Artifacts/Course work

Medical Surgical Nursing I: Case Study (Asthma)

 

                                                                                                                                       
UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

			Student: Morghan Walrich
Patient Assessment Tool   .			Assignment Date: 1/8/13
			Agency: BMC- USF
Patient Initials: H, S	Age:  61 years	Admission Date:  1/7/13
Gender:  Male	Marital Status:  Married	Primary Medical Diagnosis with ICD-10 code: Chronic Renal Failure
Primary Language:  English
Level of Education:  Some college		Other Medical Diagnoses:  Renal failure
Occupation (if retired, what from?):  Former Japanese  TV producer
Number/ages children/siblings:  3 children (ages: 24, 28, and 30)
		Code Status:  Full code
Living Arrangements:  Lives alone in a condo in St. Petersburg		Advanced Directives: Yes
		Surgery Date:  N/A          Procedure:
Culture/ Ethnicity /Nationality:  Asian
Religion:  Christian		Type of Insurance:  Medicare/Blue Cross Blue Shield

± 2 CC:
“ I fell outside my house getting the mail. I slipped because it was raining, not because I felt dizzy or lightheaded. I came
down on my elbow and it was badly bruised”
± 3 HPI: (OLD CART)
The patient is a 61 year old Asian male who came to the ER on 1/7/13 via a family friend. He came home from dialysis
and slipped and fell while getting the mail. The patient claims that he felt no dialysis side effects at the time of the fall
but that it was raining and the sidewalk was slippery. According to the patient he came down on his left elbow and did not
have any other injuries. Upon arrival the patient had a hematoma and laceration on the left elbow and complained of dull
pain (7 out of 10). The patient said that his arm hurt more when hanging, and that elevating it seemed to help. An ice pack
also seemed to alleviate some of the pain. He was given PO ibuprofen, and by the time the patient went to the floor, he
reported his pain as a 5 out of 10 with still a dull ache in the elbow. Movement was somewhat restricted.
The patient is currently in renal failure and has been receiving dialysis 3 days a week (M,W,F) for the past year.
He has an active left forearm AV fistula that was of concern. The fistula was not in fact damaged. Before being admitted
to the fourth floor, the patient had a XRAY done on his left arm, which ruled out fracture. An EKG was performed in the
ER. Nothing abnormal was found other than the patient was in A-fib before going to the telemetry floor.
± 2 PMH/PSH  Hospitalizations for any medical illness or operation
Date	Operation or Illness	Management/Treatment
5/12/11	CABG (coronary artery bypass graft)
5/12/11	Mitral valve prosthesis
	Renal failure syndrome	Dialysis (clinic in St. Pete 3 x per week)
1996	Stroke- affected left side	Physical therapy after the CVA

± 2 FMH

Age (in years)

Cause of Death (if applicable)

Alcoholism

Environmental Allergies

Anemia

Arthritis

Asthma

Bleeds Easily

Cancer

Diabetes

Glaucoma

Gout

Heart Trouble (angina, MI, DVT etc.)

Hypertension

Kidney Problems

Mental Health Problems

Seizures

Stomach Ulcers

Stroke

Tumor

Father

87

Natural

Mother

64

Hypertension, Renal disease

Brother

Sister

relationship

relationship

relationship

Comments:

± 1 immunization History
	Yes	No
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria
Adult Tetanus
Influenza (flu)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or occupational purposes? Please List

± 1 Allergies or Adverse Reactions	NAME of Causative Agent	Type of Reaction (describe explicitly)
Medications	NKA
Other (food, tape, dye, etc.)	Shrimp	Pruritis (generalized itching sensation)

± 5 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis, prognosis or treatment)

