University of Toledo – College of Nursing

CLIENT REPORT FORM

NURS 5140
Spring 2018

Patient Admission Information:

Date of Care: _
Room Number: __ Clients Initials: _ Code Status: Full Code

Allergies: Aleve_ Occupation: Supplemental staffing Religion: _catholic_

Marital Status: _single_ Previous Living arrangement__ _apartment

Plan for Discharge: estimated length of stay 2 midnights

plans for post-hospital care: home

Admission Story:

Summarize the admission story (review physician admission notes, History

and Physical, nursing admission assessment). What brought the client to the
hospital?
46-year-old white male with history of tobacco abuse about 1 pack in a given
month, remote history of alcohol last drink he had was almost a year ago who
presented to our hospital because of shortness of breath started on Tuesday.
Shortness of breath is on exertion. Patient also noticed some black tarry stool on
Saturday and another one on Sunday and it was soft in consistency. Patient
however denied having any hematemesis. Patient also did not have any vomiting,
but he did endorse nausea. Patient can keep food down. Patient denied any
abdominal pain. Important to mention that the patient has peptic ulcer disease
with possible perforation according to the patient description it was placed 7 years
ago. Patient also has small bowel obstruction for which he had another surgery.
Patient also stated that he takes ibuprofen t about 2 times a day for generalized
body ache

List past Medical History

- perforated peptic ulcer
- SBO (Small bowel obstruction)
List past Surgical History
-laporscopy for perforated ulcer
- laporscopy for SBO (unknown benign growth)
- Right leg surgery

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- Right jaw surgery
- Right scalp surgery
Basic Conditioning Factors:

Age and Gender: 46-year-old white male

List and assess Developmental State (Havighurst):
Maintain a standard of living
Adjust to physiologic changes
Single, Perform civic and social responsibilities
Health State: self-reliant, and responsible for his care
Sociocultural Orientation: Catholic, white, high school education,1 pack,
cigarettes per month, no alcohol, uses marijuana
Health Care System Factors: self-insured
Family System Factors: single, - does not know father's side of family
- no other notable history
Patterns of Living: single lives in an apartment
Environmental Factors: Independent, no special precautions needed for ADL
Resource Availability and Adequacy: Friends

ASSESSMENT DATA

Head to Toe Assessment:

Patient appears relaxed, calm with pleasant facial expression, behavior matches mood.
Patient is alert and oriented to time, place, person and event. patient is scoring a 15 on the
Glasgow Coma Scale, scoring a 4 for spontaneous eye opening, 5 for verbal response
orientation, and 6 for motor response obeying verbal commands.
Patient’s speech is clear, articulate, and appropriate for the situation
PAIN LEVEL 0 Numeric
TEMP 97.5F Oral
Weight 61.9kg
PULSE is regular elastic, 71 beats per minute
Respirations 16/ minute, regular, 1-2 inches in depth, nonlabored.
Blood Pressure 125/84
O2 saturation 98% room air
HEENT: Head is symmetrical, size is normocephalic, shape is oval, head is erect. pupils
are equal in size, round, reactive to light with direct and indirect light
pupils converge and constrict
Slightly dry mucous membranes, no thrush, no vesicles, no lesions, good dentition. Facial
pallor
Arm is a pale tan with no color variations and no abnormal lesions, there are no obvious
deformities or difference, no inflammation. no edema, temperature is warm and cooler
towards fingertips, no diaphoresis.
Neck: No lymphadenopathy no DVT

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Chest: Chest expansion is equal on both sides no wheeze/rhonchi/rales
CVS: Regular rate & rhythm, S1, S2, no murmurs/gallops/rubs, no JVD
Abdomen soft, mild epigastric tenderness, non-distended, +bowel sounds throughout, no
rebound or guarding, old surgical scar well healed
Ext: 2+ pulses, no edema, full range of motion
Neuro: Cranial nerves 2-12 grossly intact, no focal deficits
Muscle strength: All extremities Normal
Movement: All extremities to command
Sensation: All extremities No deficit
Reflexes: Reflex Present Blink, cough, swallow
Skin: warm, dry, no bruises/rashes
Psych: calm, cooperative

Universal Self-care Universal Requisite Assessment:

Air:
Subjective: room air, Breaths without difficulty, no pallor cyanosis
Objective: 100%

Water:
Fluid intake is sufficient. No Edema present.
Turgor normal for the age
Food:
Subjective: NBO, Food intake is not adequate, or the diet is not nutritious.
Objective: Hb – 10.9gm%,
Elimination:

Urine output Adequate

Voiding occult stool in blood

Activity/Rest:
Frequent rest is required due to pain, and fatigue.
Activity level has come down.
Best motor Obey verbal commands

Best verbal Oriented

GCS score: 15

Solitude/Social Interaction:
Communicates well with staff and Need for medical care is communicated to the
staff.

