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COLLEGE OF NURSING
Student: Kristine Martin
T.B.
Gender:
Age: 37
Served/Veteran: No
1 CHIEF COMPLAINT:
Patient came in for repair of incisional hernia (recurrent) and parastomal hernias with repair of prolapse of colostomy and
abdominal wall reconstruction.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
P/t diagnosed at birth with hirschprungs disease and has had multiple abdominal surgeries related with the diease
including colectomies, colostomies, recurrent incisional hernias and abdominal wall reconstruction. Patient states he has
Dull/throbbing abdominal pain occurring 24/7 for which he takes Dilaudid tablets for pain relief.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Operation or Illness
Hirschprungs disease
Colon surgery
Trach tube placement
2012, 2015
2012, 2013
10/2012, 12/2012, 2013
12/4/2012, 12/8/2012
01/2013, 08/2013
08/2013
2013
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
(angina,
MI, DVT
etc.)
Heart
Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Cause
of
Death
(if
applicable
)
Environmental
Allergies
2013
Alcoholism
2
FAMILY
MEDICAL
HISTORY
Date
Since birth
1977, 2006
2006
Incisional Hernia
Colostomy
Laparotomy
Abdominal
debridement
Proctoscopy
Enterocutaneous
fistula closure
Flexible
sigmoidoscopy
Colonoscopy
Father
Mother
Brother
Sister
Grandfather
80
s
Cousin
35
Grandmother
70
s
Comments: Include date of onset
Grandfather diagnosed recently- in his 80s
Grandmother diagnosed in her early 70s
Cousin diagnosed with type 1 diabetes when he was really young
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations- Unknown- r/t multiple surgeries as a
child
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)- unknown
University of South Florida College of Nursing Revision August 2013
NO
NAME of
Causative Agent
IV contrast
Medications
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)
Hirschprungs disease is caused by a lack of nerve cell formation along the length of the colon, causing paralysis of the
colon and the inability of peristalsis to move along stool. Hirchsprungs disease is suspected when a newborn goes 48
hours without a bowel movement and presents with a swollen belly, vomiting (usually green or brown in color), and gas
(Mayo Clinic, 2013). A diagnosis can be made by taking an abdominal x-ray using contrast dye to reveal a narrowed
portion of the colon where nerve cells did not develop, by measuring control of the muscles around the rectum through a
manometry test, or by taking a biopsy of the colon- which is the surest way to identify the disease (Mayo Clinic, 2013).
Risk factors include having a sibling with the disease, being male, and having other inherited conditions such as Down
syndrome or multiple endocrine neoplasia. The cause of this disease is unclear, however it is thought to be associated with
genetic mutation. Treatment includes surgery to bypass the affected colon and connect the healthy colon to the anus. After
surgery, most children can pass stool normally, however toilet training may take longer because the child has to learn how
to coordinate the muscles of the bowel. Constipation may be a continuous problem as well as a swollen abdomen and
leaking of stool. (Mayo Clinic, 2013).
