Beruflich Dokumente
Kultur Dokumente
COLLEGE OF NURSING
1 CHIEF COMPLAINT:
Patient complains of abdominal pain. Patient states, “it’s getting in the way of the little time I have left.”
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is a 63-year-old, married male who presented to the emergency department with abdominal pain. His husband,
who also served as his transport to LRMC, accompanied him. The patient has had flare ups of this pain that started 4
months prior to this admission. The pain is centered on the abdomen and manifests itself in short spurts. The patient
describes the pain as alternating between a stabbing and aching feeling. Aggravating factors include ingesting cold
sustenance such as iced tea and milk. The patient is able to find some relief from ingesting warm sustenance, such as
warm tea or chicken broth. Aside from pain medication, the patient uses ginger ale to treat his symptoms. He rates his
pain at a 5 out of 10. Health care team concluded that pain was due to metastasized cancer in the liver.
2
Stomach Ulcers
Environmental
Mental Health
Age (in years)
FAMILY
Heart Trouble
Bleeds Easily
Hypertension
Cause
Alcoholism
MEDICAL Glaucoma
Problems
Problems
Allergies
of
Diabetes
Arthritis
Seizures
Anemia
Asthma
Kidney
HISTORY
Cancer
Tumor
Stroke
Death Gout
(if
applicable)
Father 83
Mother 79 Cancer
Sister 60
Sister 57
Sister 46
relationship
relationship
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)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
University of South Florida College of Nursing – Revision September 2014 2
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
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
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)
Lung cancer is described as an uncontrollable growth of cells within the lungs. It is considered to be the leading cause of
cancer-related death in both men and women worldwide. Lung cancer primarily occurs in patients between the ages of 45
and 75. The greatest risk of lung cancer lies in people use tobacco products such as cigarettes and cigars. Lung cancer can
also develop in nonsmokers via secondhand smoke. Tumors can form in any place within the lung, but symptoms don’t
usually appear until they have reached an advanced stage or traveled to another part of the body. Symptoms of the disease
include incessant coughing or wheezing, shortness of breath, chest pain, unexplained weight loss, and an increased
susceptibility to lower respiratory infections. A diagnosis of lung cancer is often discovered while examining for other
conditions. Procedures for detecting cancerous lung cells include x-rays, CAT scans, PET scans, and MRI’s. Blood tests
can also be performed to search for proteins and other substances known to be associated with lung cancer. Unfortunately,
diagnosis of most cases of lung cancer comes after the disease has already spread, or metastasized from its original
location. Lung cancer metastasizes to areas such as the bone, liver, kidney, and brain. For these reasons, poorer prognoses
accompany lung cancer. Similar to other cancers, primary treatments include surgery, chemotherapy, and radiation.
General health, stage of the disease, and the type of cancer are determining factors in the choice of treatment (Huether, S.
E. & McCance, 2012).
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: diltiazem (Cardizem) Concentration: 180mg/tab Dosage Amount: 180mg
Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Route Frequency
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?
Michael (patient’s husband).
How do you generally cope with stress? or What do you do when you are upset?
“I go in my room and shut the door. If no one bothers me for a while I’ll cool down.”
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 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? ______________________
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:
“Stagnation occurs when development ceases: A stagnant middle adult cannot guide the next generation or contribute to
society” (Treas & Wilkinson, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
In the patient’s current state, he feels that he has not accomplished all that he originally set out to do. He feels that he has
been unsuccessful in providing for his family and preparing a better future for them. The disease has caused him to
experience a sort of midlife crisis, where he feels that there is so much he hasn’t gotten to do, and still wants to do. The
patient feels as though he’s provided a poor transition for both himself and his family in the wake of his prognosis of 12-
14 months of life remaining. His mind is riddled with thoughts of regret concerning many of his life choices; primarily
that of his decision to continue to smoke. The patient’s biggest concern is leaving behind his husband to death with the
aftermath of his poor decisions. His husband has been through every last bit of the last 41 years with him, and the patient
feels as though he’s failed him.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The patient’s current hospitalization further intensifies his feelings of guilt and regret. He has tried to comes to terms with
the reality of his condition, but that has proven to be extremely difficult.
+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
”Smoking cigarettes.”