Normalcy:
Patient is single, with no close relatives around.

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Hazards:
Need instruction on care of GI bleeding and prevention of falls. Need instruction
on improvement of nutritional status.

Statement of the Health Problem - Discuss:

Pathophysiology: GIT bleeding

Upper GI bleeding may originate in the esophagus, stomach, and duodenum. GI bleeding
can be ulcerative, traumatic, vascular, tumors or due to portal hypertension. The
commonest causes of acute upper GI bleeding are peptic ulcer (use of NSAIDs), variceal
hemorrhage, and gastric cancers. Other causes include esophagitis, erosive gastritis, and
vascular ectasias.

Acute lower GI bleeding may be from the small intestine, colon or rectum. The causes of
acute lower GI bleeding may be vascular, neoplastic, traumatic and inflammatory.
Common causes of lower GI bleeding are diverticular disease, colorectal cancer, Crohn’s
disease ulcerative colitis, and benign anorectal lesions such as anal fissures and rectal
ulcers. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231512/]

Signs and Symptoms: Upper GI bleeding symptoms: hematemesis, vomiting of dark

altered blood, and melena. symptomatic anemia
passing of red blood from rectum indicates bleeding from the lower GI tract. The
presence of bloody emesis indicates more active bleeding.
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231512/]

Diagnostic/Laboratory Tests:
upper endoscopy and/or colonoscopy, nuclear scintigraphy, CT angiogram and catheter
angiography.
Fecal occult blood test.
Barium enema. [ https://medlineplus.gov/gastrointestinalbleeding.html]
complete blood count, Nasogastric lavage. [https://www.mayoclinic.org/diseases-
conditions/gastrointestinal-bleeding/diagnosis-treatment/drc-20372732]

Usual Medical Treatment:

treatment depends on where the bleeding is, proton pump inhibitor (PPI) to suppress
stomach acid production in upper GI bleeding.
Blood transfusion or IV fluids might be needed. Blood-thinning medications, aspirin or
nonsteroidal anti-inflammatory medications should stop.
[https://www.mayoclinic.org/diseases-conditions/gastrointestinal-bleeding/diagnosis-
treatment/drc-20372732]

Nursing Interventions:

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Assessments
Monitor PLTs, INR, PTT, watch for signs of bleeding
Monitor BP and check for orthostatic hypotension
Assess abdominal pain
Monitor Hemoglobin (HGB)
Monitor heart rate and blood pressure
•Assess for bleeding in stool GI bleed
Interventions
•Ensure two IVs in place for blood administration, fluids, antibiotics, electrolyte
replacement.
•Make sure patient’s blood type & screen is current
•Prep patient for endoscopy or colonoscopy
•Prep patient for interventional.
•Administer medications as needed
Ensure fall precautions are in place. [https://www.straightanursingstudent.com/gi-bleeds/]
[https://nursing.com/lesson/nursing-care-plan-for-gi-bleed/]

Medications: Include patient dose, classification, action in the body,

specific reason for use, and pertinent nursing interventions (include prn’s).

 pantoprazole infusion [PROTONIX] 8 mg/hr, is a proton pump inhibitor that

decreases the amount of acid produced in the stomach. Used for Peptic Ulcer
Disease.
nursing interventions
Assess for occult blood, assess liver enzymes, assess symptoms of heart burn.
Drug can cause hyperglycemia, abdominal pain, it can decrease absorption of
certain drugs, and may increase bleeding with warfarin.[
https://nursing.com/lesson/pantoprazole-protonix/]

 ondansetron HCl injection 4 mg IV(for doses 4 mg or less) Q6 HOURS PRN. It is

Antiemetic
Selective 5-HT3 Receptor Antagonist. Ondansetron is used to prevent nausea and
vomiting.
Nursing interventions: Patient should avoid over the counter cold medications
Assess lung sounds and maintain adequate fluid intake.
[https://nursing.com/blog/ondansetron-zofran/]
 Docusate Sodium [COLACE] DAILY PRN 100mg oral for constipation, it is a
Stool Softener. It Reduces surface tension of the oil-water interface of the stool
resulting in enhanced incorporation of water and fat allowing for stool softening.
 Nursing interventions:
Assess: cause of constipation
Evaluate therapeutic response (decreased constipation).

