Pat 1 2015
Pat 1 2015
Pat 1 2015
COLLEGE OF NURSING
Student:ASHLEY KAVUMKAL
BB
F
Assignment Date:02/13/2015
Agency:SMH
Age: 72
Admission Date:02/12/2015
Advanced Directives:NO
If no, do they want to fill them out? NO
Surgery Date:
Procedure:
1 CHIEF COMPLAINT:
Patient stated that her chief complaint for today is pain in the IV site (right forearm) and numbness in lower extremities
bilaterally.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient was brought to the ER yesterday (02/11/15) for having left face, arm and leg numbness at around 9:30 am. Patient
stated that she had tingling and discomfort mainly in left foot which disappeared after a few minutes but then came back
and became persistent since then. Patient also stated that she had head pain of 6 and nausea but, did not vomit. Patient
denied having weakness or difficulty walking. Patient had a blood pressure of 173/95 upon arrival and received labetelol
which made her feel better. MRI and CT of head results were normal. Physician suspected TIA vs Anxiety and favored the
latter.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
Operation or Illness
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
(angina,
MI, DVT
etc.)
Heart
Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
cancer
Arthritis
Brother
Father
Anemia
Mother
Cause
of
Death
(if
applicable
)
pneumoni
a
cancer
Environmental
Allergies
2
FAMILY
MEDICAL
HISTORY
7/20/2007
Alcoholism
Sister
relationship
relationship
relationship
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
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
NO
1 ALLERGIES
OR ADVERSE
REACTIONS
NAME of
Causative Agent
IVP dye
Hydrocodone
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)
Cerebrovascular accident is a sudden loss of neurological function, caused by vascular injury to an area of the brain.
Causes include emboli from other organs, cerebrovascular disease, trauma, hypercoagulable states etc. Risk factors
include advanced age (65 and above),atherosclerosis of the aortic arch, atrial fibrillation, coronary artery disease,
smoking, alcohol, heart failure, hyperlipidemia, hypertension, history of myocardial infarction, diabetes mellitus, male
gender, non-white race, peripheral vascular disease, physical inactivity, obesity, pregnancy etc. Signs and symptoms
include sudden weakness/ numbness of the face, arm or leg, sudden loss of vision, double vision, difficulty in speaking,
sudden severe headache, sudden falling, gait disturbance or dizziness. Diagnosis requires physical examination,
neurological examination, CT, MRI, Doppler ultrasound or arteriography. Treatment includes recombinant tissue
plasminogen activator (rt-PA) if recognized by the first 90 to 180 min.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: ASPIRIN
Route: PO
Home
Hospital
or
Both
Concentration 20mg/tab
Route: PO
Home
Hospital
or
Both
Concentration: 0.9%
Route IV
Pharmaceutical class
Home
Hospital
or
Both
Concentration 40mg/0.4mL
Route: SQ
Frequency Q24H
Home
Hospital
or
Both
Concentration 5mg/tab
Route:PO
Home
Hospital
or
Both
Concentration 325mg/tab
Route : PO
Frequency: PRN
Home
Hospital
or
Both
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
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 patient follows at home? regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: egg, cap n crunch sweet corn and oat cereal with The patients diet consists of mainly proteins and fiber
milk
which is good. However her fuit and vegetable intake is
less than 50%. She should add more of these into her diet.
Also she could incorporate more milk or yogurt into her
diet as her diet now only consist of less than 25% of those.
Her sodium intake exceeds the daily limit by 700mg which
should be cut down. Instead of chips and crackers she could
incorporate yogurt or fruits as snack.
Lunch: Hamburger, potato, small unsweet tea
Dinner: mushroom soup, baked fish
Snacks: cheese crackers, unsalted peanuts, chips
Liquids (include alcohol): coffee with half n half
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?
daugter
How do you generally cope with stress? or What do you do when you are upset? Patient stated that she practices deep
breathing to cope with stress. Also, she talks with her daughter or friends when upset.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
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: The patient is in her late adulthood with an integrity stage. When reflecting on his or her life, the older adult may
feel a sense of satisfaction (integrity) or failure (despair) (Myers, 2008, p.87).
Reference:
Myers, D. G., (2008). Development through the life span: Psychology in everyday life (pp. 78) New York, Worth Publishers.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
Patient seems content about her life. She mentioned that her daughter is taking care of her very well and she is the one
who brought her to the hospital this time.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The disease did not seem to affect the patients developmental stage that much. She is very positive about recovering. She
is very thankful that her daughter brought her in on time to the hospital.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Anxiety
What does your illness mean to you?
Slowing down- in term of doing daily activities
+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? __once_____________________________________________
Have you or a partner ever had an abnormal pap smear? Yes, long time
ago_____________________________________________________
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?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? __________________________________
How long have you been with your current partner?
__N/A______________________________________________________
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
Yes
No
For how many years? X years
(age
thru
Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much? no
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? A glass of wine
Volume:
Frequency: occasionally, during
family gatherings
If applicable, when did the patient quit?
thru
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
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?
no
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:
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
incontinence
3/day
x/day
x/year
Hematologic/Oncologic
Metabolic/Endocrine
Diabetes
Type: 2
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?
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
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
Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
10
Other:
Other:
Other:
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? none
Any other questions or comments that your patient would like you to know? none
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10 PHYSICAL EXAMINATION:
General Survey:
Height: 165.1cm
Pulse: 85
Respirations: 18
SpO2 99
Weight 170lb
BMI: 28.28
Blood Pressure: 160/85
Pain: 0
Temperature: (route
Is the patient on Room Air or O2
taken?) 98.7
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
numbness in left foot, weak pedal pulse, got better with SCDs
was not WNL (within normal limits)
Central access device Type: peripheral
Location:
right forearm
Date inserted: 02/12/2015
Fluids infusing?
no
yes - what? NS 0.9%
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 earinches & left earinches
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
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: all clear
RUL
LUL
RML
LLL
RLL
Chest expansion
12
Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
No JVD
GU
Urine output:
Clear
Cloudy
Color: yellow
Previous 24 hour output:
N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
voids: pt reported clear and yellow with no pain
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at _______ RUE _______ LUE _______ RLE
mLs
[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]
Biceps:
Brachioradial:
Patellar:
Achilles:
13
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
Glucose POCT
Dates
Chem. 12
PTT activated
Prothrombin time w/
INR
CT head
MRI
12/02/15
12/02/15
12/02/15
12/02/15
12/02/15
12/02/15
Trend
244 high
Analysis
Type 2 diabetes
Normal values
25.2 seconds -normal
12.7 normal
0.91 normal
Low-attenuation
periventricular white
matter compatible w/
small vessel ischemic
changes. No
hemorrhage
mass/edema, ventricles
normal size, mastoid air
cells and paranasal
sinuses clear
No abnormal diffusion
is noted
normal
normal
normal
Small vessel ischemic
changes in both cerebral
hemispheres. No
intracranial
hemorrhage or acute
intracranial
abnormality seen
normal
14
15 CARE PLAN
Patient Goals/Outcomes
Patient will maintain level of
consciousness, cognition, and
motor/sensory function with stable
vital signs and absence of signs of
increased ICP.
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References
Myers, D. G., (2008). Development through the life span: Psychology in everyday life (pp. 78) New York, Worth
Publishers.
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software]. Retrieved from
http://www.unboundmedicine.com/products/nursing_central
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