Beruflich Dokumente
Kultur Dokumente
COLLEGE OF NURSING
Student: Ashley Kavumkal
PP
Age: 68
Served/Veteran:
If yes: Ever deployed? Yes or No
1 CHIEF COMPLAINT: pain of 5 on the incisions on RLE (toe amputation, intermittent aching pain that
increases with movement and decreases with pain meds.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is a 68 year old Male who was admitted to the cardiac unit on 3/4/2015. The patient was admitted from PACU
after a Right femoral popliteal bypass surgery. The patient is hospitalized for claudication with ulceration. The patient also
had amputation of 2nd ,3rd and 4th toe on right leg on 3/11/2015.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Father
Mother
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
(angina,
MI, DVT
etc.)
Heart
Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Cause
of
Death
(if
applicable
)
Heart
attack
stroke
Arthritis
2
FAMILY
MEDICAL
HISTORY
2009
Anemia
January 2015
April 2014
2014
2014
2010,2012
Age 15
Environmental
Allergies
Operation or Illness
Chronic anemia, MI-2014, CHF-jan 2015, Hypertension, Hypercholesterolemia, valvular
dysfunction,
L BKA
Pacemaker/defibrillator
L cataract surgery
TAVR
Stents times 2 in lower extremeties
R knee surgery
Diabtes- insulin, glucose home monitoring FBS=75-120
depression
MRSA
Alcoholism
Date
Brother
Sister
65
relationship
relationship
relationship
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
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?
2014
Pneumococcal (pneumonia) (Date) Is within 5 years? yes
YES
NO
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
1 ALLERGIES
OR ADVERSE
REACTIONS
NAME of
Causative Agent
NKA
Medications
NKA
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) Claudification is refered to as the cramping pain that limits the movement of the legs or arms which
is a marker of peripheral vascular disease of the aortoiliac, femoral or popliteal arteries. In patients with
suggestive history, the blood pressure is measured in the affected limb and divided by the BP in the arm on the
same side of the body. This ratio is called the ankle-brachial index. Patient with significant peripheral vascular
disease have an ABI of less than 85%. If surgery is contemplated for the patient, angiography may be used to
define anatomical obstructions more precisely. Affected patients are encouraged to begin a program of regular
exercise, to try to maximize collateral blood flow of legs. Oral pentoxifylline improves the distance patients can
walk without pain. For severely limiting claudication, patients may require angioplasty or arterial bypass
surgery to open or bypass obstructed arteries.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: Aspirin
Concentration: 81mg/tab
Route: PO
Home
Hospital
or
Both
Route: PO
Frequency: Q AM
Home
Hospital
or
Both
Concentration 3.125mg/tab
Route: PO
Frequency: BID
Home
Hospital
or
Both
Indication: hypertension,HF, MI
Adverse/ Side effects: bradycardia, HF, pulmonary edema, anaphylaxis, angioedema, dizziness, fatigue, diarrhea, erectile dysfuntion
Nursing considerations/ Patient Teaching: abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, MI
Name; Docusate sodium
Route
Concentration: 100mg/cap
PO
Frequency BID
Home
Hospital
or
Both
Concentration: 75mg/tab
Route: PO
Home
Hospital
or
Both
Concentration; 40mg/0.4mL
Route: SQ
Frequency: Q24H
Home
Hospital
or
Both
Concentration: 10mg/tab
Route: PO
Home
Hospital
or
Both
Concentration: 300mg/cap
Route; PO
Frequency: QHS
Home
Hospital
or
Both
Concentration: 25mg/tab
Route: PO
Dosage Amount
Home
Hospital
or
Both
Name: Omaprazole
Concentration 20mg/cap
Route: PO
Home
Hospital
or
Both
Concentration: 20mg/tab
Route: PO
Home
Hospital
or
Both
Indication: hypercholesterolemia
Adverse/ Side effects: Rhabdomyolysis
Nursing considerations/ Patient Teaching: notify unexplained muscle pain, tendernss, weakness accompanied by fever or malaise
Name: spironolactone
Concentration: 25mg/tab
Route: PO
Home
Hospital
or
Both
Indication: hyperaldosteronism
Adverse/ Side effects: hyperkalemia, rash, arrhythmias
Nursing considerations/ Patient Teaching: report rash,muscle weakness, cramps, fatigue, severe nausea, vomiting, diarrhea
Name: oxycodone
Concentration 325mg/tab
Route: PO
Home
Hospital
or
Both
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Low sodium
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patients diet is adequate for his comorbidities. The
patients protein, vegetable and fiber intake is adequate.
Patient must incorporate more fruits and milk/yogurt as
they consist of less than 50% based on a daily value.
Patients sodium intake is less than 2000mg which is
appropriate.
Breakfast: oatmeal, boiled egg
Lunch: grilled/baked chicken with boiled vegetables, turkey
sandwich
Dinner: low sodium vegetable soup, baked fish, potato
Snacks: crackers, almonds,
Liquids (include alcohol): coffee
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? wife
How do you generally cope with stress? or What do you do when you are upset?
Watch TV, read books, talk to wife
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
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
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:
The patient is a very strong and positive thinking man. Even with his BKA he seems to deal with it in a positive way with
the help of his wife and kids who support him very well.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
Hospitalization seems to worry him little bit, but no major changes in developmental stage.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Life style and diet
What does your illness mean to you?
Interruption in daily activites
+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? _____________________________________________________________
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? 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? __________________________________
Yes
No
For how many years? Since
1961
(age
15
thru 66
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What?
How much? 2-4 times a month
Volume:
Frequency:
If applicable, when did the patient quit?
No
For how many years?
(age
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
x/day
Hematologic/Oncologic
Metabolic/Endocrine
2/day
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?
Other: diminished bases bilaterally
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:
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? no
Any other questions or comments that your patient would like you to know?no
11
10 PHYSICAL EXAMINATION:
General Survey:
Height 193cm
Pulse: 90
Respirations 20
SpO2 98%
Weight 180.3lb
BMI 21.94
Blood Pressure: brachial 132/87
Temperature: (route
Is the patient on Room Air or O2 NC 2L
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
was not WNL (within normal limits)
Central access device Type: peripheral 18
Location: right forearm
Date inserted: 3/4/2015
Fluids infusing?
no
yes - what? D5 @ 50
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:
RUL
Cl
LUL CL
RML
D
LLL D
RLL D
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
or
mLs
with assistance
[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
accucheck
Dates
3/13/15
Trend
150 high
Analysis
diabetes
creatinie
3/13/15
1.7-1.8 high
PT/INR
3/13/15
9.1/ 2.3
Hemoglobin
3/13/15
12 low
14
15 CARE PLAN
Patient Goals/Outcomes
Pain level<4
Safety-patient will remain free
from falls
Improved mobility
Not met
Not met
Not met
15
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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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