Diagnosis: Chronic Renal Failure - Progressive loss of renal function over a period of months or years. CRF develops as a complication of systemic diseases (hypertension in this case). The disease decreases GFR and tubular functions. Evidence is available from urinalysis, and reviewing BUN, plasma, and creatinine levels, as well as CT or plain XRAYS. Etiology: CRF may be caused by congenital and connective tissue disorders (PKD), infections, hypertension, diabetes mellitus, renal calculi, and drug overdose. *Cellular level* - There is often actual loss of nephron mass (kidneys decrease in size) with CRF. Adaptive changes occur in the nephron, affecting solute and water regulation caused by advanced renal failure. Hyperfiltration causes further nephron injury and eventually results in uremia and end stage renal failure (ESRF). Genetic/Cultural Considerations: Both men and women are at risk for CRF. Geriatric patients are more susceptible to some of the causes of acute renal failure, and might experience CRF more frequently. CRF is more common in the elderly.CRF affects all races and ethnicities, and the prevalence in populations depends on predisposing conditions such as diabetes and hypertension. There is a significantly higher prevalence in African American and Native American decent rather than in Asian Americans and whites.

Physical Assessment of a patient with CRF: The disease affects all body systems. Usually patients will have significant cardiovascular problems accompanying the renal issues. Hypertension is commonly noted in the patient and may be its cause. Over time, as renal perfusion is continuously decreased, the kidneys are unable to function normally (kidney damage). These patients often have rapid, irregular heart rates (as in this patient who came in with atrial fibrillation). Respiratory symptoms include hyperventilation, Kussmaul breathing, dyspnea, orthopnea, and pulmonary congestion. Rhales might indicate fluid overload. Pulmonary edema may present with frothy sputum combined with shortness of breath. Electrolyte imbalances may result in signs of hypocalcemia, muscle cramps, and twitching. Symptoms due to increased creatinine, urea, potassium etc. do not usually occur until renal function declines to less than 25% of normal.  Treatment: The main goal of therapy is to maintain the patient’s life until renal function has been recovered (or transplant has been performed). Management includes dietary control, including protein and sodium restriction. ACE inhibitors are used to provide protection for the kidneys. Dialysis and supportive therapy are often used as treatment options.   Prognosis: Patients can survive for years on dialysis, which filters and cleans the blood, getting rid of waste. Often, patients will be on dialysis until they receive a kidney transplant. References: Huether, McCance, Brahers, Rote (2008). The Renal and Urologic Systems. Understanding Pathophysiology (4) 802-807. Nursing Central: Unbound Medicine. 2012. Diseases and Disorders: Chronic Renal Failure.Retrieved by: http://nursing.unboundmedicine.com/nursingcentral/ub/view/Diseases-and-Disorders/73707/all/renal_failure_chronic.

± 5 Medications: (Include both prescription and OTC)

Name:  Aspirin	Concentration:  325 mg= 1 tab			Dosage Amount:  325 mg
Route:  PO			Frequency:   Daily
Pharmaceutical class:   Salicylates		Home       Hospital       or       Both
Indication:   inflammatory disorders, mild to moderate pain, fever, prevention of MI/ischemia
Side effects/Nursing considerations:  GI bleeding, tinnitus, anemia, allergic reactions, hemolysis
Name :  Crestor (extended release)	Concentration: 5mg= 1 tab			Dosage Amount:  5 mg
Route:  PO			Frequency:   Daily
Pharmaceutical class:  hmg coa reductase inhibitors		Home       Hospital       or       Both
Indication:  management of high cholesterol (hyperlipidemia), slows atherosclerosis
Side effects/Nursing Considerations:  CNS weakness, abdominal pain, constipation, hepatitis, rash, rhabdomyolysis
Name:   Metoprolol (calcium acetate)	Concentration: 25 mg= 1 tab			Dosage Amount:   25 mg
Route:  PO			Frequency:  Daily
Pharmaceutical class:   Beta blocker		Home       Hospital       or       Both
Indication:  hypertension, angina, prevention of MI, management of heart failure
Sid effects/Nursing considerations:  fatigue, weakness, depression, blurred vision, stuffy nose, bronchospasm, wheeing, bradycardia, HF, pulmonary edema