+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”
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? _____condoms_____________________________
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
Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? If yes, what did they use to try to quit? Nicotine patches
N/A
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? 1or 2 glasses For how many years? 47
Vodka/cranberry
Volume: 8-16 oz (age 16 thru present)
Margaritas
Frequency: 1x/month
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?
Matijuana How much? 1 joint/day For how many years? 47
(age 16 thru present)
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?
Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: 30 Diverticulitis Life threatening allergic reaction
Bathing routine: 1x/day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy? November 2015
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: O
Normal frequency of urination:
Post-nasal drip Other:
4x/day
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth
Diabetes Type:
1x/day
Routine dentist visits
Hypothyroid /Hyperthyroid
1x/year
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? 10/19/16 menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Date of last prostate exam? March
Chest pain / Angina Anxiety
2015
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
University of South Florida College of Nursing – Revision September 2014 10
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 10/19/16 Arthritis Chicken Pox
Other: Other: Other:
General Constitution
Recent weight loss or gain
How many lbs? 40lbs
Time frame? December 2015-present
Intentional? No
How do you view your overall health? “Pretty terrible.”
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
General Survey: Patient Height: 5’5” Weight: 47.1 kg BMI: 17.1 Pain: (include rating and
is a 63-year-old male Pulse: 92 Blood Pressure: (include location) location)
who shows no signs of Respirations: 24 182/92 Abdomen, 5
distress.
Temperature: (route SpO2: 94 Is the patient on Room Air or O2
taken?) 36.7 (oral)
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
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
*patient has mediport on upper right chest, no swelling/redness/pain
Skin turgor elastic
*skin with diminished turgor
No rashes, lesions, or deformities
*bruise on right elbow
Nails without clubbing Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
*patient has very little hair, 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: mediport Location: upper right chest Date inserted:
10/19/16
Fluids infusing? no yes - what?
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 / 4mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 24 inches & left ear- 24 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: teeth yellowing, bottom front teeth missing
Comments:
Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3
PT: 3
No temporal or carotid bruits Edema: [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: pitting non-pitting
Extremities warm with capillary refill less than 3 seconds
GU Urine output: Clear Cloudy Color: dark yellow Previous 24 hour output: N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative
3. Ineffective self-health management related to cigarette smoking as evidenced by patient statement of, “If I’m only going
to live 12-14 months, there’s no point in quitting.”
4. Hopelessness related to current prognosis as evidenced by patient’s statement of, “I’ll never be able to provide for my
family the way I really wanted to.”
5. Risk for situational self-esteem related to disease process and unavoidable lifestyle changes.
Patient will demonstrate Recommend responsible use of “Use and misuse of antibiotics Patient demonstrates proper
appropriate care of infection-prone antibiotics; use antibiotics results in several problems, the techniques when caring for the
site for future care/maintenance. sparingly. most significant of which are infection-prone site.
increases in resistance (Ackley,
2014, p. 482).”
Assess and treat wounds in the “Home-based wound care, when
home. combined with comprehensive
nursing assessment, can be
effective while reducing costs.
Success can be achieved through
the implementation of multiple
clinical, educational, and
operational strategies
simultaneously (Ackley, 2014, p.
483).”
Patient will verbalize Teach the client how to safely “Safe use of walking aids and Patient was able to repeat,
understanding of methods to ambulate at home, including using assistive devices is crucial to safety verbalize, and stress the importance
prevent injury. safety measures such as hand rails and prevention of future falls of methods to prevent injury at
in bathroom, and need to avoid (Ackley, 2014, p. 337).” home and when in the outside
carrying things or performing other world.
tasks while walking.
Teach the client the importance of “Exercise can prevent falls in older
maintaining a regular exercise people. Greater relative effects are
program. If the client is afraid of seen in programs that include
falling while walking outside, exercises that challenge balance
suggest he or she walk the length and use a higher dose of exercise
of a local mall. than just walking programs
(Ackley, 2014, p.337).”
Ackley, B. J. (2014). Nursing diagnosis handbook (10th ed.), St. Louis, MO: Elsevier Mosby
Huether, S. E. & McCance, K. L. (2012). Understanding pathophysiology (5th ed.), St. Louis, MO:
Elsevier Mosby.
Kee, J. L., Hayes, E. R., McCuistion, L. E. (2015). Pharmacology: a patient-centered nursing process
Treas, L. S., Wilkinson, J. M. (2014). Basic nursing concepts, skills & reasoning. Philadelphia, PA: F.A Davis
Company.