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 If cramping, rectal bleeding, nausea or vomiting occur, Drug should be
discontinued
Administer alone for better absorption.[ https://www.nursingtimes.net/clinical-
archive/medicine-management/docusate-sodium-18-12-2004/]

Nursing Diagnosis:

List three priority Nanda Approved nursing diagnoses in order of priority

Fluid Volume Deficit Related to hemorrhage as evidenced by easy fatigue, weakness,

coffee ground looking emesis, and abdominal pain.
[https://www.scribd.com/document/278944516/Nursing-Care-Plan-for-Acute-
Gastrointestinal-Hemorrhage]

Fatigue related to decreased hemoglobin and diminished oxygen-carrying capacity of the

blood as evidenced by exertional discomfort or dyspnea, inability to maintain usual level
of physical activity, increased rest requirements, and lack of energy.[
https://nurseslabs.com/4-anemia-nursing-care-plans/]

Chronic pain related to erosion of gastric mucosa, Recent nonsteroidal anti-inflammatory

drug (NSAID) or acetylsalicylic acid (ASA) use as evidenced by nausea and vomiting,
and weight loss.

Planning:

Client will be normovolemic as evidenced by systolic BP greater than or equal to 90 mm

Hg (or client’s baseline), absence of orthostasis, HR 60 to 100 beats/minute, urine output
greater than 30 ml/hr, and normal skin turgor.

Implementation:
 Assess for the signs of hematemesis or melena.
The patient may vomit bright red blood or coffee grounds emesis. Melena occurs when
there is bleeding in the upper GI tract.
 Monitor the client’s vital signs and observes BP and HR for signs of orthostatic
changes.
The patient may develop anemia. If bleeding is brisk, changes in vital signs and
physical symptoms of hypovolemia may develop rapidly. A hypotension and
tachycardia with changes in position is an early indicator of decreased circulatory
volume.
 Monitor the client’s fluid intake and urine output.

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 The kidney will reabsorb fluid into circulation to support hypovolemia. A
decrease in circulatory blood volume leads to decreased renal perfusion and
decreased urine output. [https://nurseslabs.com/peptic-ulcer-disease-nursing-care-
plans/5/]

Evaluation of your goal:

S: Abdominal pain, frequent dark tarry stools, feels dizzy and very weak.
O: patient HB in 10.9 gm and still needs to be elevated more
A: Pt looks pale, diaphoretic, mucous membranes are dry, Hgb 10.9.
P: Pt’s HGB will be greater or equal to 14 as evidence by lab values within 72 hours.
-Pt’s input will be equal to output as evidence by shift I & O reports within 72 hours.
-Pt’s mucous membranes will appear moist as evidence nursing documentation within 72
hours.
Reflection:

Discuss your learning in the acute care setting this semester:

What are your strengths?

Discuss an area of your learning or nursing care that needs improvement:

What are your goals for next semester?

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 CLIENT REPORT FORM
Grading criteria - Total points = 100

5 Points- Patient Admission Information: Accurate completion of the first section of

the client report form is essential to the provision of care.

5 Admission Story, Points-Past Medical and Past Surgical History: This is also essential
information to consider when you are providing care for the patient.

10 Points- BCF and Developmental Tasks: Refer to text for consideration of

developmental tasks and discuss this person's developmental stage, appropriate
developmental tasks and any indications of where they are in relation to these tasks –
consider their health status and the ability to meet the developmental requisites.

10 Points-Head to toe Assessment

15 Points-Self-Care Universal Requisites: Should include pertinent subjective and

objective data in all requisite areas, looking for increasing thoroughness and significance
(Should use purple assessment papers as a guide).

15 Points –Statement of the Problem: include definition of pathophysiology, diagnostic

tests, signs and symptoms, and usual care provided to the patient.

10 Points-Medications: Include generic and trade name, patient dose, classification,

action, specific reason for use with your client based on current diagnosis and medical
history, and pertinent nursing interventions. (Don’t forget to include prn medications)

10 Points-Nursing Diagnoses: Demonstrate analysis of the assessment data and devise

a Nanda Approved Self Care Deficit/Nursing Diagnosis. This should be related to
definition of problem statement, etiology must be amendable by nursing.

5 Points-Planning/Goal: Realistic for client, action oriented, and measurable.

5 Points-Implementation: Nursing interventions that are individualized to your client-

focused on the etiology of the problem.

5 Points – Evaluation: Using SOAP format

5 Points- Written Reflection – Learning, Strengths, Areas for improvement, and Goals
for the following week.