	Name:  Norvasc (amlodipine)	Concentration: 5mg= 1 tab				Dosage Amount:   2.5 mg= .5 tab
	Route:  PO				Frequency:   Daily
	Pharmaceutical class:   Calcium channel  blocker		Home       Hospital       or       Both
	Indication:   Management of hypertension, angina, and vasospastic angina
	Side effects/Nursing considerations:   headache, dizziness, fatigue, peripheral edema, angina, flushing, hypotension, palpitations, inguinal hyperplasia
	Name	Concentration				Dosage Amount
	Route				Frequency
	Pharmaceutical class		Home       Hospital       or       Both
	Indication
	Name	Concentration				Dosage Amount
	Route				Frequency
	Pharmaceutical class		Home       Hospital       or       Both
	Indication
	Name	Concentration				Dosage Amount
	Route				Frequency
	Pharmaceutical class		Home       Hospital       or       Both
	Indication
	Name	Concentration				Dosage Amount
	Route				Frequency
	Pharmaceutical class		Home       Hospital       or       Both
	Indication
	Name	Concentration				Dosage Amount
	Route				Frequency
	Pharmaceutical class		Home       Hospital       or       Both
	Indication
	Name	Concentration				Dosage Amount
	Route				Frequency
	Pharmaceutical class		Home       Hospital       or       Both
	Indication
	Name	Concentration				Dosage Amount
	Route				Frequency
	Pharmaceutical class		Home       Hospital       or       Both
	Indication
± 4 NUTRITION:  (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis)
Diet ordered in hospital?     Regular diet				Analysis of home diet (Compare to food pyramid and
				Consider co-morbidities and cultural considerations):
Diet pt follows at home?				This patient does follows a strict diet, which is necessary
Breakfast: 2 fried eggs, 1 piece of wheat toast, 1 cup of				for his condition. His renal failure/end stage kidney disease
black coffee (8 oz)				requires a diet low in sodium and protein, which he seems
				to understand based on his home diet.
Lunch: bowl of soup (varies), mixed greens salad with tomato, cucumber, bleu cheese etc., hot tea (8 oz)
				According to the Food Pyramid, this patient does consume
Dinner: 1 cup of brown rice, 6 oz pork, steamed broccoli or other vegetable, 1 glass (8 oz) of iced green tea				regular servings of vegetables, meat, and some dairy. His
*Main meal sometimes consists of: salmon, swordfish, chicken, etc.				eating habits are quite healthy and meals consist of foods
				rich in essential vitamins/nutrients. He does have a variety of meals he enjoys cooking, and takes pride in doing so.
Snacks: 1 serving of yogurt with ¼ cup granola, rice cake with ½ cup peanut butter				some of his favorite Japanese dishes are usually high in carbohydrates (rice and egg noodles), yet he balances these
				with plenty of green vegetables.
				(Jensen, 152)
±2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? The patient is very independent with the exception of help from a neighbor and long
time friend. He is able to drive and does own a car, but says he occasionally gets a ride to and from Tampa general where
he has been undergoing tests for a possible kidney transplant.
How do you generally cope with stress? or What do you do when you are upset?
The patient reports that he does not usually get anxious or stressed, but that he enjoys going for walks every day on St.
Pete beach. He used to do martial arts, including Tai Kwando and Judo, but now does some occasional Tai Chi to help
with relaxation.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The patent states that his greatest struggle isn’t his health, but that he worries about his wife, who is currently living in
New York receiving treatment for her own medical problems. He feels very alone at times, but realizes that right now they
cannot be together. He has traveled to see her, but now that he is dependent on dialysis, it makes it harder for him to leave.
+2 DOMESTIC VIOLENCE ASSESSMENT 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 felt unsafe in a close relationship? _____No_____ 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
± 5 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
Give the textbook definition of both parts of Erickson’s developmental stage for your patient’s age group:
Generavity vs. Stagnation:
Generavity~ refers to "making your mark" on the world (through caring for others, creating things and accomplishing things that make the world a better place)
Stagnation~ refers to the failure to find a way to contribute to society and earlier generations. These individuals may feel disconnected or uninvolved with their community and with society as a whole.
(Jensen, 182)
Describe the characteristics that the patient exhibits that led you to your determination:
I noticed while interviewing the patient that he was exceptionally interested in the medical field and my life as a student
nurse. He told me multiple times how wonderful it is that I’m in this field and studying to do something that will
help others. The patient was also interested in some of what I do for fun, saying that I should make sure to take time for
myself outside my busy schedule to enjoy life.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The patient is dependent on weekly dialysis (MWF), which he says limits his ability to travel. This seems to bother him
most, because it keeps him from seeing his wife as much as he’d like. He also makes regular trips to Tampa General each
month to determine his status for a kidney transplant.
+3 Cultural Assessment:
“What do you think is the causes of your illness?”  The patient states that his renal failure is mainly due to severe
hypertension, which put a lot of stress on  his kidneys. He realizes that his mother suffered from the same illness, and he
has tried to stay fairly healthy with diet and exercise.
What does your illness mean to you?
The patient voiced that his kidney disease is a product of heredity and hypertension.
+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? _____Women__________________ 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____________When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?  __________________________________ How long have you been with  your current partner?___________34 years 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

