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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kristine Martin

PATIENT ASSESSMENT TOOL .


1 PATIENT INFORMATION
Patient Initials:

T.B.

Gender:

Assignment Date: 03/25/2015


Agency: TGH

Age: 37

Admission Date: 03/18/2015

Marital Status: Married- 4yrs

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Incisional Hernia- 553.21

Level of Education: College- Bachelors in Business

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Business owner


Number/ages children/siblings: 1 daughter- 2yrs old

Served/Veteran: No

Code Status: Full

Living Arrangements: Home with wife and child- no home hazards

Advanced Directives: Yes


If no, do they want to fill them out?
Surgery Date: 3/18
Procedure: Incisional
Hernia repair

Culture/ Ethnicity /Nationality: American


Religion: Christian

Type of Insurance: Private

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.

University of South Florida College of Nursing Revision August 2013

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

Age (in years)

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

Adult Tetanus (Date)


Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
IV contrast

Type of Reaction (describe explicitly)


Hives

Medications

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)
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

Dosage Amount (mg): 5mg


Frequency: Q4

Pharmaceutical class: benzodiazepines


Indication: anxiety, muscle

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

Dosage Amount: 200mg

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

University of South Florida College of Nursing Revision August 2013

Name: famotidine

Concentration

Dosage Amount: 20mg

Route: Oral

Frequency:

Pharmaceutical class: Histamine h2 antagonists

Home

Hospital

or

Both

Indication: Prevention and treatment of stress-induced upper GI bleeding


Side effects/Nursing considerations: confusion, dizziness, drowsiness, hallucinations, headache, arrhythmias, nausea, decreased sperm count, erectile
dysfunction, gynecomastia, agranulocytosis, aplastic anemia, neutropenia, thrombocytopenia
Name: Duragesic (fentanyl)
Concentration
Dosage Amount: 75mg
Route: transdermal

Frequency: every 48 hours

Pharmaceutical class: opioid agonists

Home

Hospital

or

Both

Indication: post-op anesthesia


Side effects/Nursing considerations: confusion, sedation, weakness, dizziness, restlessness, apnea, bronchoconstriction, laryngospasm, respiratory depression,
bradycardia, anorexia, constipation, dry mouth, nausea, vomiting, sweating, erythema, skeletal and thoracic muscle rigidity
Name: Flonase (fluticasone)

Concentration

Dosage Amount: 50mg

Route: nasal spray

Frequency: daily

Pharmaceutical class: corticosteriods

Home

Hospital

or

Both

Indication: seasonal or perennial nonallergic rhinitis


Side effects/Nursing considerations: headache, epistaxis, nasal burning, nasal irritation, nasopharyngeal fungal infection, pharyngitis, adrenal suppression,
decreased growth in children, rash, urticarial, cough, anaphylaxis, angioedema
Name: Lasix (furosemide)

Concentration

Dosage Amount: 40mg

Route: Oral

Frequency: Daily

Pharmaceutical class: loop diuretics

Home

Hospital

or

Both

Indication: Hypertension, edema


Side effects/Nursing considerations: blurred vision, dizziness, headache, vertigo, hearing loss, tinnitus, hypotension, anorexia, constipation, diarrhea, dry mouth,
dyspepsia, liver enzymes, nausea, pancreatitis, vomiting, BUN, excessive urination, nephrocalcinosis, erythemia multiforme, stevens-johnson syndrome, toxic
epidermal necrolysis, photosensitivity, pruritis, rash, urticarial, hypercholesterolemia, hyperglycemia, hypertriglyceridemia, hyperuricemia, dehydration,
hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis, aplastic anemia, agranulocytosis, hemolytic
anemia, leukopenia, thrombocytopenia, muscle cramps, paresthesia
Name: Neurontin (gabapentin)

