Assessment

NR 325 Adult health 2

Care plan #2

By

Kadidia Tall

PATIENT ASSESSMENT AND CARE PLAN

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 Assessment

STUDENT: ____Kadidia Tall__________________________________ Date of Care: ___3/12/2018____________

Client Initials: ___.P______ Room # _____46_______ DOB: _____3/19/1959__________ Age: 56_________ Gender: F
__________

Admitted to facility Date: __2/23/2018_________________ Resuscitation Status ___full code______ Allergies: Non__________

Reason for Admission: __Shortness Of Breath

______________________________________________________________________________

Social: Single Significant other, Next of Kin or POA for Health Care: __________________________________

Occupation or former occupation: ___self employed

________________________________________________________________________

Primary Health Care Provider(s): ___Dr _AHMED-Z _________________________

Consultants/Specialists____________________________

Medical Diagnoses: pneumonia of Right middle lobe

__________________________________________________________________________________

________________________________________________________________________________________________________

Surgeries/Procedures and Dates: ___________________________________________________________________________

Current Physician/Health Care Provider Orders (Prescriptions for Care)

ITEM TYPE THIS RESIDENT’S ORDERS RATIONALE

Diet Full liquid diet No restriction
Activity As tolerated No Restriction
I/O Monitor No restruction
VS Q4h Telemetry Monitoring
Accu-Cheks
Foley
NG
PEG/PEJ tube
Wound Care /
Dressing Change
Respiratory Treatments Orders Oxygen PRN
Tracheostomy
Suctioning
Chest Tube
Special Equipment Hospital compression stockings To prevent embolism because patient is in
bed rest.
Lab orders ABGs See below for results
Other
Rehab Services Activity or Treatment Plan & Schedule Rationale

Physical
Therapy
Speech Therapy
Occupational Ther

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 Assessment
IV Access: Type peripheral Site: Left forearm
Last Dressing Change Last Tubing Change: 2/27/2018 at 9AM
Reason for IV access Medication administration
IV fluids and meds

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 Assessment
Most recent Imaging Findings: (CXR? CT? MRI?)
Type of Imaging Body Area Imaged Reason for testing and results of test
(X-Ray, CT, MRI,
etc)
X-RAY Chest To confirm diagnosis

Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?)
Date Lab Test Results Norms Comments
1/7/18 WBC 12.7H 4.00-10.50 Pt have infection
RBC 3.94L 3.90-5.03 Normal
Hemoglobin 14L 12.0-15.5 Normal
Platelet Count 317 150-450 Med side affect
Sodium 137 mEq/L 135-145 normal
Potassium level 4.8 mEq/L 3.5-5 Normal
Chloride 102mEq/L 98-108 normal
Carbon Dioxide 31.2 mmol/L 21-31 Resp impairement
Blood Urea Nitrogen 23 mg/dl 5-27 Normal
Creatinine 0.70 mg/dL 0.50-1.10 Normal
Bedside Glucose level 102 mg/dL 65-110 Normal
Calcium 8.8 mg/dL 8.2-9.8 Normal

Other recent, significant procedures or tests (EKG, etc)

Date Test Reason for testing and results of test

Resident’s Developmental Stage according to Erikson: __Generativity vs.

Isolation_______________________________________

Your assessment of this resident’s response to the opportunities and potential conflicts of this stage:
productive at work and involve in community activity.
_________________________________________________________________________

_________________________________________________________________________________________

List one of the resources you used to learn more about this resident’s diagnoses: patient health summary.

Based on the information on these pages and your assessment of this resident, what is your FIRST or
PRIORITY concern? (“What worries you the most about this resident?”) : client's Respiratory distress.

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 Medications
Brand Name and Generic Name Normal Dosage Ranges Contraindications
1g/50ml Allergic reaction to any cephalosporin antibiotic
Ceftriaxone

Pharmacotherapeutic Class Dosage Ordered Adverse Reactions

1g Itching, or hives, dark Urine, Nausea and
Cephalosporin ( antibiotics) vomiting, loss of appetite.

Why is patient receiving this med? (Can list Route and Frequency Nursing Considerations and Teaching
related diagnosis, symptom, or need)
IV push q24h Assess for allergies to cephalosporin, make
infection sure pt get full treatment to clear up infection,
advice pt to prevent hcp if symptom not
improve.

Brand Name and Generic Name Normal Dosage Ranges Contraindications

Acetaminophen ( Tylenol) 650mg Allergies, Alcohol, liver disease.

