UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Patricia Korovich

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 10/27/15

Agency: Bayfront Medical Center

Patient Initials: D. S.

Age: 18

Admission Date: 10/22/15

Gender:

Marital Status: Single

Primary Medical Diagnosis:

Guillain-Barre syndrome
Admitting Dx: Generalized weakness, respiratory
insufficiency

Level of Education: Currently a senior in High School

Other Medical Diagnoses: cerebral pseudotumor,

sinus tachycardia

Primary Language: English

Occupation (if retired, what from?): Student

Number/ages children/siblings: No children
Three siblings: two brothers (23,21), one sister1 (3)
Served/Veteran: No
Living Arrangements: Single story home with parents and
siblings, no pets

Culture/ Ethnicity /Nationality: Dominican/Puerto Rican

Religion: Christian

Code Status: Full Code

Advanced Directives:
If no, do they want to fill them out? No/Declined
Surgery Date:
Procedure:
No surgical procedure was scheduled for this
admission
Type of Insurance: Cigna

1 CHIEF COMPLAINT:
I got treatment from a different hospital. There they couldnt figure out what was wrong with me. I got numbness in
my feet and it started traveling up my legs. Then I had numbness in my hands that started traveling up my arms. I decided
to go to the hospital when I started and couldnt stop throwing up.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The patient is an 18 year old female with history of HTN and morbid obesity who was transferred to Bayfront Medical
Center from St. Cloud Regional Medical center on 10/22/15. In July of 2015, the patient underwent gastric bypass surgery
at St. Cloud and was released several days after, as planned. A week or two following the procedure she began to
experience profound nausea and vomiting upon attempting to progress her diet as directed by her physician; she sought
medical attention and was admitted to St. Cloud. During that admission a lumbar puncture was performed and the patient
was diagnosed with Pseudotumor Cerebri, treated, and discharged. After several days the patient began to experience
Parathesia and weakness in her feet, bilaterally, and became unable to walk. She was admitted back to St. Cloud on
9/25/15. Several CT scans were done of the head, lumbar and cervical spine, which were negative. During this admission,
she began to experience bilateral hand weakness and parathesia. It was decided that the patient may have Guillain-Barre
syndrome, and was transferred to Bayfront Medical Center for further neurological assessment and care on 10/22/15.

University of South Florida College of Nursing Revision August 2013

The patient claims the symptoms that the lower limb weakness she is experiencing began three weeks before her
admission to St. Cloud on 9/25/15. She is now experiencing the weakness and parathesias in both the upper and lower
limbs, below the knees and elbows, which is constant. She describes the sensation as numbness and tingling with sharp
pains during movement. She also has occasional positional aching pain in the hips when left in one position for a
prolonged period of time; she is unable to reposition herself, however.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date

Operation or Illness

7/2015
9/2015

Gastric bypass
Lumbar puncture

Father

43

Mother

42

Brother

23

Brother

21

Sister

Tumor

Stroke

Stomach Ulcers

Seizures

Hypertension
Kidney
Problems
Mental Health
Problems

(angina, MI, DVT etc.)

Heart Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

HTN, Morbid Obesity

Comments: Include date of onset

Patient denies any significant family medical history

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)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

University of South Florida College of Nursing Revision August 2013

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS
Medications
Other (food, tape,
latex, dye, etc.)

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKDA
NKA

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)
Guillain-Barre Syndrome (GBS) is an autoimmune disorder which causes an acute inflammatory polyneuropathy
characterized by varied degrees of motor weakness or paralysis. GBS, a demyelinating disease, is typically caused as a
result of a viral infection, usually gastrointestinal or respiratory, but can also occur following other disease processes
and/or vaccination. GBS usually presents as ascending and symmetrical weakness, areflexia and flaccid paralysis in the
limbs, first starting with the lower limbs, followed by the upper extremities. Other muscles that may be effected are those
in the trunk, bulbar and respiratory areas, which can lead to respiratory failure; GBS can also affect facial nerve causing
facial droop, dysphagia, pupillary and visual irregularities (Osborn, Wraa, Watson, & Holleran, 2014).
The cause of GBS is unknown and there is no racial predisposition for the disease; however, there is a peak incidence
in young adulthood and is more likely to affect men than women. Prognosis for patients with GBS is generally favorable
with most making a full recovery. There is also a link between GBS and Campylobacter jejuni infections following
bariatric surgeries (Aluka, Turner, & Fullum, 2009).
Changes in sensation can include parethesias, beginning in the fingers and toes, which can progress up to, but stop
at the wrists and ankles. Aching and/or throbbing pain can typically be experienced in the thigh, back and/or shoulder
areas. Other changes in condition can include orthostatic hypotension, urinary retention, cardiac arrhythmia, exertional
dyspnea, shortness of breath, and/or dysphagia.
Criteria for diagnosing GBS includes progressive weakness of two or more limbs to due areflexia, neuropathy, with a
disease process less than four weeks, with other causes of symptoms ruled out. Recent viral infections, normal cell count
and elevated protein in cerebral spinal fluid can also be indicators. Evaluation of thyroid panels, rheumatology profiles,
vitamin B1 and 12, glycosylated hemoglobin, heavy metal tests, and serum autoantibody tests for C. jejuni bacteria
(which is the most common causing infective agent of GBS) can be useful in eliminative diagnosing, as well.
Electromyography (EMG) tests can show demyelination abnormalities consistent with GBS. (Aluka, Turner, & Fullum,
2009).
GBS treatment involves symptom management and can help lessen the severity of the disease and hasten recovery.
Close respiratory and cardiac monitoring are indicated, as well as frequent neurological assessments. Supportive
interventions may also be helpful, including physical and occupational therapy. Deep vein thrombosis prophylaxis
for probable prolonged immobility and medications for pain management may be necessary, including NSAIDs, opioids,
and/or Gabapentin. Additional care may include plasmaphoresis and IV immunoglobulin (IVIG) (Aluka, Turner, &
Fullum, 2009).

