UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Alexis Daubney
Assignment Date: July 12, 2016
.
Agency: Florida Hospital Tampa
 1 PATIENT INFORMATION
Patient Initials: CC Age: 45 Admission Date: July 11, 2016
Gender: Female Marital Status: Divorced Primary Medical Diagnosis: achalasia
Primary Language: English
Level of Education: High School Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retail None
Number/ages children/siblings: No Children

Served/Veteran: No Code Status: Full Resuscitation

If yes: Ever deployed? Yes or No
Living Arrangements: Living in apartment with partner
Culture/ Ethnicity /Nationality: White, Non-Hispanic
Religion: None
Advanced Directives: None
If no, do they want to fill them out? No
Surgery Date: July 13 Procedure: Heller
fundoplication
Type of Insurance: Blue Cross Blue Shield

 1 CHIEF COMPLAINT:
“I’ve been unable to eat solid foods. I’ve lost 150 lbs. over the past three years. I feel like a fat girl again, I can’t even
walk to the mailbox.”

 3 HISTORY OF PRESENT ILLNESS:

45 year old female patient with a history of GERD and esophageal sutures admitted to the ER on 06/11/2016 for
dysphagia, and pain. Patient reports a decrease in food intake over the past few months. Symptom onset 2013. Location of
pain consists of neck, chest, and abdomen. Constant duration of pain, aggravated by swallowing. Characteristics of pain
include dull constant abdominal pain. No present relief from symptoms. Pain level upon assessment 6 out of 10.
CT ordered upon admission, with follow up XR 06/12/2016. CT of abdomen with pelvis found fluid distention with
tapered to GE junction concentric thickening. No definitive conclusion observed from CT. XR of the esophagus with a
timed barium study found limited emptying of the esophagus, at only 5-10%.
Final diagnosis 07/14/2016 at 1555: gastroesophageal junction muscle biopsy; finding smooth muscle with aganglionic
myenteric plexus mild chronic inflammation and fibrosis, suggestive of achalasia.

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
2013 Esophageal dilation
Patient states that they completed a surgery in which “they ballooned my esophagus”.
2013 Upper GI surgery—patient does not state specific surgery
University of South Florida College of Nursing – Revision September 2014 1
 Age (in years)
2

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY

Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma
of

Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
MEDICAL

Gout
Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Father 63
Mother 60
Brother 30
Brother 31
Brother 32
relationship

relationship

Comments: Include age of onset

Mother’s heart trouble: onset 45
Adopted, no knowledge of medical history regarding father

 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): U
Adult Tetanus (Date): 2006, 10 years ago from cut at work
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Patient states she has no allergies to medications, iodine, tape,
environmental allergens, etc.

Medications

Other (food, tape,

latex, dye, etc.)

University of South Florida College of Nursing – Revision September 2014 2

 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)
Achalasia is a motor disorder of the esophagus, with los of esophageal peristalsis and failure of the lower esophageal
sphincter to relax. There is currently no known cause of achalasia; a possible explanation is due to autoimmune
destruction of nerves. It occurs equally in both genders. There is an increased incidence of achalasia with the 30 to 60 year
old population. Symptoms are utilized to diagnosis; some symptoms include aspiration of solid foods or liquids, nausea,
vomiting, nocturnal cough, heartburn, and weight loss. Progression of this condition leads to the degeneration of ganglion
cells, loss of inhibitory neurotransmitters nitrous oxide and vasoactive intestinal peptide. Pseudo achalasia includes
tumors, or secondary achalasia from tight fundoplication or laparoscopic adjustable gastric band. There are a variety of
treatments for achalasia including: graded pneumatic dilation or laparoscopic surgical myotomy with partial
fundoplication, botulinum toxin therapy, or pharmacologic therapy. A non-invasive treatment includes symptom
management through eating small meals, taking fluids, and sleeping with an elevated head. (Heuther, & McCance, 2012)
(Stefanidis et al., 2011) (Vaezi, Pandolfino, & Vela, 2013)