Pharmacotherapeutic Class Dosage Ordered Adverse Reactions

Relive mild to moderate pain and reduce 650mg Angioedema, dizziness, rash, hyperammonemia,
fiver urticaria, GI hemorrhage.
Why is patient receiving this med? (Can list Route and Frequency Nursing Considerations and Teaching
related diagnosis, symptom, or need)
For mild pain Rectal Q6h Assess for allergies and liver disease. Monitor
for side affect.

Brand Name and Generic Name Normal Dosage Ranges Contraindications

Azithromycin (zithromax) 500mg Allergies, Alcohol

Pharmacotherapeutic Class Dosage Ordered Adverse Reactions

antibiotics 500mg Itching or hives, blistering, dark urine, dizziness
Chest pain, diarrhea, nausea and vomiting
Why is patient receiving this med? (Can list Route and Frequency Nursing Considerations and Teaching
related diagnosis, symptom, or need)
pneumonia IV Q24h Assess for allergies, teach pt to alert HCP if
blood in stools. no alcohol during treatment,
complete treatment as prescribe.

Brand Name and Generic Name Normal Dosage Ranges Contraindications

5000 unites Allergies, pregnancy, diarrhea.

Decusate sodium
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Stool softners 5000 unites Stomach pain, diarrhea, cramping, irritated
throat
Why is patient receiving this med? (Can list Route and Frequency Nursing Considerations and Teaching
related diagnosis, symptom, or need)
constipation Sc Q8h Take with food, stop if have diarrhea,

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 Medications

Brand Name and Generic Name Normal Dosage Ranges Contraindications

Heparin 10units Allergies, pregnancy, alcohol. (may need to stop
before surgery or other medical procedure).
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Prevent blood clots from forming or growing 10units Easy bleeding and bruising, redness, headache,
larger in blood and blood vessels. Gas, abdominal pain, bloating, loss of hair, taste
change and feeling cold or having chills.
Why is patient receiving this med? (Can list Route and Frequency Nursing Considerations and Teaching
related diagnosis, symptom, or need)
To prevent DVT, Pulmonary embolism and Q24h Assess for allergies and bleeding. Advice pt to
Arterial thromboembolism. use electronic razor and toothbrush.

Brand Name and Generic Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage Ordered Adverse Reactions

Why is patient receiving this med? (Can list Route and Frequency Nursing Considerations and Teaching
related diagnosis, symptom, or need)

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 Nurses Notes
For this clinical, we are having you write out your assessment findings in the form of a narrative nurse’s note. See samples of
assessments on the next page. Take the “Physical Assessment Worksheet” into the resident’s room to take notes during your
assessment.

Date / Time

NURSES NOTES
2/27/2018 (This form will expand to fit your typing.)
Type your Physical Assessment findings (Head-to-Toe Assessment) below.

Vital Signs: 98.7 Apical HR : 72 Resp 22 BP: 132/85 spo2

Client was Alert and Oriented to place, time and year. No stress or Anxiety noted. Motor and
sensory functions grossly intact. No involuntary movement or abnormal posture noted. Muscle
weakness noted.

Skin dry and warm, slight bruising on chest. Redness on Left forearm (IV sites), Nail and hair
evenly distributed.
Edema of low extremities Crackles at bilateral bases to auscultation, no JVD noted.
Cap refill < 3 sec, pulses palpable and equal bilaterally.
Abdomen skin is intact. Decreased bowel sounds in all 4Q. non abdominal distension , non-tender.
Decrease bowel movement.
Limited mobility, at high risk for fall.

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 Sample Narrative Notes

Sample note for essentially “normal” findings

12/22/2010 1400 Vitals: 98.6, 72, 16, 128/62, height weight
Alert and oriented x 3. Recent and remote memory intact. Motor and sensory functions grossly intact.
No weakness or paralysis. No involuntary movement or abnormal posture. Appropriate mood and affect.
Skin pink, warm, dry, free of lesions. Elastic turgor. Hair and nails unremarkable.
Pupils equal, reactive to light and accommodation. Oral mucosa moist, pink. Dentition intact. Oropharynx
clear without erythema or exudate.
Lung fields clear bilaterally to auscultation. Respirations non-labored.
Apical pulse regular (rate) and rhythm. Carotid, radial, and pedal pulses palpable and equal bilaterally. Cap
refill < 3 sec.
Bowel sounds active x 4. Abd soft, non-distended, non-tender. Last BM this morning, large, soft- formed,
Extremities c equal strength bilaterally, unlimited ROM. No tenderness, swelling or joint deformities noted.
Denies numbness or tingling to extremities. No peripheral edema noted.

