by verbal explanation of pain with the use of pain scale, guarding of surgical site,
moaning, and facial grimacing.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
The patient will identify a comfort- Explain the pain scale, 1-10, to the Choosing a comfort-function goal The patient was comfortable with
function goal, a pain level on the 1- patient and have her choose a allows the patient to feel more in using 4/10 on the pain scale as a
10 scale that the patient feels number that she feels she is able to control of her pain, and having this comfort-function goal, but would
comfortable performing normal tolerate or aims to be under. conversation shows her that the like to maintain her pain below that
activities, at least tolerably. nurse and her healthcare team as a if possible
whole care about her and managing
both her recovery and her comfort.
Patients pain will be managed. Frequent assessments of pain and The main rationale is that the The patients pain was managed,
then the nurse can manage the patient will have less, or preferably, tending to be around a 2/10 on the
patients pain using a multimodal no pain. The rationale for the use of pain scale. She felt it was managed
approach, which is when the a multimodal approach is that it well enough that the basal rate on
patient takes two or more allows for the lowest effective dose her PCA could be turned off and
medications to decrease pain. In of each drug to be administered she just just press the button to
this case, Fentanyl (an opioid) from which then results in fever or less administer medication as needed.
the PCA and Tylenol severe side effects. (Ackley &
(acetaminophen). Ladwig, 2014)
Perform activities of recovery or Encourage the patient to perform Since IV opioids can effectively The patient ambulated a lot
ADLs easily. the activities, and observe or assist decrease the pain associated with throughout the day and performed
as needed. Some patient may some procedures, it can help to other activities, like going to the
require premedication of analgesics encourage our patients to press the bathroom, on her own. However,
for things like ambulating or more PCA pump button before going to this is still a work in progress, but
possibility painful activities, as per the procedure or performing as the patients recovery progresses
patients request. potentially painful activities. as will her ability to perform ADLs.
(Ackley & Ladwig, 2014)

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
University of South Florida College of Nursing Revision September 2014 15
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

15 CARE PLAN
Nursing Diagnosis: Risk for infection related to surgical incisions
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
The patient will remain free of The nurse will observe the patient for In a patient who has had a bowel The patient was given Cefazolin IV,
symptoms of infection. signs and symptoms of infection, and resection, an infection in the abdomen an antibiotic. Her WBC count was
watch lab values like WBC. In the would not be beneficial to healing and within normal range, and she
mean time the nurse will work on could have complications, therefore showed no symptoms of infection.
reducing the risk through hand we want to avoid that. And
hygiene, and patient education on meticulous infection prevention
proper hygiene as well. * precautions are required to prevent
health care associated infection, with
particular attention to hand hygiene
[instead of just the alcohol based hand
scrub] and standard precautions.
(Ackley & Ladwig, 2014)
The patient and her spouse is able Take the time to educate the patient on Since infections dont always occur The patient and her spouse were
to observe and report signs of the signs and symptoms of infection, immediately after surgery, it is good already somewhat familiar with the
infection. like redness, warmth, discharge at the for the patient to be able to catch the typical signs of infection, and
incisional site, and increased body infection if she so happens to get one agreed that they would inform their
temperature. It is also important to once she is discharged. doctor if they noticed any of them.
educate the patient on when to handle
it at home and when to go to the
Emergency Room, but to report it to
her doctor nonetheless. *
The patient will demonstrate The nurse can teach the patient how Having the patient care for the The patient accepted the education
appropriate care of infection prone and with what to clean the incision infection prone site promotes and demonstrated cleansing care of
site. area with to reduce the risk for independence, and will be necessary the infection prone site.
University of South Florida College of Nursing Revision September 2014 16
infection. The patient will then for them to know how to do so they
demonstrate how they can wash and can do so at home once they are
pat dry skin, and then moisturize the discharged. Moisturizing is also
skin around the incisions. * important as increasing skin hydration
restores the skin barrier function
which helps with reducing infection
risks. (Ackley & Ladwig, 2014)

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014 17


References

Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care

(10th ed.). Maryland Heights, Mo.: Elsevier.

Choose MyPlate. (n.d.). Retrieved November 15, 2015, from http://www.choosemyplate.gov/

Halter, M. (2014). Varcarolis' foundations of psychiatric mental health nursing: A clinical approach. (7th ed.).

St. Louis, Mo.: Elsevier.

Nursing Central from Unbound Medicine. (n.d.). Retrieved November 18, 2015, from

http://nursing.unboundmedicine.com/nursingcentral/ub/

Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2013). Medical surgical nursing: Preparation for

practice (2nd ed.). Boston: Pearson.

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