 5 MEDICATIONS: [Include both prescription and OTC; hospital, home (reconciliation), routine, and PRN medication (if
given in last 48°). Give trade and generic name.]
Name enoxaparin (Lovenox) Concentration Dosage Amount 40 mg

Route subcutaneous injection Frequency daily

Pharmaceutical class low molecular weight heparin Home Hospital or Both
Indication increase clotting time, decrease clot formation, maintain blood flow
Adverse/ Side effects bleeding, abdominal pain, constipation, nausea/vomiting; heparin-induced thrombocytopenia, allergic reaction, hemorrhage,
hyperkalemia
Nursing considerations/ Patient Teaching check current aPTT before administration, do not rub skin after injection, adjust infusion rate based on
orders; patient teaching: report injuries immediately, do not take aspirin containing products without consulting prescriber

Name docusate Concentration Dosage Amount 100 mg

Route oral Frequency PO, Q12H

Pharmaceutical class stool softeners Home Hospital or Both
Indication relieves constipation
Adverse/ Side effects electrolyte imbalances, dehydration, nausea, vomiting, diarrhea, rahses
Nursing considerations/ Patient Teaching assess for abdominal distention, presence of bowel sounds, assess COCA of stool; patient teaching: advise
that laxatives are for short term therapy; encourage increased fiber and fluids in their diet

Name alprazolam (Xanax) Concentration Dosage Amount 0.25 mg

Route oral/ tablet Frequency Q8H; PRN once a month

Pharmaceutical class benzodiazepines Home Hospital or Both
Indication anxiolytic
Adverse/ Side effects drowsiness, dizziness, confusion, blurred vision, weakness, sleep disturbance, GI distress
Nursing considerations/ Patient Teaching Be aware of multiple interactions; patient teaching: smoking decreases antianxiety effects, withdrawal
develops slowly in 2-10 days some symptoms of withdrawal include tremor, agitation, nervousness, sweating, and insomnia.

Name ondansetron (Zofran) Concentration Dosage Amount 4 mg

Route Injection IM Frequency Q6H

Pharmaceutical class 5-HT3 agonist Home Hospital or Both
Indication management of nausea and vomiting
Adverse/ Side effects HA, mild elevation LF enzymes; hypersensitivity
Nursing considerations/ Patient Teaching monitor liver enzymes; patient teaching: use as scheduled not PRN

Name dextrose 5% with .45% sodium chloride Concentration 5% dextrose/ .45% sodium Dosage Amount 1,000 mL

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 chloride
Route IV Frequency 75 mL/hr over 13.3 hr
Pharmaceutical class carbohydrates Home Hospital or Both
Indication Hypoglycemic protocol administration with blood glucose level below 65.
Adverse/ Side effects hyperglycemia
Nursing considerations/ Patient Teaching ensure correct infusion rate; continue to monitor blood glucose until blood glucose is in proper range and is
sustained

Name hydromorphone (Dilaudid) Concentration Dosage Amount 0.5 mg

Route INJ, IV Frequency Q5Min; PRN

Pharmaceutical class opioids Home Hospital or Both
Indication pain relief
Adverse/ Side effects constipation, nausea, vomiting, drowsiness, dizziness, orthostatic hypotension; anaphylaxis, respiratory depression, addiction,
dependence, seizures, urinary retention in older adults
Nursing considerations/ Patient Teaching ensure baseline vitals are obtained particularly respiratoyr rate and O2 saturation; continually monitory
vitals and O2 saturation hourly; patient teaching: do not drive or operate machinery, take with food, change positions slowly, increase fluids and
fiber, use stool softeners or laxatives as ordered

Name acetaminophen-oxycodone (Percocet) Concentration Dosage Amount 325 mg—5 mg

Route oral Frequency Q4H, PRN

Pharmaceutical class opioid and analgesic Home Hospital or Both
Indication moderate to moderately severe pain
Adverse/ Side effects agitation, restlessness, anxiety, insomnia, tremor, abdominal cramps, blurred vision, vomiting, and sweating; hepatotoxicity,
hypersensitivity reaction, pneumonia, metabolic acidosis
Nursing considerations/ Patient Teaching