Concentration

Dosage Amount: 300mg

Route: Oral

Frequency: 3x per day

Pharmaceutical class: analgesic adjuncts, therapeutic,


Anticonvulsants, mood stablilizers
Indication: postherpetic neuralgia

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

Dosage Amount: 5000 Units

Route: Subcutaneous

Frequency: 2x daily

Pharmaceutical class: antithrombotics

Home

Hospital

or

Both

Indication: prophylaxis and treatment of venous thromboembolism


Side effects/Nursing considerations: drug-induced hepatitis. Rashes, pain at injection site,
Name: Dilaudid (hydromorphone)

Concentration

Dosage Amount: 1-2mg

Route: IV

Frequency: Every 2 Hours PRN

Pharmaceutical class: opioid agonists

Home

Hospital

or

Both

Indication: moderate to severe pain


Side effects/Nursing considerations: Confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred
vision, diplopia, miosis, respiratory depression, hypotension, bradycardia, constipation, dry mouth, nausea, vomiting, urinary retention, flushing, sweating,
physical dependence, psychological dependence, tolerance
Name: Dilaudid (hydromorphone)
Route: oral

Concentration

Dosage Amount: 8mg


Frequency: Every 4 hours PRN

University of South Florida College of Nursing Revision August 2013

Pharmaceutical class: opioid agonists

Home

Hospital

or

Both

Indication: moderate to severe pain


Side effects/Nursing considerations: Confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred
vision, diplopia, miosis, respiratory depression, hypotension, bradycardia, constipation, dry mouth, nausea, vomiting, urinary retention, flushing, sweating,
physical dependence, psychological dependence, tolerance
Name: Zofran (ondansetron)

Concentration

Dosage Amount: 4mg

Route: IV

Frequency: Q6 hours

Pharmaceutical class: five ht3 antagonists

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

Dosage Amount: 17mg

Route: Oral

Frequency: daily

Pharmaceutical class: osmotics

Home

Hospital

or

Both

Indication: treatment of occasional constipation


Side effects/Nursing considerations: urticarial, abdominal bloating, cramping, flatulence, nausea
Name: Flomax (tamsulosin)

Concentration

Dosage Amount: 0.4 mg

Route: Oral

Frequency: Daily

Pharmaceutical class: peripherally acting antiadrenergics

Home

Hospital

or

Both

Indication: management of outflow obstruction in male patients with prostatic hyperplasia


Side effects/Nursing considerations: dizziness, headache, rhinitis, orthostatic hypotension, priapism, retrograde/diminished ejaculation

University of South Florida College of Nursing Revision August 2013

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

+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.

University of South Florida College of Nursing Revision August 2013

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? ______________________
Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust


Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
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: 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________________________________________________

University of South Florida College of Nursing Revision August 2013

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

University of South Florida College of Nursing Revision August 2013

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)


What importance does religion or spirituality have in your life?
__Up and down with his beliefs, was raised in a religious household but has had doubt because of his disease.
____________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:


1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what? Cigars
How much?(specify daily amount)
Two per month

Yes
No
For how many years? X years
(age

33

thru

current

If applicable, when did the


patient quit?

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)

For how many years?


(age

thru

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

Is the patient currently using these drugs?


Yes No

thru

If not, when did he/she quit?

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

University of South Florida College of Nursing Revision August 2013

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

Nausea, vomiting, or diarrhea


Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? 2014
Other:

Chills with severe shaking


Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

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:

Central Nervous System


WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam? Nov 2015
BPH
Urinary Retention

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:

University of South Florida College of Nursing Revision August 2013

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

University of South Florida College of Nursing Revision August 2013

11

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)


General Survey:
Temperature: (route taken?)
98.2- oral

Height: 64
Pulse: 68
Respirations: 18

Weight:267lbs
BMI:
Blood
Pressure: 130/68 L arm

Pain: (include rating & location)


8/10 Abdomen

(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

Peripheral IV site Type:


Location:
no redness, edema, or discharge
Fluids infusing?
no
yes - what? Normal saline
Peripheral IV site Type:
Location:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Fluids infusing?
no
yes - what?