+3 Smoking, Chemical use, Occupational/Environmental Exposures:
1.  Does the patient currently, or has he/she ever smoked or used chewing tobacco?          Yes          No
If so, what?	How much?			For how many years?
				(age          thru                   )
				If applicable, when did the patient quit?
Does anyone in the patient’s household smoke tobacco?  If so, what, and how much?  No		Has the patient ever tried to quit?
2.  Does the patient drink alcohol or has he/she ever drank alcohol?          Yes          No
What?	How much?			For how many years?
				(age          thru                   )
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?
	How much?		For how many years?
			(age          thru                   )
Is the patient currently using these drugs?    Yes     No	If not, when did he/she quit?
4.  Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No

± 10 Review of Systems

General Constitution	Gastrointestinal	Immunologic
Recent weight loss or gain	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:	Diverticulitis	Life threatening allergic reaction
Bathing routine:	Appendicitis	Enlarged lymph nodes
Other:	Abdominal Abscess	Other:
	Last colonoscopy?
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:
Post-nasal drip	Normal frequency of urination:     3  x/day	Other:
Oral/pharyngeal infection	Bladder or kidney infections
Dental problems		Metabolic/Endocrine
Routine brushing of teeth        2   x/day		Diabetes        Type:
Routine dentist visits             2   x/year		Hypothyroid /Hyperthyroid
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?	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
Chest pain / Angina	Date of last prostate exam?	Anxiety
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
Arrhythmias	Osteomyelitis	Scarlet Fever
Last EKG screening, when? 1/7/13	Arthritis	Chicken Pox
Other:	Other:	Other:

                                  Review of Systems Narrative

General Constitution

Pt’s perception of 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

±10 PHYSICAL EXAMINATION:
Orientation and level of Consciousness:  A &O x 3
General Survey: Patient is a 61 year old Asian male who appears stated age. He is oriented to person, place, and date. His responses are appropriate and movement is not limited.	Height:  68 inches (5’8)		Weight:  156         BMI: 24		Pain: (include rating & location) 1 out of 10 (dull pain in the left elbow- hematoma)
	Pulse:  70		Blood Pressure: 121/80 (include location)
Temperature: (route taken?) 97.3 (oral)	Respirations:  18
	SpO2:   98%		Is the patient on Room Air or O2: Yes
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
Large hematoma on left elbow with 2 inch laceration. The
cut is shallow and is not producing blood or discharge. Area
is black and blue and is swollen. Left forearm AV fistula
Peripheral IV site     Type:   Primary                        Location:     right  wrist                        Date inserted:        1/7/2013
no redness, edema, or discharge
Fluids infusing?    no      yes - what?....was discontinued due to possible discharge
Peripheral IV site     Type:                                    Location:                                 Date inserted:
no redness, edema, or discharge
Fluids infusing?    no      yes - what?
Central access device    Type:                               Location:                                  Date inserted:
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
Functional vision: right eye -            left eye -          without corrective lenses				right eye -               left eye -             with corrective lenses
Functional vision both eyes together:  with corrective lenses or  NA
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 ear-   2         inches & left ear-    2      inches
Weber test, heard equally both ears             Rinne test, air          time(s) longer than bone
Nose without lesions or discharge    Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Teeth are white and intact. Tongue is pink and rough. Palate and gums are pink and smooth
Comments:

Pulmonary/Thorax:  Respirations regular and unlabored      Transverse to AP ratio 2:1   Chest expansion symmetric
		Lungs clear to auscultation in all fields without adventitious sounds
	CL – Clear	Percussion resonant throughout all lung fields, dull towards posterior bases
	WH – Wheezes	Tactile fremitus bilaterally equal without overt vibration
	CR - Crackles	Sputum production:     thick     thin           Amount:    scant    small     moderate    large
	RH – Rhonchi	Color:  white      pale yellow     yellow   dark yellow   green     gray     light tan   brown    red
	D – Diminished
	S – Stridor
	Ab - Absent

Cardiovascular:    No lifts, heaves, or thrills     PMI felt at: 5th ICS midclavicular line

Heart sounds:   S1 S2     Regular        Irregular   A-fib     No murmurs, clicks, or adventitious heart sounds          No JVD

Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze)

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:    +1        [rating scale:  0-none,  +1 (1-2mm),  +2 (3-4mm),   +3 (5-6mm),    +4(7-8mm) ]

Location of edema:       Left arm                         pitting        non-pitting

Extremities warm with capillary refill less than 3 seconds

GI/GU:  Bowel sounds active x 4 quadrants; no bruits auscultated         No organomegaly         Liver span          cm

Percussion dull over liver and spleen and tympanic over stomach and intestine         Abdomen non-tender to palpation

Urine output:   Clear     Cloudy          Color:      amber/yellow                  Previous 24 hour output:              mLs  N/A

Foley Catheter    Urinal or Bedpan     Bathroom Privileges    without assistance     or      with assistance

CVA punch without rebound tenderness

Last BM: (date   01   /   06      / 2013    )         Formed       Semi-formed        Unformed        Soft        Hard        Liquid      Watery

Color:  Light brown        Medium Brown         Dark Brown           Yellow        Green          White       Coffee Ground          Maroon          Bright Red

Hemoccult positive / negative

Genitalia:  Clean, moist, without discharge, lesions or odor      Not assessed, patient alert, oriented, denies problems

Other – Describe:

	Musculoskeletal: o Full ROM intact in all extremities without crepitus
	Strength bilaterally equal at  _4+__ in UE   &   __4+__ in LE     [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]
	vertebral column without kyphosis or scoliosis
	Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias
	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:  +2        Biceps:  +2     Brachioradial:  +2        Patellar:  +2      Achilles:  +2     Ankle clonus:  positive    negative   Babinski:   positive    negative
	±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):
	WBC: 6,000
	RBC: 5
	Hgb: 14.6
	Hct: 45
	BUN: 35
	Creatinine: 5
	CO2: 36
	pH: 7.4
	Sodium:
	Calcium: 8.1 (somewhat low…normal is 8.5)
	HCO3: 25
	Albumin: 4.2
	Labs (CBC, Metabolic Panel etc.) done on 1/7/2013
	*BUN and creatinine are elevated due to the kidneys’ inability to effectively excrete waste
	*Diagnostic tests: EKG performed on 1/7/13 upon admission to ER. Patient appeared to be in A-fib. XRAY was
	done to rule out fracture. There appeared to be no fracture, and the AV fistula still has thrill and bruit present.
	+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:
	The patient currently undergoes dialysis every Monday, Wednesday, and Friday at a clinic in St. Petersburg. He
	also visits Tampa General Hospital once a month to test kidney function (for transplant purposes).
± 2 Medical Diagnoses (as listed on the chart)		± 8 Nursing Diagnoses (actual and potential -  listed in order of priority)
1. Left elbow hematoma		1. Risk for ineffective perfusion to AV fistula related to
		Injury to affected arm.
2. Chronic renal failure		2. Risk for fall related to possible side effects of dialysis
		treatment (filtering of the blood) such a fatigue, dizziness,
		etc.
3. Hypertension		3.Risk for electrolyte imbalance related to renal
		dysfunction
4.		4. Risk for infection related to trauma/breakdown of skin as
		a primary defense (page 491)
		(Ackley and Ladwig. 2011)
5.		5.

± 15 for Care Plan    Nursing Diagnosis: Risk for fall related to possible side effects of dialysis treatment (filtering of the blood) such as fatigue, dizziness, etc.