Reference for Medications: (Kee, Hayes, & McCuistion, 2015)

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? NPO Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Patient consumes liquids Consider co-morbidities and cultural considerations):
only due to difficulty swallowing. She used to consume
protein shakes and Ensure shakes, however they are too
thick for her to swallow.
24 HR average home diet: Previously, home diet was insufficient to sustain the patient
nutritionally. The diet lacks fruits, vegetables, grains, and
Breakfast: Pudding protein. This nutritionally lacking diet has lead to the
weight loss that the patient has experienced over the past
Lunch: Chicken Broth three years. Due to dysphagia patient was unable to
swallow thicken liquids. Until recently she had consumed
Dinner: Beef Broth Ensure nutritional shakes, however they have become to
thick for the patient to swallow effectively. It is important to
Snacks: none ensure that liquids are pureed, and do not irritate the
esophagus due to GERD. Increased caloric intake with her
Liquids (include alcohol): patient only consumes liquids liquids will be the priority to increase her nutritional
intake.
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.

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
“I help myself. Like when I throw up I hold my own hair.”

How do you generally cope with stress? or What do you do when you are upset?
“I smoke pot when I’m upset.”

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“None, only this not being able to swallow or eat anything.”

+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?

Are you currently in a safe relationship? Yes

University of South Florida College of Nursing – Revision September 2014 5

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your
patient’s age group:
“Successfully resolving the adolescent conflict of identify versus role confusion paves the way for resolving the early
adulthood conflict of intimacy versus isolation and for becoming ready to participate in a committed, long-term
relationship” (Sigelman & Rider, 2012).
“Erikson (1963) defined intimacy as ‘the capacity to commit himself to concrete affiliations and partnerships and to
develop the ethical strength to abide by such commitments’ (p.263). Isolation is the avoidance of intimacy. The task at this
stage is to develop a commitment to work and relationships. Failure to do so will results in impersonal relationships and
difficulty with maintaining a job.” (Treas, & Wilkinson, 2013, p. 213)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient is in the stage of isolation vs. intimacy. Currently, being in the hospital she is leaning toward isolation. For
the past few years her condition has been progressing. Patient is unable to participate in activities of socialization such as
eating out with friends. She stated that one of her goals would be to eat a meal with her family. Since the onset of her
condition she has been unable to swallow solids foods, which isolates her form not only friends but her family and
partner.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
Since the patient is in the hospital it has brought her into more of a time of isolation. She has her partner visit her,
however she continues to reference back to not being with her family. This is important for the plan of action for her well
being as we further her treatment.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“I don’t know, my esophagus shut down I guess.”

What does your illness mean to you?

“I don’t know. I can’t go out to dinner with my family anymore.”

+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? Yes 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? “Pull out, no birth control or anything.”

How long have you been with your current partner? 2 years

Have any medical or surgical conditions changed your ability to have sexual activity? No

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? “Very important, it keeps me focused, and keeps me full of gratitude.”

Do your religious beliefs influence your current condition? No

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much?(specify daily amount) For how many years? 30 years
Cigarettes ½ a pack a day (age 15 thru current )

If applicable, when did the

Pack Years: 15 pack years
patient quit?
2014
Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? No If yes, what did they use to try to quit? Patch

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years?
Volume: (age thru )
Frequency:
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?
Marijuana How much? For how many years? 15 years
“1 joint a day” (age 30 thru current )

