Assessment 1

Running head: NURSING ASSESSMENT

Nursing Assessment and Care plans
Yonchu Choe
New Mexico State University Nursing School
NURS 410 – Adult Health Nursing II
Instructor: Jane L. Smith, MSN, RN
Assessment 2

Demographic information
78 year old male, Hispanic, Married with one daughter , Catholic, Speaking English. He arrived to the
emergency department with reports of “crushing pain” to chest.

History, Review of systems, physical and mental assessment

He has history of diabetes mellitus and hypertension
Social history was positive tobacco 21 pack year smoking history and negative for IV drug use.Patient
has no known allergies to drugs, food, or latex.
Vital signs were taken at 0810 and the following results were temperature 98.5 oF, pulse 78 BPM,
respiration 14, and blood pressure 130/76mmHg. O2 saturation was 96% with patient receiving 4 L/min
via nasal cannula.
The lab values were found out of the normal ranges for this patient were:
Hemoglobin 13.1 g/dL, Hematocrit 39.0
BUN 36mg/dL, Creatinine 1.40 mg/dL and Red Blood cell count 4.44 mg/dL.
Assessment 3
The patient recieved a Coronary Artery Bypass surgery on 4//10 with the inscion site to the right groin
area with no complications.

The patient was awake, alert and oriented X 4. Glasgow coma scale (eye opening response –
spontaneous – four points; verbal response – converses oriented – five points; Motor response –
to verbal command – six points) was total 15 points. Pupils were equally round and reactive to light
and sizes of pupils were 2mm bilaterally. Heart rhythm was normal sinus rhythm at 80 beats per minute
with S1 and S2 sounds heard. There was no murmur. Neck veins were flat. Pulses were symmetrical in
right and left upper extremities and weak in both lower extremities. There was no edema in right and
left upper extremities. The right and left lower extremities had 2+ pitting edema. Capillary refill of all
extremities were less than 3 second with pink nail beds. The
patient was receiving O2 at a rate of 4 L/min via nasal cannula. O2 saturation was 96%. Breath sounds
of right and left upper quadrant were crackles and both lower quadrants were diminished.
Chest expansion was symmetric.
He denied nausea and vomiting.