University of South Florida College of Nursing Revision August 2013

 5 MEDICATIONS:
Name Acetazolamide (Diamox)

Dosage Amount 250 MG

Concentration

Route PO
Pharmaceutical class Carbonic anhydrase inhibitor
Indication Edema

Frequency BID
Home

Hospital

or

Both

Side effects Stevens-Johnson syndrome, metabolic acidosis, hepatic necrosis

Nursing considerations Do not crush, monitor CBCs and platelets during therapy, may cause drowsiness, may cause paresthesia
Name Digoxin

Dosage Amount 0.125 MG

Concentration

Route PO
Pharmaceutical class Cardiac glycoside
Indication Atrial fibrilation

Frequency Daily
Home

Hospital

or

Both

Side effects N/V, dizziness, headache, cardiac dysrhythmias, ischemia, sinus bradycardia, thrombocytopenia
Nursing considerations Monitor serum levels, renal function and electrolytes. Be aware of signs of Digoxin toxicity: N/V, visual
changes, cardiac arrhythmias, confusion, weakness
Patient Education Take after morning meal
Name Enoxaparin (Lovenox)

Concentration 100MG/mL

Route SQ

Dosage Amount 50 MG/0.5 mL

Frequency Q24h

Pharmaceutical class Anticoagulant, Low molecular

weight heparin
Indication DVT prophylaxis

Home

Hospital

or

Both

Side effects Nausea, diarrhea, anemia, bleeding, thrombocytopenia, hepatotoxicity

Nursing considerations Rotate injection sites, administer in abdomen 1-2 inches away from umbilicus, may cause hematomas at
injection sites. Do not expel air bubble in syringe, do not aspirate, do not rub injection site after administration. Monitor CBC and
platelets and assess for signs of bleeding.
Name Immune globulin IV

Concentration

Dosage Amount 30 GM

Route IVPB
Frequency Daily
Pharmaceutical class Immune serum
Home
Hospital
or
Both
Indication Guillain-Barre syndrome treatment
Side effects PE, ARF, Hypokalemia, allergic reaction, arthralgia, N/V, increased heart rate
Nursing considerations Monitor trough levels, assess neurological/muscular function for signs of improvement, monitor renal function,
and asses for volume overload (crackles).
Name Regular insulin

Concentration

Dosage Amount (Sliding scale)

Route SQ
Frequency ACHS
Pharmaceutical class Antidiabetic
Home
Hospital
or
Both
Indication Long-term use of steroid medications/Critical care protocol
Side effects Hypoglycemia (confusion, agitation, tremors, headache, flushing, hunger, weakness, lethargy, fatigue, tachycardia,
palpations, etc.) rebound hyperglycemia
Nursing considerations Test glucose levels, administer 30 minutes before meal

University of South Florida College of Nursing Revision August 2013

Name Metoprolol (Lopressor)

Dosage Amount 50 MG

Concentration

Route PO

Frequency BID

Pharmaceutical class Beta-adrenergic blocker

Home
Hospital
or
Both*
Indication Hypertension
Side effects Bradycardia, hypotension, orthostatic hypotension, N/V, diarrhea, headache, dyspnea, fatigue, weakness, dizziness,
impotence, hypoglycemia
Nursing considerations Take with or immediately following meal with a full glass of water, assess blood pressure and heart rate before
administration, monitor heart rate and rhythm
Name Pantoprazole (Protonix)

Dosage Amount 40 MG

Concentration

Route PO
Pharmaceutical class Proton pump inhibitor

Frequency Daily

Home
Hospital
Indication Critical care protocol prevention of gastric ulcers
Side effects N/V, diarrhea, dizziness, fatigue, thirst, elevated ALT & AST

or

Both

Nursing considerations Monitor ALT, AST and magnesium levels

Name Alprazolam (Xanax)

Dosage Amount 0.25 MG

Concentration

Route PO
Frequency PRN
Pharmaceutical class Benzodiazepine
Home
Hospital
or
Both
Indication Anxiety
Side effects Constipation, light-headedness and incoordination, lethargy, liver failure, drug withdrawal seizure, depression
Nursing considerations Patients who abruptly discontinue use need to be monitored for withdrawal symptoms. A patient on Xanax
may be a fall risk, and it is important to monitor blood counts, and liver function tests.
Name Acetaminophen (Tylenol)

Dosage Amount 650 MG

Concentration

Route PO
Frequency PRN
Pharmaceutical class Analgesic
Home
Hospital
or
Both
Indication For pain, as needed
Side effects Liver failure, N/V, constipation, rash, hemolytic anemia, oliguria, hemorrhage,
Nursing considerations Reassess pain scale within hour, mind the amount given daily to lessen risk of liver failure

Name Ondansetron (Zofran)

Concentration 2MG/mL

Route IV Push
Pharmaceutical class Antiemetic
Indication Nausea/Vomiting
Side effects diarrhea, constipation, atrial fibrilation

Dosage Amount 4MG/2mL

Frequency PRN
Home

Hospital

or

Both

Nursing considerations Reassess levels of nausea after administration, monitor EKG, especially if patient has electrolyte imbalance

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Consistent carbs, 1500k cal (w/ ensure
high protein, no potato/starch).