5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name : Valium
(diazepam)
Concentration (mg/ml)
Route: Oral
Home
Hospital
or
hours
Both
spasms
Side effects/Nursing considerations: dizziness, drowsiness, lethargy, depression, slurred speech, headache, blurred vision, respiratory depression, constipation,
N/V, weight gain, rashes, dependence
Name: Colace
(docusate sodium)
Concentration
Route: Oral
Frequency: 2x
stool softener
Indication: Stool softener
Pharmaceutical class:
Home
Hospital
daily
or
Both
Side effects/Nursing considerations: electrolyte imbalances, dehydration, abdominal cramps, nausea, vomiting, diarrhea, Rashes, urine discoloration
Name: famotidine
Concentration
Route: Oral
Frequency:
Home
Hospital
or
Both
Home
Hospital
or
Both
Concentration
Frequency: daily
Home
Hospital
or
Both
Concentration
Route: Oral
Frequency: Daily
Home
Hospital
or
Both
Concentration
Route: Oral
Home
Hospital
or
Both
Side effects/Nursing considerations: suicidal thoughts, confusion, depression, dizziness, drowsiness, sedation, anxiety, concentration difficulties, malaise, vertigo,
weakness, abnormal vision, nystagmus, hypertension, weight gain, anorexia, flatulence, gingivitis, rhabdomylosis, arthralgia, creatine kinase, ataxia, altered
reflexes, hyperkinesia, paresthesia, multiorgan hypersensitivity reactions
Name: Porcine (heparin)
Concentration
Route: Subcutaneous
Frequency: 2x daily
Home
Hospital
or
Both
Concentration
Route: IV
Home
Hospital
or
Both
Concentration
Home
Hospital
or
Both
Concentration
Route: IV
Frequency: Q6 hours
Home
Hospital
or
Both
Indication: nausea
Side effects/Nursing considerations: headache, dizziness, drowsiness, fatigue, weakness, torsade de pointes, QT interval prolongation, constipation, diarrhea,
abdominal pain, dry mouth, liver enzymesextrapyramidal reactions
Name: Miralax (polyethylene)
Concentration
Route: Oral
Frequency: daily
Home
Hospital
or
Both
Concentration
Route: Oral
Frequency: Daily
Home
Hospital
or
Both
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Regular
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
After Analysis of MyPlate, the patient eats a fairly balanced
diet, including 111 % of his daily value of whole grains,
90% of his DV of vegetables, 78% of his DV of fruits, 69%
of his daily value of dairy, and 114% of his daily value of
protein.
Breakfast: None, 12oz orange juice
Patient stated that he likes to eat a lot of protein to help the
healing of his wounds. Patient stated that most foods he can
eat without having any adverse effects relating to his
colostomy.
I would advise the patient to increase his intake of fruit,
Lunch: Sandwich: 3slices ham, swiss cheese, lettuce,
vegetables, and dairy, as these categories did not reach
tomato, wheat bread, 12oz Gatorade
100% of the target value for daily intake. I would also
advise the patient that eating breakfast is recommended,
Dinner:1 chicken breast, 2 cups parmesan pasta, 2 cups
and that it may help give him more energy throughout the
broccoli, 12 oz water
day as well as give him an opportunity to increase his
intake of fruits and dairy.
Snacks: 1 granola bar, flavored yogurt
Liquids (include alcohol):Water, Gatorade, Orange juice
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as reference.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Family, Self (meditation)
How do you generally cope with stress? or What do you do when you are upset?
Meditation, talking with family and friends
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Anxiety about recent surgeries, worried about the effects his disease is having on his family
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: During adulthood, we continue to build our lives, focusing on our career and family. During adulthood, we
continue to build our lives, focusing on our career and family. Care is the virtue achieved when this stage is handled successfully.
Being proud of your accomplishments, watching your children grow into adults, and developing a sense of unity with your life partner
are important accomplishments of this stage. (Osborn et al., p215)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient is in the Generativity vs. Stagnation stage of development as described by Erikson. My patient has been successful in this
stage, as he has completed school despite the struggles his illness has caused him, and became a public speaker to educate others about
his little-known disease. My patient is very proud of how far he is come in his life given the difficulties presented to him; he is proud
of the family he has created and takes pride in knowing that he is spreading awareness about his illness. Rather than becoming
depressed about his state of health, the patient made a choice to embrace the life he was given and make use of it.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
This illness, while causing my patient much distress, has made him feel empowered. Although one might think a disease such as this,
with the many complications my patient has had as a result, would make someone become stagnant in their life, the disease did not
bring my patient down, rather it allowed him to rise and educate others about his disease.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? Hereditary
What does your illness mean to you? empowerment ; Feels it has made him a stronger person.
