JACKSON COMMUNITY COLLEGE

NUR 171
SUPPORTIVE EDUCATIVE NURSING

PREPARATION FOR SAFE PATIENT CARE

Student Name
Date

Sarah Jones
2/6/15

Rev 06.25.2012

DAY ONE PREPARATION - Critical Thinking Summary

Patient Room Number
2210 Age
92 M/F
F CODE Status
Primary Medical Diagnosis Reason for Admission

DNAR_____

Pyelonepherosis

Secondary Medical Diagnoses

List all that impact patients care

Chronic UTI, Chronic Kidney Disease, Diverticulitis, Bipolar Disorder

Nursing Care Plan for PRIORITY Physiological Nursing Diagnosis

Nursing Diagnosis in PES
Patient Expected Outcome
Individualized & Prioritized Nursing
Format
(measurable and with time
Interventions with Referenced
Evidence/Rationale
frame)
Client will: Report that pain
P Acute pain
1. Assess: Assess pain intensity level q 3 hours and 30
regimen achieves acceptable level
of 3/10 without side effects within
24 hours of admission.

E R/T pylonephrosis
S AEB patient stating "pain is at a
6/10" on the pain scale.

Defining Characteristics Use Ackley

text book did you pick the correct
diagnosis?

Pain is a subjective experience and its

presence cannot be proved or

minutes after administration of PRN analgesic using the

0-10 numerical pain rating scale. Rationale: The first
step in pain assessment is to determine if the client can
provide a self-report, etc. (Ackley, Ladwig pg. 577.)

AEB
Patient reporting pain level of less
than 3/10 and without complaints
of side effects from pain
management regimen by 2/7/15.

2. Intervene: Treat acute pain by administering PRN

analgesics as ordered when patient states that pain
level exceeds an acceptable level of 3/10 on the pain
scale. Rationale: Analgesics are administered ATC for
continuous pain, PRN dosing is appropriate for
intermittent or breakthrough pain (Ackley, Ladwig pg
579.)

3.

Teaching: Teach the client to use the self-reporting

numerical pain scale tool to rate the intensity of past or
current pain. Ask the client to set a comfort-function goal by
selecting a pain level on the self report tool that will allow
performance of desired or necessary activities of recovery
with relative ease. If the pain level is consistently above the
comfort-function goal, the client should take action that
decrease pain or notify a member of the health care team so
that a PRN analgesic may be given promptly. Rationale: The
use of comfort-function goals provides direction for the
treatment plan, etc. (Ackley, Ladwig pg 582-3)

4. Discharge Planning: Reinforce the importance of taking

prescribed pain medications to maintain the comfort-function

disproved. Self report is the most

reliable method of evaluating pain
presence and intensity (Ackley, Ladwig
pg 576.)

goal of 3/10 or less on the numerical pain scale. Rationale:

Teaching clients to stay on top of their pain and prevent it
from getting out of control etc. (Ackley, Ladwig pg 592.)

Potential Complications
If this patients condition were to
worsen, what would be the most likely
reason?
-Worsening anemia
-Worsening UTI
-Abnormal Depakote/ Lithium levels
-Hyperkalemia
-Patient Falls
-Patient develops skin impairment
-Sepsis/ DIC

SCHEDULE
How will you organize your time?
(Report, medications, ambulation, bath,
charting, procedures, etc.)

AM report
Check Vital Signs
Pass Meds
Give Breakfast
AM Care
Head-Toe Assessment
Diagnostic Tests if any scheduled
Subjective Interview
Check Vitals
Report

How will you be vigilant in monitoring

for and preventing this complication?

What will you do if it happens?

Call Bill and report to primary nurse.

-Vitals q 3 hrs
-Pain Scale q vitals and 30 mins post
administration of analgesic
-Response to analgesic
-Monitor Labs
-Report anything Im uncomfortable with
doing to ensure patient safety
-Head-Toe assessment q shift

PROCEDURES
What procedures do you have to do?
Be ready! (Catheters, injections, blood
glucose monitoring, dressing changes, etc.)

None Applicable

CARE PATHWAYS
Is the patient on a Care Pathway?
Attach pathway and/or agency PMP.
(What do you need to do Day 1 and Day 2
according to the path or management plan?)