Analysis of home diet (Compare to My Plate and Consider co-morbidities

and cultural considerations):
Note: the My Plate website does not have recommendations for post-bariatric
surgery patients, so percentages in the graphics are not entirely accurate.

Diet pt follows at home? The

patient had been following a
mostly liquid diet at home, but
we had difficulty discussing her
home diet since she has spend
most of her time post-gastric
bypass hospitalized.
24 HR average home diet:
Breakfast: 1/2 bottle of ensure
Lunch: One sugar free
chocolate pudding cup, 1/2
ensure bottle
Dinner: One sugar free
chocolate pudding cup, 1/2
ensure bottle
Snacks: Nothing
Liquids (include alcohol):
Only water with meds

Due to the patients history of bariatric surgery, she was recommended a 1500k cal puree diet
with consistent carbohydrates with high protein ensure, sugar-free puddings and no potato or
starch during her stay at Bayfront. Dietarys recommendation is that she attempt 75-80 grams of
protein/day, keep her carbohydrate consumption low and attempt to eat pureed vegetables and
meats. At this point in her recovery, however, the patient should be in the final phase of the
post-bariatric surgery diet and be consuming regular, albeit easily digestible foods.
Dietary recommendations for post-gastric bypass patients vary depending on the source, and
the length of time since the procedure took place. However, the consistencies include eating
small, frequent meals that are nutrient dense, since the amount of food to be eaten in one sitting
should not exceed cup, total. Foods should be eaten slowly and chewed thoroughly, and the
patient should rest after meals to avoid dumping syndrome (Osborn, Wraa, Watson, & Holleran,
2014). Also, liquids should not be consumed during meals in order to ensure maximum
nutrition intake. A cup of water sipped slowly between each meal is suggested.
According to the University of California San Francisco, the recommended meal plan for
a patient two to six months post-surgery (and this patient is three months post-op) is 900-1,000
calories, with 65-75 grams of protein per day. Also, three servings each of milk/dairy (such as
non-fat milk or cottage cheese), meat (like fish), starch (mashed potatoes), and fruits (melon)
and vegetables (peas, spinach, etc.), each serving being cup for solid foods and cup for
liquids are suggested. It is also very important to take supplements including calcium, folic
acid, vitamin b12 and a regular multivitamin to complement the diet.
The patient has a fairly poor diet considering that she is only consuming two sugar-free
chocolate pudding cups, and about 1 bottles of ensure a day. She is not drinking fluids
beyond what is required during medication administration, as well. Her caloric intake is just
over 500 calories per day (and that is being generous), and based on the Ensure website, she is
getting about 24g of protein from their shakes. Dietary recommends that she attempt more solid
foods; however, she is hesitant since what brought her to the hospital in the first place was
nausea and vomiting after attempting pureed foods, and she is physically unable to feed herself.
One intervention that may benefit the patient is to encourage her to attempt new foods
while she is in the hospital. Reinforcing that we have orders for Zofran in the event that she
feels ill after eating may help her feel more confident in progressing her intake. This is of great
importance since her immobility paired with her inadequate dietary intake can leave her at risk
for skin breakdown and muscular impairment.

(USDA Supertracker)

University of South Florida College of Nursing Revision August 2013

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? The patient began to cry when asked this and she explained that her mom is her main
support. Since she is several hours away from the hospital, her mother has been unable to visit her consistently, but the
patient speaks with her mother several times a day. The mother is seeking to find housing with the Ronald McDonald
house or another similar organization.
How do you generally cope with stress? or What do you do when you are upset? I talk with my mom.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Ive been diagnosed with depression. While Ive been in the hospital, Ive been pretty sad and anxious. I do go to
therapy, though, and Im doing the exercises I was taught to help me while Im here.
+2 DOMESTIC VIOLENCE ASSESSMENT
Have you ever felt unsafe in a close relationship? Patient denies.
Have you ever been talked down to? Denies Have you ever been hit punched or slapped? Denies.
Have you been emotionally or physically harmed in other ways by a person in a close relationship with
you? Denies. If yes, have you sought help for this? N/A
Are you currently in a safe relationship? No, Im single.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Intimacy vs. Isolation

Autonomy vs.
Generativity vs.

Doubt & Shame

Initiative vs. Guilt
Industry vs.
Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

Identity vs. role confusion is the stage in life that coincides with puberty, typically ages 11-21. During this stage,
adolescents develop their sense of self as well as plans for the future, and test out behaviors and ideas in social situations.
If the individual has constructive role models, they will develop a healthy sense of self; if they are unable to do so, they
will not find their place in the world, may develop unhealthy relationships, and or show poor occupational performance.
The patient confided that she has experimented with alcohol and sex, indicating that she is testing new behaviors, but
also indicated that she has no interest in continuing to do so. She states that her mother and her older siblings are her
role models, and she is developing plans for the future. She expressed that the gastric bypass surgery is giving her another
chance at the life that she wants which includes becoming a nurse, getting married and starting a family.
(Treas & Wilkinson, 2014, p.164)
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The patient was previously hindered by her morbid obesity in pursuing the long-term goals she seeks to achieve; Now
after having had the bariatric surgery, she feels that these goals are attainable. The development of Guillain-Barre
syndrome poses another challenge for her, but she is confident and determined to make a full recovery and continue
progressing.