+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? __Women___________________________________________________
Are you aware of ever having a sexually transmitted infection? __No_________________________________________
Have you or a partner ever had an abnormal pap smear?___No_____________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___No__________________________________
Are you currently sexually active? _Yes_____________________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? __No___________________________
How long have you been with your current partner?__7 Years________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _Yes_____________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
Yes
No
For how many years? X years
(age
33
thru
current
Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No
Has the patient ever tried to quit? Smokes recreationallydoes not believe he is addicted
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)
thru
thru
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No
10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen none
SPF:
Bathing routine: 1 per day
Other:
HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:
Gastrointestinal
Immunologic
Genitourinary
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections
5 x/day
Hematologic/Oncologic
Metabolic/Endocrine
2 x/day
2 x/year
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? Feb 2015
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 01/2015
Other:
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:
Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:
10
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
11
Height: 64
Pulse: 68
Respirations: 18
Weight:267lbs
BMI:
Blood
Pressure: 130/68 L arm
(include location)
SpO2: 96
Is the patient on Room Air or O2: RA
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
apathetic
bizarre
agitated
anxious
tearful
Other:
Integumentary
Skin is warm, dry, and intact
- Lateral surgical incision to abdomen
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
talkative
withdrawn
Left Forearm
quiet
boisterous
aggressive
hostile
Date inserted:
flat
loud
3/18
Date inserted:
Date inserted:
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- 6 inches & left ear- 6 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: no abnormalities
Comments:
12
Pulmonary/Thorax:
Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th ICS LMCL
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
No JVD
GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated - Hypoactive r/t colostomy
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine - unable to assess due to bandage over
abdominal surgery
Abdomen non-tender to palpation- unable to assess due to bandage
Urine output:
Clear
Cloudy
Color:
Pale 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
/
/
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done) Patient has colostomy
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:
[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]
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:
Biceps:
Brachioradial:
Patellar: 2
Achilles:
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
WBC
Dates
7.88
(03/19/2015)
6.80
(03/20/2015)
4.24 (L)
Normal (4.6-10.2)
(03/22/2015)
BUN
8
03/19/2015
03/20/2015
9
(Normal: 6-20)
03/22/2015
Creatinine
1.1
03/19/2015
03/20/2015
0.9
03/22/2015
(Normal: 0.72-1.25)
Trend
Upon admit, the patients
WBC were in the normal
range, but dropped 1.08
the next day. The WBC
continued to trend
downward and is low
below normal.
Patients BUN has
remained on the lower
end of the normal limit
since he was admitted.
Analysis
Number of infection
fighting cells. A low
WBC count can indicate
damage or dysfunction of
the bone marrow or an
overwhelming infection
that is using up WBCs
faster than they can be
produced.
BUN is used to assess
kidney function. The
patient is at risk for
decreased kidney function
due to long term use of
pain relievers.
Creatinine is used to
assess kidney function.
The patient is at risk for
decreased kidney function
due to long term use of
pain relievers.
CT scan of Abdomen
No acute findings in
abdomen or pelvis
11/2014
No acute findings in
abdomen or pelvis
01/2015
15 CARE PLAN
Patient Goals/Outcomes
By end of shift, Patients
temperature will remain within
normal limits (96-100.4F)
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
15 CARE PLAN
Nursing Diagnosis: Acute Pain related to surgical procedure as evidenced by reported pain level of 8/10
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
By end of shift, patient will report
-Nurse will administer analgesics
-Dilaudid is used to relieve
By end of shift, patients pain level
pain level of a 4/10 or below
(Dilaudid) as prescribed
moderate to severe pain
was not at/below 4/10; Patient
reported pain as 6/10 after
administration of analgesic
By discharge, patient with have
adequate knowledge regarding
nonpharmacological methods used
to reduce pain*
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 patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
15 CARE PLAN
Patient Goals/Outcomes
Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Evaluation of Interventions on
Day care is Provided
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 patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
References
Ackley, B., & Ladwig, G., (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to PlanningCare.
St. Louis, Missouri: Elsevier Inc.
Cherry, K. (n.d.). Erikson's Theory of Psychosocial Development. Retrieved from:
http://psychology.about.com/od/psychosocialtheories/a/psychosocial.htm
Mayo Clinic. (2013, March 28). Hirschsprungs Disease. Retrieved from: http://www.mayoclinic.org/diseasesconditions/hirschsprungs-disease/basics/definition/con-20027602
MyPlate. (n.d.) Supertracker. Retrieved from: https://www.supertracker.usda.gov/foodtracker.aspx
Osborn, K. S., (2014). Medical Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson
Education, Inc.
Unbound Medicine. (2014.) Nursing Central (Version 1.24 (414)) [Mobile application software]. Retrieved
from: http://nursing.unboundmedicine.com/nursingcentral