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?
N/A

University of South Florida College of Nursing – Revision September 2014 7

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? “Not great”
Integumentary: No rashes, lesions, or abnormal growths; does not report sunscreen usage; reports bathing daily
HEENT: patient utilizes glasses, as a young child reports ear infections; routine tooth brushing b.i.d.; routine
dentist visits every 3 months; vision screenings one every 2 years; back teeth cracked extraction followed 2003
Pulmonary: dry cough, CXR 07/11/2016 (for current hospital stay)
Cardiovascular: chest pain, EKG 2004, 07/12/2016 (for current hospital stay), “my blood pressure tends to run
on the low side”
GI: Nausea, vomiting, GERD
GU: Kidney stones 2011; normal frequency of urination b.i.d. currently, before swallowing difficulty 6 or more
times a day
Women/Men Only: reports conduction of monthly self breast exam, last gyn exam 2014, menstrual cycle
regular, menarche 12, last mammogram 3 years ago no abnormal results,
Musculoskeletal: broke finger and elbow “a few years ago”
Immunologic: No report of recent fever, lupus, arthritis, enlarged lymph nodes, or allergic reactions
Hematologic/Oncologic: no report of anemia, or bleeding easily
Metabolic/Endocrine: no report of diabetes, or hypo/hyperthyroidism
Central Nervous System: dizziness
Mental Illness: reports no anxiety, depression, bipolar
Childhood Diseases: chicken pox

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
None reported

Any other questions or comments that your patient would like you to know?
Reports no further questions.

±10 PHYSICAL EXAMINATION:

General survey pt. appears to be alert, white female, petite frame, symmetrical, lying in bed
Height 160 cm Weight 43.25 kg BMI 16.9 kg/m2 Pain (include rating and location) 6 (abdomen and neck)
Pulse 45 Blood Pressure (include location) 89/56 left arm Temperature (route taken) 98°F (orally)
Respirations 16 SpO2 100% Room Air
Overall Appearance Appears to be tired, slept from 1100-1300, states “those three tests they had me do made me tired”
Overall Behavior appears to be in no distress, appears to perform proper hygiene absent body odor; makes eye contact
Speech Clear and consistent, follows train of thought, answers questions clearly
Mood and Affect affect is appropriate regarding the surgery that is scheduled for next day
Integumentary Skin is intact, no lesions, or redness observed, temperature warm, dry, and moist, slight discoloration with
light brown spots (appear to be lentigines/sunspots)
IV Access slight tenderness, secure to patient left arm
HEENT PERRLA observed; no lesions on the face; oral mucous is intact, light pink; a few fillings present in patient’s
teeth; tongue pink and moist; nares pink, no drainage noted
Pulmonary/Thorax All lobes clear, no abnormal breath sounds, unlabored breathing; no nasal flaring observed
Cardiovascular S1 and S2 sounds auscultated; slight tenderness upon palpation of the carotid arteries
GI flat contour of abdomen; hypoactive bowel sounds auscultated in RUQ and RLQ; normative bowel sounds auscultated
LUQ and LLQ
GU reports normal flow of urine, and no pain upon urination
Musculoskeletal no tingling or numbness in extremities reported; pedal pulse 2+, tibial pulse 2+
Neurological oriented to person, place, and time
University of South Florida College of Nursing – Revision September 2014 8
±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):
Diagnostic Exam Date Finding
Time
CT abdomen with 07/11/2016 Marked fluid distention of thoracic esophagus tapers at
pelvis 1204 gastroesophageal junction
Stomach decompressed
Finding: either high grade chronic obstruction lesion or achalasia
XR Esophagus 07/12/2016 Distended esophagus with limited passage through the gastroesophageal
1031 junction; concern for achalasia
Transthoracic 07/12/2016 Pre op
Echocardiogram 1352 LV systolic function normal ejection fraction estimated in range 60-
65%; no regional wall motion abnormalities
XR Esophagus 07/12/16 Timed barium study esophageal emptying with 5, 10, 15, and 20 minute
1515 intervals
Limited emptying of esophagus within 20 minutes just barium passed
through the esophagogastric junction to coat walls of gastric fundus,
without distal extension into the stomach without distention of stomach
5-10% emptying of esophagus
XR UGI W KUB 07/13/216 Immediate post op
with gastrogafin 1724 No evidence of leak
Minimal passage of contrast into stomach occurring only during marked
distention of esophagus obtained with ingestion of flow water soluble
contrast followed by water
Lab Dates Trend Analysis
WBC Upon admittance, the High WBC count
13.8 07/11/2016 WBC was high indicating indicates possible
7.9 07/15/2016 possible infection. infection.
Normal However upon discharge
4.5-11 the WBC was back in
normal range.
RBC Lower RBC from This lower RBC may be
4.92 07/11/2016 admittance to 2 days after due to the surgery and
3.83 07/15/2016 surgery. healing process.
Normal Lower than normal range.
4.3-5.5

HGB Lower hemoglobin count

14.8 07/11/2016 from admittance to 2 days
11.3 07/15/2016 after surgery.
Normal Slightly lower than
12-16 normal range.