What do you think is the cause of your illness?

Nobody knows what causes Guillain-Barre syndrome.
What does your illness mean to you?
For me its a challenge to overcome. I want to get better so I can start college I want to be a nurse.

University of South Florida College of Nursing Revision August 2013

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Have you ever been sexually active? Yes, with her ex-boyfriend. Do you prefer women, men or both genders? Men.
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? Yes.
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? Nothing. The patient was educated on practices to ensure safe sex in the future.
How long have you been with your current partner? N/A
Have any medical or surgical conditions changed your ability to have sexual activity? My weight kind of made it
difficult before. Now with whats going on, I wouldnt be able to. I cant even walk.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended
pregnancy? No.

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
God and my religion are very important to me. Especially now. Its been helping me through this.
Do your religious beliefs influence your current condition?
Yes, I believe it does. I pray a lot.

University of South Florida College of Nursing Revision August 2013

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much? (specify daily amount)

Yes
No*
For how many years?
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients 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? (give specific volume)
I tried it once but I didnt like it.

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No.

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain: 40 lb. weight
loss since gastric bypass surgery in July

Gastrointestinal
Nausea, vomiting, or diarrhea

Immunologic
Chills with severe shaking

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: Pseudotumor*
Use of sunscreen
SPF: No
Diverticulitis
Life threatening allergic reaction
Bathing routine: shower 1x/day
Appendicitis
Enlarged lymph nodes
Other:
Abdominal Abscess
Other:
Last colonoscopy? Im not sure about a colonoscopy, but I had an endoscopy when I was at St. Cloud.
Other:
Patient states she is regular, BM 1x/2days, occasionally constipated
HEENT
Hematologic/Oncologic
Difficulty seeing: Uses glasses when
Anemia (blood work indicates anemia)
Genitourinary
reading/studying
Cataracts or Glaucoma
nocturia
Bleeds easily
Difficulty hearing
dysuria
Bruises easily
Ear infections
hematuria
Cancer
Sinus pain or infections: occasional
polyuria
Blood Transfusions
sinus headache
Nose bleeds
kidney stones
Blood type if known: A+
Post-nasal drip
Normal frequency of urination: 3x/day
Other:
Oral/pharyngeal infection
Bladder or kidney infections
Dental problems
Metabolic/Endocrine
Routine brushing of teeth
1-2x/day
Diabetes
Type:
Routine dentist visits: 1x/year
Hypothyroid /Hyperthyroid
Vision screening: 1x/year
Intolerance to hot or cold
Other:
Osteoporosis
Other:

Integumentary

Pulmonary
Difficulty Breathing SOB, heavy
chest
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? Before my surgery.
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias: Tachycardia

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? Has never been.
menstrual cycle
regular *
irregular
menarche
age? 13
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness: Generalized
Pain: hips, knees, wrists
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision August 2013

10

Last EKG screening, when? This

morning.
Other:

Arthritis
Other:

Chicken Pox: when 8 years old

Other:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone? N/A.
Any other questions or comments that your patient would like you to know? N/A.

University of South Florida College of Nursing Revision August 2013

11

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: Patient is
alert and oriented, obese,
breathing rapidly, but not in
any obvious state of distress.
Temperature: PO 98.4*

Height: 51
Pulse: 123*

Weight: 215 BMI: 40.6

Blood
Pressure:
125/94 (right upper arm)

Pain: (include rating & location)

Patient denies having pain at
present

Respirations: 33*
SpO2: 100%
Is the patient on Room Air or O2: RA
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 speech is soft.
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
Skin is warm, dry, and intact (except for hands and feet)
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds (somewhat delayed)
Hair evenly distributed, clean, without vermin
Notes: Patients hands and feet are pale and cold to touch,
and feet are somewhat flaccid. She has six healed
abdominal scars from surgery, also has ecchymosis on arms
from venipuncture, in various stages of healing. PICC RUE.
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type: PICC
Location:
Right upper arm
Date inserted: 10/18/15
Fluids infusing?
no
yes - what?

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 L4mm/R4mm
Peripheral vision intact
EOM intact through 6 cardinal fields w/o nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 12 inches & left ear- 12 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: appropriate for age, has had several cavities filled.
Comments: lips are somewhat dry from lack of fluid intake, has occasional sinus headache.

University of South Florida College of Nursing Revision August 2013

12

Pulmonary/Thorax:
breath at present time.

Respirations regular and unlabored: respirations are 33, but the patient claims no shortness of
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
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished

S Stridor
Ab - Absent

Respirations are regular, and unlabored but rapid (33/min); may be due to GBS
disease process, metabolic acidosis and/or weakness related to Guillain-Barre
syndrome.
Lung sounds are clear, but somewhat diminished in lower lobes, possibly due to
excess skin tissue, or fluid accumulation due to inactivity. Patient has been
instructed on how to use and the need for incentive spirometry, although she is
having difficulty holding the tool.