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:

University of South Florida College of Nursing Revision August 2013

12

Pulmonary/Thorax:

Respirations regular and unlabored


Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

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

Calf pain bilaterally negative


Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 68 Carotid:
68 Brachial: 68 Radial: 68 Femoral: 68
Popliteal: 68
DP:
PT:
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/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:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: Full ROM intact in all extremities without crepitus - Yes


Strength bilaterally equal at ___5____ RUE ____5___ LUE ___4____ RLE

& ____4___ 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 parathesias

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:

2 Ankle clonus: positive negative Babinski: positive negative

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.

Patients creatinine has


been stable since
admission.

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

Patient has remained


unchanged since
11/27/2014

Used to visualize and


assess abdominal
structures and assist in
diagnosing tumors,
bleeding, and abscess.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled


diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient is currently on a regular diet and has vitals checked Q4 hours to monitor for infection. Abdomen is
assessed at start of shift for distention, assess wound and surrounding skin as well as bandage for drainage.
Patient takes IV Dilaudid and Dilaudid tablets for pain management. Patient is up ad lib and is not currently
scheduled for any diagnostics or consults.

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


1.Risk for infection related to impaired skin integrity
2. Acute Pain related to surgical procedure as evidenced by reported pain level of 8/10
3.Chronic pain related to pathological process as evidenced by diagnosis of Hirschprungss disease
4.Risk for injury related to muscle weakness and unsteady gait
5.

15 CARE PLAN
Patient Goals/Outcomes
By end of shift, Patients
temperature will remain within
normal limits (96-100.4F)

Nursing Diagnosis: Risk for infection related to impaired skin integrity


Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
-Frequently take patients
A rise in fever is a sign of
temperate to assess for signs of
infection- by closely monitoring
infection
the patients temperature the nurse
-administer an antipyretic if patient will be able to recognize if the
begins to develop a fever
patient may be developing an
infection and treat it early

Evaluation of Goal on Day care is


Provided
By end of shift, patients
temperature remained within
normal limits (98.2)

By discharge, patients wound will


remain free from infection

-Change patients bandages as


needed to ensure wound stays
dry/moist and clean
-clean wound as needed to prevent
bacteria growth
-ensure bandage remains intact to
prevent foreign bodies from
entering wound

- Frequently changing the patients


bandages will reduce the risk for
infection by removing soiled
bandages and keeping the site dry,
as bacteria grow in damp
environments.
- cleaning out the wound as needed
will prevent infection by removing
foreign bodies that have the
potential to cause infection

Upon discharge, patients wound


presented with no signs of infection
(no abnormal redness, heat, or
inflammation)

By discharge, patient will adequate


knowledge regarding wound care
at home *
- Patient can identify S/S of
infection*

-Nurse will teach to patient how to


change their bandages/clean wound
in the home setting to prevent
infection
-Nurse will inform patien of signs
and symptoms of infection and
when to contact their provider if
infection is suspected.

-By teaching the patient the proper


techniques to care for his wound,
he will prevent infection by
knowing when to change the
dressing and how to properly clean
the wound.
-By informing the client of the S/S
of infection, patient will be able to
detect infection early and prevent
detrimental and systemic effects of
infection

By discharge, Patient was informed


of the S/S of infection and how to
properly care for his wound in the
home setting.

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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH- wound care
Palliative Care

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*

-Nurse will inform patient of


nonpharmacological methods to
reduce pain; provide handouts for
patient to refer to at home

- frequent analgesic use can result


in kidney damage, therefore the
patient should be aware of
alternative options

- by discharge, patient was


informed of ways to relieve pain
using nonpharmacological methods

By discharge, patient will be able


to perform ADLs easily

-patient will be prescribed pain


medication to provide comfort and
therefore the ability to perform
daily activities
-nurse will consult occupational
therapy to help patient learn how to
perform ADLs post-procedure

-providing pain medication will


allow patient to perform ADLs
without being limited by pain
-occupational therapy will teach
the patient how to perform ADLs
without extenuating the abdominal
muscles

-By discharge, patient was


prescribed pain medication
-Patient was informed of the option
to consult occupational therapy,
however the pt did not want their
services because he has been
through this before

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