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COLLEGE OF NURSING
Student: ASHLEY KAVUMKAL
Agency: SMH
1 PATIENT INFORMATION
Patient Initials:
Gender:
AK
M
Age: 54
Level of Education:
Served/Veteran:
Code Status:
Living Arrangements:
Advanced Directives:
If no, do they want to fill them out?
Surgery Date:
Procedure:
Type of Insurance:
1 CHIEF COMPLAINT:
None: CAME FOR ROUTINE DIALYSIS for kidney failure
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
(angina,
MI, DVT
etc.)
Heart
Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Environmental
Allergies
Cause
of
Death
(if
applicable
)
Alcoholism
2
FAMILY
MEDICAL
HISTORY
Operation or Illness
Date
Father
Mother
Brother
Sister
relationship
relationship
relationship
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
University of South Florida College of Nursing Revision August 2013
NO
1 ALLERGIES
OR ADVERSE
REACTIONS
NAME of
Causative Agent
Medications
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)
5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name
Concentration (mg/ml)
Route
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
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 pt follows at home?
Consider co-morbidities and cultural considerations):
24 HR average home diet:
This diet meets the daily protein requirement. Howver it
meets only 50 percent of the daily grain and vegetable
requirements. More dairy products should also be added to
the diet. This diet also exceeds the daily limit of empty
calories because of the peanut butter crackers and cookies
which should be consumed less.
Breakfast: 1 egg and 1 white bread toast
Lunch: chicken salad
Dinner: steak- red meat, okra, corn
Snacks: 3 peanut butter crackers, cookies 2
Liquids (include alcohol): 1 cup cranberry juice, coffee (3
times a week)
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 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?
By watching TV, reading books, being in happy places
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
None
Have you ever been talked down to?___no____________ Have you ever been hit punched or slapped? __by second exwife____________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
__by second ex-wife________________________________________ If yes, have you sought help for this? ______left
the relationship________________
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: In middle age , people discover a sense of contributing to the world usually through family and work
(generativity) or they may feel a lack of purpose (stagnation). (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 was very active and had a positive attitude towards life. Also, he seems very satisfied with his family life.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
God is testing me.
+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? _____________yes______________When sexually active, what measures do you
take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?
_____________________none_____________
How long have you been with your current partner?____________14
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
Yes
No
For how many years?
(age
thru
Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much?
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)
thru
thru
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
The patient worked as an electrician where he had to work near locations with high voltage. Also, another risk was while
spraying a chemical called round up which was harmful.
10 REVIEW OF SYSTEMS
General Constitution
Gastrointestinal
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: every night, sometimes
morning
Other:
HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
twice/day
Routine dentist visits
6months/year
Vision screening
Other:
Immunologic
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:
Other:
Genitourinary
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: O+
Other:
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections
Hematologic/Oncologic
x/day
RENAL FAILURE
Metabolic/Endocrine
Diabetes
every
Type: 2 borderline
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? 2013
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures at a younger age
Weakness
Pain
Gout
Childhood Diseases
Measles
Mumps
Polio
Arrhythmias
Last EKG screening, when?
Other: aortic leak dissrhythmia
Osteomyelitis
Arthritis
Other:
Scarlet Fever
Chicken Pox
Other:
Integumentary:
HEENT:
Pulmonary:
Cardiovascular:
GI:
GU:
Women/Men Only:
Musculoskeletal:
Immunologic:
Hematologic/Oncologic:
Metabolic/Endocrine:
Central Nervous System:
Mental Illness:
Childhood Diseases:
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient remembers an eye damage by a staple in the right eye for which a surgery was done in 1980s.
Any other questions or comments that your patient would like you to know? no
10
11
Height: 6. 1
Pulse: 70-150 irregular
Respirations: 16
Weight:224lb
BMI: 29.6
Blood 142/45
Pressure:
(include location)
SpO2
Is the patient on Room Air or O2:
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
apathetic
bizarre
agitated
anxious
tearful
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
talkative
withdrawn
quiet
boisterous
aggressive
hostile
flat
loud
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:
12
Pulmonary/Thorax:
Cardiovascular:
No lifts, heaves, or thrills PMI felt at:
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
No JVD
GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color: 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 7 / 26 / 14 )
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 (leave blank if not done)
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:
[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:
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
WBC
Dates
7.2
(06/26/2014)
Normal (4.5-11)
RBC 8.1
Current 2.48
6/26/2014
6/27/2014
6/27/2014
6/27/2014
Trend
Upon admit, the patients
WBC were in the normal
range
Analysis
No infection present
15 CARE PLAN
Nursing Diagnosis: (Which nursing diagnosis you are doing your care plan on goes here.)
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
2 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 patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
15 CARE PLAN
Patient Goals/Outcomes
Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
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 patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
15 CARE PLAN
Patient Goals/Outcomes
Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
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 patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
15 CARE PLAN
Patient Goals/Outcomes
Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
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 patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care