Cardiovascular:
No lifts, heaves, or thrills
Heart sounds: S1 S2 Regular*
Irregular

PMI felt at: Mid-clavicular line, 4th intercostal space

No murmurs, clicks, or adventitious heart sounds

No JVD

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

Sinus tachycardia, 111bpm

Calf pain bilaterally negative
Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 2+ Carotid: 2+ Brachial: 2+ Radial: 2+ Femoral: 2+ Popliteal: 2+
DP: 1+ PT: 1+
No temporal or carotid bruits
Edema:
N/A
[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
Feet were cold bilaterally, but patient was barefoot at time of assessment. Capillary refill was slightly >3 seconds.
Pedal pulses were not easily felt.
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: ~750 ml
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 10 / 25 / 15 )
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
Not assessed, patient alert, oriented, denies problems
Other Describe: The patient has bathroom privileges with assistance, but typically requests bedpan as she has difficulty

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ambulating. Bowel sounds are present in all four quadrants but are hypoactive.
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at 3 RUE 3 LUE 2 RLE & 1 LLE
[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 (assessed in bed patient unable to stand)
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias
Although not at present, patient often has pain in all extremities. During exam, peripheries were cool, pale
and pedal pulses were diminished. The patient has significant parathesias and paralysis r/t Guillain-Barre syndrome. Patient
has wrist splints placed d/t wrist drop and rotates one boot for foot drop (ordered by occupational therapy).
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
Rombergs Negative (unable to test)
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

DTR not assessed: reflex hammer unavailable

Romberg and gait assessment unable to be assessed d/t difficulty with ambulation and fall risk.

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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):
The primary means for diagnosing GBS include CSF protein levels via lumbar puncture, electromyography and nerve
conduction studies; Other tests may be done to rule out other disease processes including CT and MRI scans. Blood
counts and other lab values typically run in the normal ranges. (If, for example, a patient presents to the ER with
peripheral neuropathy but has a low level of vitamin B12, anemia may be suspected instead of GBS). One exception is
the arterial blood gases (ABG), which should be monitored for metabolic acidosis related to respiratory insufficiencies
related with the disease. This patient, however, has the added issue of being a post-operative bariatric patient who is
nutritionally compromised. I assume, then, that when her lab values vary from the normal range, it is related to this
circumstance, rather than the GBS.
Many of the diagnostic tests done for diagnosing GBS were done at St. Cloud when the patient was initially admitted
there, including the lumbar puncture and the CT scans of the head and spine. I did not have access to the results of these
tests other than reading that they were all negative. It would have been useful to see the level of protein in the CSF,
though.
Today (10/27/15) a nerve conduction tests was done and found absent motor and sensory responses in the legs, other than
a very small tibial motor response. Upper extremity sensory responses are absent but motor responses are normal.
Electromyography (EMG) demonstrates profound ongoing denervation in the distal upper extremity with normal
proximal extremity. Motor unit morphology is normal with reduced recruitment in the upper extremities but finger and
wrist extensors do not show any volitional activity. The findings, according to the report, are consistent with severe and
subacute generalized polyneuropathy with active denervation.

Lab
Potassium
Normal:
3.5-5
ABG

Dates

Trend

Analysis

10/27/15: L 3
10/26/15: L 3
10/25/15: L 3.1
10/24/15: 3.6
10/23/15: L 3.4

The patients K+ levels are

low. The level has
consistently but slowly
decreased since admission.

The hypokalemia this patient is experiencing is

likely due to her vomiting as well as her lack of
dietary intake.

pH (N 7.35-7.45)
10/25/15 (1500): 7.4
10/25/15 (0300): 7.39

Although the patients pH

was in the normal range
both times the ABG was
drawn, the base excess,
HCO3 and PaCO2 levels
decreased.

Since the worry with a patient with GBS is

metabolic acidosis due to ineffective breathing
patterns, ABGs should be monitored. This
patient has a normal pH, but the bicarb, carbon
dioxide and base excess values all indicate
metabolic acidosis with respiratory
compensation. The test was not repeated after
this instance, however.

HCO3 (N 24-28)
10/25/15 (1500): L 20.7
10/25/15 (0300): 24.2
PaCO2 (N 34-45)
10/25/15 (1500): L 33.8
10/25/15 (0300): 40
Base Excess:
10/25/15 (1500): -3.1*
10/25/15 (0300): -0.1
Liver
Function
Tests

ALT (N 10-35)
10/26/15: H 188
10/25/15: H 232
10/23/15: H 210
AST (N 8-38)
10/26/15: H 74
10/25/15: H 107
10/23/15: H 137

The liver function tests

do not show a clear
pattern other than they
are labile and most seem
to be improving.

The results of these tests indicate some level of

liver dysfunction. ALT increases when there is
liver damage and the AST increases when there
is cellular injury. Elevated bilirubin indicates
obstructive jaundice, possibly in liver
dysfunction. An elevated PT indicates liver
malfunction since clotting factors are made
there; when the liver cant produce them,
coagulation time increases. Similarly, decreased

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Total Bilirubin (N 0.1-1.2)

10/26/15: 0.9
10/25/15: H 1.1
10/23/15: H 1.3

albumin can occur in liver damage since albumin

is synthesized by the liver.
This liver dysfunction can be due to the
hepatotoxic medications she is on, possibly fatty
liver disease (?), or some other cause.

PT (N 10-13)
10/23/15: H 13.9
Serum Albumin (N 3.5-5)
10/26/15: L 2.6
10/25/15: L 3
10/23/15: L 2.5
CPK Total

10/26/15: C 593
10/25/15: C 1,428

The levels are decreasing

but are still critically
high.

Blood
Counts

Hemoglobin (N 12-15)
10/25/15: L 11.2
10/25/15: 12.1
10/24/15: 12
10/23/15: L 11.4

The H&H levels for this

patient are fluctuating but
consistently low. The
RDW levels have been
consistently high.