Patient Goals/Outcomes	Nursing Interventions to Achieve Goal	Rationale for Interventions Provide References	Evaluation of Interventions on Day care is Provided
1.  Patient will remain free of falls	1. Evaluate the client’s medications	1. Polypharmacy or taking more	In this patient’s case
while in the hospital and after	or therapy to determine whether	than 4 meds has been associated	polypharmacy is not the direct
discharge	they increase the risk of falling.	with increased falls.	cause of his fall. He is only on 2
			regular home meds.
	2. Screen patient for balance and	It’s important to determine the	I asked questions in the interview
	mobility skills (as well as	patient’s functional abilities and	regarding the patient’s ability
	orthostatic changes)	then plan for ways to improve	to do some sort of daily exercise.
		problem areas
	3. Assess home environment for	Even if the patient doesn’t usually	I did ask the patient about his home
	threats to safety including clutter,	suffer from impaired mobility, it is	environment and any hazards that
	rugs, and other potential hazards	important to have the patient	may cause him to fall, such as
		voice certain hazards that can cause	stairs, cords, etc.
		future falls.
		(Ackley, 2011 pages 357-358)
± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching) Consider the following needs: □SS Consult □Dietary Consult □PT/ OT □Pastoral Care □Durable Medical Needs □F/U appts □Med Instruction/Prescription  §  □ are any of the patient’s medications available at a discount pharmacy? □Yes   □ No   □Rehab/ HH □Palliative Care

± 15 for Care Plan    Nursing Diagnosis:  Risk for infection related to trauma/breakdown of skin as a primary defense

Patient Goals/Outcomes	Nursing Interventions to Achieve Goal	Rationale for Interventions Provide References	Evaluation of Interventions on Day care is Provided
1. Patient will remain free from	1. Observe and report signs of	1. These signs of infection will be	I myself performed a thorough
symptoms of infection from time	infection such as redness, warmth,	seen first, especially fever and	assessment on the patient and
of admission until discharge.	discharge, and increased temp.	elevated WBC. We want to avoid	he reported not having any of the
		hospital acquired infection.	following symptoms.
	2. Note and report laboratory	2. The WBC and neutrophil count	Labs were drawn early morning
	values (WBC, protein, albumin,	are good diagnostic tests for adult	and did not show that his WBCs
	and cultures).	infection.	were elevated.
	3. Use appropriate hand-hygeine	3. Infection prevention precautions	When examining the patient, all
	and standard precautions when	are required to prevent hospital	medical staff wore gloves and most
	examining the patient’s arm	associated infection.	used an alcohol based foam in/out
			of the patient’s room.
		(Ackley &Ladwig. 2011 page 493)
± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching) Consider the following needs: □SS Consult □Dietary Consult □PT/ OT □Pastoral Care □Durable Medical Needs □F/U appts □Med Instruction/Prescription  §  □ are any of the patient’s medications available at a discount pharmacy? □Yes   □ No   □Rehab/ HH □Palliative Care

± 15 for Care Plan

Nursing Diagnosis:  

Patient Goals/Outcomes	Nursing Interventions to Achieve Goal	Rationale for Interventions Provide References	Evaluation of Interventions on Day care is Provided
± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching) Consider the following needs: □SS Consult □Dietary Consult □PT/ OT □Pastoral Care □Durable Medical Needs □F/U appts □Med Instruction/Prescription  §  □ are any of the patient’s medications available at a discount pharmacy? □Yes   □ No   □Rehab/ HH □Palliative Care

± 15 for Care Plan

Nursing Diagnosis:  

Patient Goals/Outcomes	Nursing Interventions to Achieve Goal	Rationale for Interventions Provide References	Evaluation of Interventions on Day care is Provided
± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching) Consider the following needs: □SS Consult □Dietary Consult □PT/ OT □Pastoral Care □Durable Medical Needs □F/U appts □Med Instruction/Prescription  §  □ are any of the patient’s medications available at a discount pharmacy? □Yes   □ No   □Rehab/ HH □Palliative Care

                                                                                                                                                                            
Preceptorship: QI Project (Infant Thermoregulation)