SAMPLE Narrative Note with Numerous Abnormal Findings

Resident sitting in wheelchair. Pressure reduction cushion in place. No foot rests as resident propels self in
wheelchair. Speech soft but clear. Occasional stutters.
Alert, oriented to self, unaware of date, unable to name location. Can recall name of daughter.
Cannot remember what she ate for breakfast. Hx of CVA with R hemiparesis; moves R foot well enough to
propel chair; R hand is slightly contracted. Grip stronger on L than R. Resident leans very slightly to R.
Eye prosthesis on R; L pupil is reactive to light and accommodation.
Skin pale, warm, very dry, with flaking. Skin tear noted R forearm, Band-Aid in place. No other breaks in
skin integrity, no redness. Turgor fair. Scar over L chest wall at old mastectomy site. No masses palpated
over scar. Hair thin. Toenails thick and yellow. Sees podiatrist monthly.
Oral mucosa moist, pink. Hard white lesion noted at R base of tongue. Referred to charge nurse T. Sabaj for
follow up. Upper and lower dentures in place with oral debris noted. Oral care provided. Oropharynx clear
without erythema or exudate.
Lung fields auscultated. Crackles at bilateral bases. Cleared with cough. Lung fields otherwise clear to
auscultation.
Apical pulse 68 with occasional “skipped beats”. Resident has history of PVCs. 3 skipped beats per minute.
Pt in no distress. Carotid, radial, and pedal pulses palpable and equal bilaterally. Cap refill < 3 sec. Slight
mottling of toes in dependent position.
Bowel sounds active x 4. Abd soft, non-distended, non-tender. Last BM 2 days ago.
Moderate ROM limitations on R side. Cannot raise R arm to shoulder level. Discussed with Charge Nurse,
and referral made to Rehab Services for screening. No tenderness, swelling or joint deformities. Denies
numbness or tingling to extremities. No peripheral edema noted.

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 Physical Assessment Worksheet
Use this sheet for jotting down your assessment findings. Follow guidelines from NR 302/NR 304 head-to-toe sheet.

Routine Findings Patient Variations/Abnormals

Skin –
Skin: warm, dry and intact with adequate turgor. No rashes, Skin is warm and dry with redness on left
or lesions present. forearm (IVsite)

Head and neck – no JVD, No JVD noted

Breasts - Deferred
Respiratory – : Even, and unlabored. Lung sounds to
auscultation
presence of crackles on auscultation

Cardiovascular BP and Epical rate are within pt normal

limits. regular rhythm, no edema no JVD
Dysrhythmias, decrease BP

Abdomen – Soft, no-tender No tender, hypoactive, constipation.

.

Neurological : pt Alert and oriented time 4 Patient alert and oriented to time, location and
year.
Musculoskeletal - . : Normal posture no muscle atrophy or Muscle weakness, peripheral edema.
weakness, symmetric movement
Genitourinary - : Voiding adequate amount Increase urine output.

Pelvic - . Deferred

Rectal - Deferred

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 Nursing Care Plan
Patient Initials, Age, Gender: J.T, 67, F STUDENT NAME AND DATE: Kadidia Tall

Nursing Diagnosis
or Collaborative Problem: Activity intolerance

 Related to: Imbalance between oxygen supply/demand

As Evidenced By: weakness and fatigue

Desired Patient Outcomes Nursing Interventions

1) Encourage client to perform independent activity as tolerated. It will

Patient will: participate in desired activities; meet own self care needs indicate what patient can tolerate.
after treatment. 2) Document cardiopulmonary response to activity. Note tachycardia,
dysrhythmias, dyspnea, diaphoresis, pallor.
3) Provide assistance with self-care activities as indicated. Intersperse
Patient will: Achieve measurable increase in activity tolerance, and activity periods with rest periods. Meets patient’s personal care needs
reduced fatigue and weakness by discharge.
without undue myocardial stress and excessive oxygen demand

4) Implement graded cardiac rehabilitation program. Strengthens and

improves cardiac function under stress, if cardiac dysfunction is not
irreversible. Gradual increase in activity avoids excessive myocardial
workload and oxygen consumption.

5) Assist patient with ROM exercises. Check regularly for calf pain and
tenderness. To prevent DVT due to vascular congestion.