CPK increases when there is muscle damage

present. CK-MB levels should be drawn to
determine the cause. It is possible that the CPK
levels are increased in this patient due to the
inflammatory process of GBS, dietary
insufficiencies, and/or muscle breakdown from
inactivity.
These levels indicate moderate macrocytic
anemia. This can be due to vitamin or protein
insufficiencies.

Hematocrit (N 36-44%)
10/26/15: L 34.2
10/25/15: 37.1
10/24/15: 37.7
10/23/15: L 34.4
RDW (N 11.5-14.5%)
10/26/15: H 19.3
10/25/15: H 19.2
10/24/15: H 19.6
10/23/15: H 18.8
Since admission the patients sodium, chloride, glucose, BUN, creatinine, calcium, magnesium, total protein, bilirubin,
and B12 levels have been normal.

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+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
The current treatment plan includes vitals every 2 hours, accu checks ACHS (due to
critical care protocol), and telemetry monitoring for tachycardia. She has ambulatory privileges with
assistance, but is a high fall risk and has not had much success with ambulation with physical therapy. The
patient also has a bi-pap machine at bedside which she has been non-compliant in using.
For medical treatment, the patients symptoms are being addressed with Zofran, Tylenol and Xanax, and the
Guillain-Barre syndrome is being treated with IVIG (treatment 5/5 is being administered today). Her tachycardia
And HTN are being addressed with Lopressor, Digoxin and Diamox. A nerve conduction study was also
performed earlier today to test nerve responses in the peripheries.
There has been extensive inclusion of physical therapy, occupational therapy, dietary, neurology and case
management in the patients care.
Dietary: Recommended a 1500k calorie, consistent carbohydrate, puree diet with high protein ensure and
Sugar-free puddings. Dietary listed her nutritional needs as 75-80 grams of protein/day, 1500-1600 kcals/day,
and a decreased need for carbohydrates (patient states her doctor recommends up to 7g sugar/day).
(At this point, the patient should have progressed to a later stage in the bariatric diet and eating more pureed food,
if not solid foods.) However, when she attempted to do so several weeks ago, she had profound nausea and
vomiting, which was partly the reason she was hospitalized at St. Cloud.) She has since maintained a full liquid
diet with pudding- albeit with insufficient calories and protein. Dietarys recommendation is that she increase her
protein, attempt to eat pureed vegetables and meat, increase her fluid intake between meals and notes that she
needs total assistance to eat due to extremity weakness.
Physical Therapy: Noted impaired proprioception and light touch sensitivity, as well as gross motor function
bilaterally in upper and lower extremities (on 10/23/15). Bilateral lower extremities were noted as hypotonic and
flaccid with strengths ranging from 1-2. In the upper extremities notes strength 2-3, unsteady motor function and
wrist drop (requested occupational therapy). Patient has ability to roll and control upper trunk, but less able to
control lower trunk. The plan of care involves balance training, therapeutic exercise, neuromuscular reeducation,
5 times a week with a recommendation that she transfer to rehab upon discharge.
(Occupational Therapy: placed and educated patient on use of wrist splints (2hrs on, 2 hrs off), and will provide
PRN occupational exercises and training).
Case Management: Case management was consulted to see about charitable housing for the family since they
live several hours from Bayfront and have a three year old to care for. All Childrens hospital was contacted
due to their involvement with Ronald McDonald House, but the family was denied since the patient is not
admitted to All Childrens. A call was also placed to SW (?) for housing, but stated Bayfront no longer
provides charitable housing. As an alternative, the family was given contact information for local hotels and
offered a bedside cot.

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 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Ineffective breathing pattern related to hyperventilation, respiratory muscle weakness, decreased activity, neuromuscular
impairment, and immobilization.
2. Decreased cardiac output related to altered heart rate and rhythm as evidenced by heart rate of 123 beats per minute.
3. Altered tissue perfusion related to hypovolemia associated with decreased fluid intake and fluid loss related to
hyperventilation, and peripheral pooling of blood associated with decreased activity.
4. Risk for infection related to lowered natural resistance associated with malnutrition, break in integrity of skin associated
With PICC placement, and stasis of secretions in lungs due to decreased mobility.
5. Risk for impaired tissue integrity related to accumulation of waste products and decreased oxygen and nutrient supply to
the skin and subcutaneous tissue associated with reduced blood flow resulting from prolonged pressure on the tissues, and
increased fragility of the skin associated with inadequate nutritional status.
6. Risk for trauma: falls relate to generalized weakness, lower limb paralysis and use of hypotensive medications.
7. Imbalanced nutrition, less than body requirements related to poor eating habits status post-bariatric surgery.

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 15 CARE PLAN
Nursing Diagnosis: Ineffective breathing pattern related to hyperventilation,
respiratory muscle weakness, decreased activity, neuromuscular impairment, and immobilization.
Patient Goals/Outcomes

Nursing Interventions to Achieve

Goal

Rationale for Interventions

Provide References

Evaluation of Goal on Day care

is Provided

The client will maintain an effective

breathing pattern during shift as
evidenced by:
1. Normal rate and depth of
respiration
2. Absence of dyspnea

1. Nurse will assess for signs and

symptoms of an ineffective breathing
pattern q hour (e.g. shallow
respirations, dyspnea, tachypnea, use
of accessory muscles when breathing,
limited chest excursion)

1, 2. When the respiratory rate exceeds

30 breaths per minute, along with
other physiological measures, a study
demonstrated that a significant
physiological alteration existed.