HCT Lower hemoglobin count

45.1 07/11/2016 from admittance to 2 days
35.1 07/15/2016 after surgery.
Normal Within normal range.
38-54

University of South Florida College of Nursing – Revision September 2014 9

Platelet Lower platelet count from
200 07/11/2016 admittance to 2 days after
138 07/15/2016 surgery.
Normal
150-450

Na Lower sodium from Well within normal range,

142 07/11/2016 admittance to 2 days after there should be no
138 07/15/2016 surgery. indication of change or
Normal Within normal range. need of treatment from
135-145 this lab value.

K Lower potassium from Well within normal range,

4.6 07/11/2016 admittance to 2 days after there should be no
3.6 07/15/2016 surgery. indication of change or
Normal Within normal range. need of treatment from
3.5-5.0 this lab value.

Chloride Slightly higher chloride Well within normal range,

102 07/11/2016 from admittance to 2 days there should be no
104 07/15/2016 after surgery. indication of change or
Normal Within normal range. need of treatment from
98-106 this lab value.

CO2 Slightly lower carbon Well within normal range,

28 07/11/2016 dioxide level from there should be no
26 07/15/2016 admittance to 2 days after indication of change or
Normal surgery. need of treatment from
23-39 Within normal range. this lab value.

BUN Slightly lower BUN from This low BUN level may
8 07/11/2016 admittance to 2 days after be due to low protein
6 07/15/2016 surgery. intake, this may be due to
Normal Slightly lower than NPO as well as the
8-21 normal range upon surgery.
second lab.
Creatinine Slight increase in Within normal range,
0.7 07/11/2016 creatinine. there should be no
0.8 07/15/2016 Within normal range. indication of change or
Normal need of treatment from
0.8-1.3 this lab value.

Blood Glucose Lower glucose level from Due to this low blood
76 07/11/2016 admittance to 2 days after glucose level, it was
59 07/15/2016 surgery. necessary to enact
Normal This value fluctuated hypoglycemic protocol.
65-110 throughout hospital stay. This ensures a quick
Required hypoglycemic acting dextrose saline
protocol. solution be administered
University of South Florida College of Nursing – Revision September 2014 10
 to increase the patient’s
blood glucose level.

Pre-Op No trend These values were tested

Prothrombin—16.6 07/13/2016 the day of surgery due to
Normal the laparoscopic incision.
11-14
INR—1.31 07/13/2016
Normal
0.9-1.2
aPTT—33 07/13/2016
Normal
20-40

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Scheduled Surgery: laparoscopic hellar myotomy with anterior fundoplication possible 07/13/2016
Diet: NPO due to dysphagia and risk for aspiration 07/13/2016
Progression of diet from NPO, clear liquids, full liquids, etc.
Vitals:
 Vitals 07/12/2016 9000
o Temp 98 HR 66 BP 98/63 RR 16 O2 100 via Rm Air
 Vitals 07/13/2016 pre op
o Temp 98 HR 48 BP 105/69 RR -- O2 100 via Rm Air
 Vitals 07/13/2016 immediate post op
o Temp 99.1 HR 66 BP 88/55 RR 20 O2 95
 Vitals 07/13/2016 one hour post op
o Temp 98 HR 60 BP 95/62 RR 16 O2 100
Activity: patient is able to ambulate independently, patient is fatigued ambulates 4 times in shift 07/12/2016;
encourage the patient to ambulate around unit
Scheduled diagnostic tests: biopsy scheduled for 07/13/2016 during surgery

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

1. Acute pain related to difficulty swallowing as evidenced by pain level of 6 out of 10.
2. Risk for aspiration related to difficulty swallowing as evidenced by inability to swallow solid and thickened liquids.
3. Feeding self-care deficit related to difficulty swallowing as evidenced by inability to complete a meal, fatigue, and pain.