Assessment 4
During the shift he did void of dark yellow urine, no bowel movement was reported. Patient reports
bowel movements every Abdomen was soft without
tenderness or mass. Bowel sounds in all four quadrants were heard. Flatus were present last bowel
movement 3days ago. Sensation in four extremities was normal without numbness
or tingling. Limb strength of all extremities was weak. Skin was warm and dry.
IV site was below antibrachial without tenderness, redness or infiltration, which was correctly
connected to the patient. Dialysis catheter
site was left subclavian without tenderness or redness.
The patient was on full liquid diet and she had cough when trying to eat. It was under
close observation of her intake since she had feeding difficulties related to swallowing problem
and chocking episode, and unsuccessful ko fed tube placement. After the fluoroscopy was
scheduled this afternoon, the diet was changed to NPO and explained to the patient the reason of
NPO.
Pychosocial assessment
The patient fluctuated between relaxed, stressed, and sleepy. She expressed getting lots of
sleep since admission of hospital. Since she had lived in assisted living home, activities of daily
living were assisted by staff and she used walker for movement due to weakness. She denied
using any illegal drugs or alcohol. The patient was awake, alert and oriented to time and space.
Based on ego integrity vs. despair developmental level (Berman, Erb, Kozier & Snyder (2008),
the patient belongs to integrity. The reasons are that she is 83years old and expressed being very
Assessment 5
satisfied with the life she is leading. In addition, she stated that though she was getting sick, it is
a normal part of getting old. She felt very proud of both of her sons and lovely daughter-in-laws
and her grandchildren.
Transcultural Assessment
What is the problem?
“My kidneys are affecting my blood.”
What do you think has caused the problem?
“I am getting older. I’m 83 now and my body is old.”
Why do you think it started when it did?
“I’m not sure, but I am old.”
What do you think the sickness does?
“My kidneys don’t work so I have bad blood.”
How does it work?
“Well that’s why I go to dialysis, to clean the blood.”
How severe is the sickness?
“I have to go to dialysis all the time, and I have problems from infection because of that
now too. This is all really bad.”
Will it have a short or long course?
“Long because my doctor said I have to go to dialysis forever.”
What kind of treatment do you think the client should receive?
“Dialysis and maybe some pills if I have other problems like my infection.”
What are the most important results you hope he or she receives from this treatment?
“That my blood will be healthy so I don’t feel so bad and tired.”
Assessment 6
What are the chief problems the sickness has caused?
“I am tired and sometimes I feel faint and dizzy.”
What do you fear most about the sickness?
“I am not happy about all this infection stuff. I am afraid I will get stuck in the hospital
now, and then I will lose more freedom.”
The patient denies using any alternative medicine including herbal teas or remedies. She
does not use chiropractors, massages, or any relaxation techniques, she relies in her physicians’
instructions and medications
Management of care
Emergency department team – performed initial care and admission, Physician –
performed the diagnosis’ test, monitor and fill orders for patient’s recovery, Diagnosis’
procedures and Lab tests team of nurses and technicians – support of the procedures and tests,
Telemetry unit RN – perform closely monitoring and following up the patient, assessing for
patient needs, and caring for the patient since the admission, Telemetry unit cardiac monitoring
technician – perform closed monitoring of cardiac condtions, record and report, Respiratory
technicians – monitor saturation and perform O2 delivery, Dietary – Provide meals according to
doctor’s orders, Janitorial – keep the room and toilet clean, CNAs – assess vital signs, help in
performing bed baths, and linens changes. The patient’s daughter-in-law and son who live in Las
Cruces care and assist the patient.
The patient has had hemodialysis since last May due to ESRF. Recently she had
thyroidectomy due to thyroid cancer.
Assessment 7
The medications used in the care of the patient: Bacitracin (Bacitracin ointment)
0.9g/TP/TID administered at 0945. It was prescribed for this patient to treatment of thrush in the
oval cavity by killing bacteria. It should be provided Oral hygiene prior to applying medication.
Calitriol (Rocaltrol) 0.25mcg/PO/D– Vitamins/ Fat-soluble vitamins administered at 0945. It is
for treatment of hypocalcemia due to ESRF. Serum calcium level should be monitored and
observed signs of hypocalcemia including parensthesia, muscle twitching, cardiac arrhythmias,
Trousseu’s and Chvostek’ssign. Signs of hypercalcemia should be assessed including nausea,
vomiting, weakness, headache, bone pain and metallic taste. Calcium Carb/Vit (Caltrate + D)
600mg/PO/D– Vitamins/ Fat-soluble vitamins administered at 0945. It is for treatment of
hypocalcemia with Vitamin D to assist absorption of calcium. Serum calcium level and serum
phosphate level should be monitored and observed signs of hypocalcemia and hypercalcemia.
Diltiazem CD (Cardizem CD) 600mg/PO/D – Antianginals, antiarrhythmics, antihypertensives/
Calcium channel blockers administered at 0945. It inhibits calcium entering into myocardial and
vascular smooth muscle cells to decrease blood pressure. Assess BP & HR prior to administering
medication. Linezolid (Zyvox) 600mg/PO/Q12H – Anti-infectives/ Oxazolidinones –
Bacterialcidal action against MRCA administered at 0945. The specimens for culture should be
obtained prior to initiating therapy. Assess for infection including vital signs, urine, sputum,
stool, and WBC. ECG should be monitored for bradycardia or prolonged hypotension. I&O and
daily weight should be monitored.
For the safety and health promotion, until MRSA is fully treated, health care staff and
visitors should wear gloves and gown every time entering the room and the patient should have
compliance of antibiotic medication even though the signs of infections are decreased. It was not
set up the discharge planning for the patient whether she would return to the assisted living home
Assessment 8
or long term care at this moment. Not only in hospital but also after discharge, she needs more
careful body hygiene to prevent infection and sepsis on dialysis catheter. Since the patient has
weakness and fatigue related to anemia secondary to ESRF, she needs appropriate diet and fluid.