The patients respiration rate

decreased from 45 breaths per minute
to 33. She was tachypnic and took
shallow breaths, but did not complain
of shortness of breath.

The client will demonstrate a

breathing pattern that supports blood
gas results within the clients normal
parameters before end of shift.

2. Nurse will monitor for signs of

hyperventilation including rapid
respiratory rate, lightheadedness,
numbness and tingling of hands and
feet, and assess the cause of it
(emotional, exertion, etc.)

3. 1. in order to prevent the shallow

and/or rapid breathing that can occur
with fear and anxiety

The patient demonstrated her ability to

use incentive spirometry, but she was
unable to hold the spirometer up
herself due to wrist drop. Also, when
she was having a bout of anxiety,
sitting with her and demonstrating
deep breaths decreased her respiratory
rate. With assistance she was turned
every hour or two. The patient was
found to be non-compliant with the
bipap machine, however.

The patient will report ability to

breathe comfortably within the hour.

3. The nurse will implement measures

to improve breathing pattern:
1. perform actions to reduce fear and
anxiety (e.g. assure client that
staff are nearby; provide a
calm, restful environment;
explain all tests and
procedures)
2. perform actions to reduce pain (see
Diagnosis 4, action d)
3. if client must remain flat in bed,
assist with position change at
least every 2 hours
4. instruct client to deep breathe or use
incentive spirometer every 1-2
hours
5. assist with positive airway pressure
techniques (e.g. bilevel
positive airway pressure

3.2 in order to increase the client's

willingness to move and breathe more
deeply
3.3 in order to prevent stasis of
secretions in the lungs
3.4 in order to prevent stasis of
secretions in lungs
3.5 in order to ensure adequate
oxygenation

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[BiPAP])
4. Consult appropriate health care
provider (e.g. respiratory therapist,
physician) if:
1. within 2 hours if ineffective
breathing pattern continues
2. immediately if signs and
symptoms of atelectasis (e.g.
diminished or absent breath
sounds, dull percussion note
over affected area, increased
respiratory rate, dyspnea,
tachycardia, elevated
temperature) develop
3. immediately if signs and
symptoms of impaired gas
exchange (e.g. restlessness,
irritability, confusion,
significant decrease in
oximetry results, decreased
PaO2 and increased PaCO2
levels) are present.

4. 1. Prolonged ineffective breathing

patterns can cause exhaustion, and
poor tissue perfusion
4. 2,3. Atelectasis and impaired gas
exchange can lead to hypoxia, which
can be life threatening

The physician was informed when the

patients respiratory rate was in the
40s; however, the patient was not in
distress when her respirations were in
the 30s so the doctor deemed her
status acceptable. We did have orders
to watch her rate closely, though.

Durable Medical Needs

F/U appts *
above care plan that you would include for discharge teaching)
Med Instruction/Prescription
Consider the following needs:
are any of the patients medications available at a discount
SS Consult *
pharmacy? Yes No
Dietary Consult*
Rehab/
HH *
PT/ OT *
Palliative Care
Pastoral Care
The patient will be discharged to rehab upon stabilization of respiratory rate, heart rate and the patient works with physical therapy to regain some
use of her extremities. Case management is already starting the process of getting her approved for rehab. Further reinforcement of dietary goals will
be necessary and will benefit from a dietary consult. Follow-up appointments will need to be maintained with her surgeon, as well as physical
therapy.

2 DISCHARGE PLANNING: (put a * in front of any pt education in

(Ackley & Ladwig, 2014, Elsevier, Ineffective breathing pattern, 2012)

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20

 15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output related to
altered heart rate and rhythm as evidenced by heart rate of 123 beats per minute.
Patient Goals/Outcomes

Nursing Interventions to Achieve

Goal

Rationale for Interventions

Provide References
Hypovolemia, hypotension and
decreased cardiac output put the
patient at risk for poor tissue
perfusion and oxygenation.

Evaluation of Interventions on
Day care is Provided
The patient was assessed every two
hours and was not found to be
hypovolemic or hypotensive and
she did have consistently adequate
oxygen saturation. The persistent
tachycardia, diminished peripheral
pulses and postural hypotension
suggests decreased cardiac output,
though. The physician was
notified.

The client will maintain adequate

cardiac output as evidenced by:
1. B/P within range of 130 - 100/80
60
2. apical pulse regular and between 60
-100 beats/minute
3. absence of or no increase in
intensity of gallop rhythm
4. increased strength and activity
tolerance
5. unlabored respirations at 12 20/minute
6. absence of adventitious breath
sounds
7. usual mental status
8. absence of dizziness and syncope
9. palpable peripheral pulses
10. skin warm and usual color
11. capillary refill time less than 3
seconds
12. urine output at least 30 ml/hour
13. absence of edema and jugular
vein distention

Assess every two hours for and report

signs and symptoms of:
1. hypovolemia (e.g. low B/P;
resting pulse rate greater than 100
beats/ minute; postural
hypotension; cool, pale, or
cyanotic skin; diminished or
absent peripheral pulses; urine
output less than 30 ml/hour)
2. hypotension (systolic B/P
persistently below 100 mm Hg)
3. decreased cardiac output:
variations in B/P (may be
increased because of
compensatory vasoconstriction;
may be decreased when
compensatory mechanisms and
pump fail)
tachycardia
presence of gallop rhythm
fatigue and weakness
dyspnea, tachypnea, crackles
(rales)
restlessness, change in mental
status
dizziness, syncope
diminished or absent peripheral
pulses, cool extremities, pallor or
cyanosis of skin, capillary refill
time greater than 3 seconds
oliguria
edema
jugular vein distention (JVD)