6) Assist with identification or treatment of underlying causes. Client will

tolerates activities if in better health condition.

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 Nursing Care Plan

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 Nursing Care Plan
Patient Initials, Age, Gender: STUDENT NAME AND DATE:

Nursing Diagnosis
or Collaborative Problem: Ineffective airway clearance
 Related to: Impaired respiratory muscle function

As Evidenced By: stasis of secretions, and ineffective cough 

Desired Patient Outcomes Nursing Interventions

Make sure they are specific, measurable, realistic and have a time frame
stated.
Client will demonstrate increased air exchange by the end of the shift. 1) Monitor and record vital signs to obtain baseline data
2) Elevate the head of the bed to open up the airway.
3) Teach the patient the proper ways of coughing and breathing. The
most convenient way to remove most secretions is coughing.
4.) Provide supplemental oxygen if needed. Oxygen therapy is
recommended to improve oxygen saturation and reduce possible
complications.
Patient will maintain clear, open airways and normal breath sounds, 5) Maintain humidified oxygen as prescribed. Increasing humidity of
normal rate and depth of respirations, and ability to effectively cough up inspired air will reduce thickness of secretions and aid their removal.
secretions by discharge. 6) Give medications as prescribed, such as antibiotic. A variety of
medications are prepared to manage specific problems. Most promote
clearance of airway secretions and may reduce airway resistance.

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 Nursing Care Plan

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 Nursing Care Plan
Patient Initials, Age, Gender: STUDENT NAME AND DATE:

Nursing Diagnosis
or Collaborative Problem: high Risk for falls

 Related to: fatigue and muscle weakness

As Evidenced By:

Desired Patient Outcomes Nursing Interventions

1) Move items used by the patient within easy reach, such as call light,
Patient will demonstrate selective prevention measures after teaching. urinal, water, and telephone. Items that are too far from the patient may
cause hazard and can contribute to falls.

2.) Transfer the patient to a room near the nurses’ station. To provides
Client and family will implement strategies to increase safety and more constant observation and quick response to call needs.
prevent falls when return home.
3.) teach client appropriate use of mobility assistive devices.
Inappropriate use and maintenance of mobility aids such as canes,
. walkers, and wheelchairs increase the patient’s risk for falls.

4.) Monitor for Drug side affect; Risk factors for falls also include the use
of medications such as antihypertensive agents, ACE-
inhibitors, diuretics...

5.) Make sure that the beds are at the lowest possible position and use
side rails on beds. Keeping the beds closer to the floor reduces the risk of

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 Nursing Care Plan
falls and serious injury. 

6) Instruct client family to remove all factors known to increase fall risk
such as unfamiliar setting, inadequate lighting, wet surfaces, waxed
floors, clutter, and objects on the floor at home.

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RUBRIC for Grading Patient Assessment & Care Plan

Student:_____________________________ Clinical Date:_____________ Site:_______________________

Points Points Comments, Kudos,

Section Grading Criteria
Possible Earned Things to Improve for Next Time
Client  Patient Demographics, Diagnoses,
Assessment Surgeries, Orders, Rehab, IV,
Imaging and Lab are fully and
correctly completed
 Developmental stage & potential 10 10
conflict correctly identified
 Priority concern identified &
appropriate
 Used appropriate resource
 Medication Trade & Generic
Medication name, Pharmacological
Cards Classification, Normal Dosage
Range, dose ordered, route &
frequency, contraindications &
Adverse Effects/Reactions 10 10
identified appropriately
 Nursing Considerations &
Teaching appropriate for this
patient
 Legibly written or typed clearly
 Head-to-toe assessment
Head-to-Toe documented clearly and accurately
Assessment  Nurses Note is in logical order,
using appropriate language & 10 8
clearly understood.
 Abnormal findings have a follow
up note
Nursing plan of care completed 20 17
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RUBRIC for Grading Patient Assessment & Care Plan
Patient Care  Total of three appropriate Nursing
Plan Diagnosis (ND) or Collaborative
Problems (CP) identified.
 ND or CP properly formatted with
“Related to” statement correctly
formatted and appropriate for this
patient.
 “As evidenced by” is appropriately
stated and correct for this patient
 Outcomes specific, measurable,
timed
 Interventions are logical and
appropriate for this patient
Total points possible/Total points earned 50 45

Reference

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2016). Medical surgical nursing: Assessment and management of clinical
problems (10th ed.). St. Louis, MO: Elsevier.

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