University of South Florida College of Nursing – Revision September 2014 11

± 15 CARE PLAN
Nursing Diagnosis: Acute pain related to difficulty swallowing as evidenced by pain level of 6 out of 10.
Patient Goals/Outcomes
Decreased pain level to 3 by end of Assess pain intensity level in client Self-reporting is considered the
shift.
Perform activities of recovery:
Ability to swallow comfortably,
demonstrate effective swallowing
without signs of aspiration after
procedure and recovery time of 2-3
weeks.
Decreased pain level day two after Manage acute pain using a
surgery.
Nursing Interventions to Achieve
Goal
every 3 hours using valid and
reliable self-report pain tool.
- The scale of 0 to 10.
Obtain a prescription to administer Non-opioids, such as
a non-opioid analgesic for mild to
moderate pain.
If client has impaired swallowing,
do not feed orally until an
appropriate diagnostic workup is
completed.
Ensure proper nutrition by
consulting with a physician
regarding alternative nutrition and
hydration when oral nutrition is not
safe/adequate.
multimodal approach.
University of South Florida College of Nursing – Revision September 2014
Rationale for Interventions
Provide References
single most reliable indicator of
pain presence and intensity.
Single dimension pain rations are
valid and reliable as measures of
pain intensity level.
acetaminophen and NSAIDs are
first line analgesics of the treatment
of mild and some moderate acute
pain.
Feeding a client who cannot
adequately swallow results in
aspiration and possible death.
It is imperative that the patient
receives adequate nutrition due to
upcoming surgery.
When combining two medications Patient will adhere to prescribed
from different pharmacological
classes they target different
pathways. This allows for lower
doses of both medications, which
results in fewer side effects.
Evaluation of Goal on Day Care
is Provided
Patient will report their pain on the
scale of 0-10.
Patient will report decreased pain
level from 6 to 3 or less.
Continue diet of NPO for patient
until diagnostic tests are completed.
Then after surgery, proceed with
diet plan of progressing to clear
liquids, full liquids, etc. Patient will
progress through levels upon safe
consumption of each liquid.
Patient will meet adequate
nutritional intake, through safe
means.
medication (acetaminophen-
oxycodone (Percocet)) after
discharge. Patient will report
decreased pain level from surgery
pain level report.
12
 Ask the client to report side effects,
such as nausea and pruritus, and to
describe appetite, bowel
elimination and ability to rest and
sleep. Administer medications and
treatments to prevent and improve
these conditions and function.
Care Plan Reference: (Ackley, & Ladwig, 2014)
Opioids cause constipation by Patient will report side effects if
decreasing intestinal motility and applicable. Ensure that patient is
reduce mucosal secretions. It receiving preventative treatment for
would be necessary to obtain a possible side effects.
prescription to treat the side effects
prior to an uncomfortable side
effect for the patient to experience.

±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Education
- signs and symptoms of infection with incision
- education for cough and deep breathing, as well as incentive spirometer

Consider the following needs:

□SS Consult
□Dietary Consult
- A dietary consult would be required to ensure that the patient adheres to the progression of the diet from clear liquid, to full liquid, to soft foods, etc.
- Ross-Rosemurgy Diet Plan

□PT/ OT
□Pastoral Care
□Durable Medical Needs
□F/U appointments
- A follow up appointment would be necessary 1-2 weeks after surgery to ensure adequate healing and recovery post op.

□Med Instruction/Prescription
 □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No
- pain management and side effects
- glucose monitoring

□Rehab/ HH
□Palliative Care

University of South Florida College of Nursing – Revision September 2014 13

 References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning

Care (10th ed.). Maryland Heights, MO: Mosby Elsevier.

Huether, S. E., McCance, K. L. (2012). Understanding Pathophysiology (5th ed.). St. Louis, MO: Elsevier

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Kee, J. L., Hayes, E. R., McCuistion, L. E. (2015). Pharmacology: A Patient-Centered Nursing Process

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