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21

abnormal blood gases

significant decrease in oximetry
results
dysrhythmias (e.g. irregular heart
rate; heart rate less than 60 or
greater than 100; abnormal rate,
rhythm, or configurations on the
ECG).
Implement measures to maintain an
adequate cardiac output:
1. perform actions to prevent or treat
hypovolemia:
maintain a minimum fluid
intake of 1000 ml/day unless
ordered otherwise
implement measures to
prevent and control bleeding

Hypovolemia due to inadequate

fluids and/or bleeding can further
exacerbate a poor cardiac output
due to tachycardia.

Administer positive inotropic agents

(e.g. digoxin) as ordered to increase
myocardial contractility

Increasing myocardial contractility

will improve cardiac output

Perform actions to reduce cardiac

workload:
1. perform actions to prevent or treat
hypertension:
implement measures to warm
client (e.g. increase room
temperature, apply warm
blankets) if he/she is hypothermic
implement measures to reduce
stress (e.g. initiate pain relief
measures, reduce fear and
anxiety)
2. implement measures to promote rest
(e.g. maintain activity restrictions,
administer prescribed pain
medications, limit the number of

1. Warming helps prevent

vasoconstriction associated with
hypothermia and also prevents
shivering, which elevates the
metabolic rate and increases cardiac
workload. Also, stress causes a further
increase in heart rate
2. Rest promotes a decrease in heart
rate
3. Proper respiratory function
promotes adequate tissue oxygenation
4. nicotine has a cardiostimulatory
effect and causes vasoconstriction; the
carbon monoxide in smoke reduces
oxygen availability
5. Caffeine is a myocardial stimulant

University of South Florida College of Nursing Revision August 2013

This was a difficult task to manage

since the patients oral intake of
fluids has consistently been
inadequate. However, the patient
did receive a continuous
administration of IV fluids.
There is also a risk for bleeding
since the patient is on
anticoagulation therapy, her
coagulation levels are prolonged,
coagulation factors are impaired
and her H&H are low.
Digoxin was administered and
caused her heart rate to decreases
for a period of time.
The patients temperature was
assessed frequently. We considered
ordering a Bair Hugger for her at a
point due to how cold she was and
how much she was shivering.
For her stress, the environment around
the patient (as well as those around
her) was kept quiet and dimly lit. I
held her hand while her nerve
conduction study was being performed
since she was scared to the point of
tears. She was also offered pain
medication routinely, which she
declined.
For respiratory function, the patient
was instructed on the use of incentive

22

3.

4.
5.

6.

visitors, reduce anxiety)

throughout shift
implement measures every two
hours to maintain adequate
respiratory function
discourage smoking
discourage excessive intake of
beverages high in caffeine such as
coffee, tea, and colas
increase activity gradually as
allowed and tolerated each shift.

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

and can increase myocardial oxygen

consumption
6. Slowly increasing activity will help
increase endurance and improve
cardiac ability

spirometry. However, since she was

unable to hold the spirometer up on
her own, I routinely went to her
bedside to help her use it.
The patient denied a desire to smoke,
and her dietary intake was void of
caffeine.
Gradual increase in physical activity
has been an ongoing effort in
conjunction with physical therapy;
however, during every position shift,
the patient was encouraged to assist us
and increase her movement.

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

The patient will be discharged to rehab upon stabilization of respiratory rate, heart rate and the patient works with physical therapy to regain some
use of her extremities. Case management is already starting the process of getting her approved for rehab. Further reinforcement of dietary goals will
be necessary and will benefit from a dietary consult. Follow-up appointments will need to be maintained with her surgeon, as well as physical
therapy.
(Ackley & Ladwig, 2014, Elsevier, Decreased cardiac output, 2012)

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23

References
Ackley, B.J. & Ladwig, G.B. (2014). Nursing diagnosis handbook: an Evidence-based guide to
planning care. St. Louis, MO: Mosby Elsevier.
Aluka, K. J., Turner, P. L., & Fullum, T. M. (2009). Guillain-Barr syndrome and postbariatric
surgery polyneuropathies. JSLS: Journal of the society of laparoendoscopic surgeons,
13(2), 250253.
Kee, J. L., Hayes, E. R. & McCuistion, L. E. (2015). Pharmacology: a Patient-centered nursing
process approach (8th ed.). St. Louis, MO: Mosby Elsevier.
Nursing diagnosis: Decreased cardiac output. (2012). Retrieved from
http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=152
Nursing diagnosis: Ineffective breathing pattern. (2012). Retrieved from
http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=348
Osborn, K., Wraa, C., Watson, A., Holleran, R. (Eds.). (2014). Medical-surgical nursing:
Preparation for practice (2nd ed.). Upper Saddle River, New Jersey: Pearson.
Treas L.S. & Wilkinson, J.M. (2014). Basic nursing: Concepts, skills & reasoning. Philadelphia,
PA: F.A. Davis Company.
United States Department of Agriculture. Supertracker. Retrieved from:
https://www.supertracker.usda.gov
University of California San Francisco. (n.d.). Dietary guidelines after bariatric surgery.
Retrieved from
http://www.ucsfhealth.org/education/dietary_guidelines_after_gastric_bypass/

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