Refer to PMP in IPOC

PATHOPHYSIOLOGIES
Primary Diagnosis Pathophysiology
Pylonephrosis
Pylonephrosis is a condition of the renal parenchyma and colleting system. The most common cause is bacterial infection, but
fungi, protozoa, or viruses can also infect the kidney. Pylonephritis usually begins with colonization and infection of the lower
urinary tract via the ascending urethral route. (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg 1069.)

Reference Med/Surg or Patho text (less than 5 years old):

o Textbook S&S The clinical manifestations of acute pyelonephritis vary from mild fatigue to the sudden onset of chills, fever,
vomiting, malaise, flank pain, and the LUTS characteristic of cystitis, including dysuria, urgency, and frequency. Costovertebral
tenderness to percussion is typically present on the affected side (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg 1070.)

o Patients S&S The client presented with left flank pain, increasing with movement, significant CVA tenderness on the left and right
side bilaterally.

Secondary Diagnosis Pathophysiology

Chronic Urinary Tract Infection
The urinary tract above the urethra is normally sterile. The organisms that usually cause UTIs are introduced via the ascending route from the
urethra and orignate in the perineum. Most infections are caused by gram-negative bacilli normally found in the gastrointestinal tract,
although gram-positive organisms such as streptococci, enterococci, and staphylococcus saprophyticus can also cause UTIs (Lewis, Dirksen,
Heitkemper, Bucher, 2014 pg 1065.)

Reference Med/Surg or Patho text (less than 5 years old):

o

Textbook S&S Dysuria, frequent urination, urgency, suprapubic discomfort, or pressure, hematuria, cloudy urine, flank pain, chills,
fever, fatigue, anorexia (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg 1066.)

Patients S&S Flank pain, urinary frequency, decreased appetite, increased WBC, hematuria

Secondary Diagnosis Pathophysiology

Chronic Kidney DiseaseChronic Kidney Disease involves progressive, irreversible loss of kidney function. the KDOQI defines CKD as either the
presence of kidney damage or a decreased GFR less than 60ml/min for longer than three months (Lewis, Dirksen, Heitkemper, Bucher, 2014
pg 1107.)

Reference Med/Surg or Patho text (less than 5 years old):

o

Textbook S&S retention of urea, creatinine, phenols, hormones, electrolytes, and water. Uremia may develop, as well as

Patients S&S flank pain, hydronephrosis, weight loss, increased creatinine, increased BUN, protein in urine

metabolic disturbances, electrolyte and acid base imbalances, etc (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg 1108.)

Use additional sheets as necessary to complete all pertinent medical diagnoses.

Secondary Diagnosis Pathophysiology

Diverticulitis
Diverticulitis is characterized by inflamed diverticula and increased luminal pressures that cause erosion of the bowel wall, and thus
perforation into the peritoneum. (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg 995.)

Reference Med/Surg or Patho text (less than 5 years old):

o

Textbook S&S Acute pain in the LLQ, a palpable ABD mass, and systemic symptoms of infection (Lewis, Dirksen, Heitkemper,
Bucher, 2014 pg 995.)

Patients S&S Increased WBC

Secondary Diagnosis Pathophysiology

Bipolar Disorder
The exact cause of bipolar disorder is unknown, but several factors seem to be involved in causing and triggering bipolar episodes such as:
biological differences, neurotransmitters, hormones, inherited traits, and environment (Mayo Clinic Staff, 2014.)

Reference Med/Surg or Patho text (less than 5 years old):

o

Textbook S&S mood swings, mania, depression, psychosis, suicidal thoughts (Mayo Clinic Staff, 2014.)

Patients S&S History: Patient on Lithium/Depakote.

MEDICATION SUMMARY
ALLERGIES and usual reaction
NKA
Generic/Brand
Name and
Class

Normal Dose

Patients Dose
Times to Give

Drug Action

Why ordered
for this patient?

Items to check
before giving;
when to hold

Two common
side effects

You know med

is working
when:

aspirin
(Bayer)
[NSAID]

81, 325, 500, 650

Max: 4 g/day

81mg, PO, Daily

Prevent thrombus
formation

CR at baseline,
does patient
have a clotting
disorder?

Dyspepsia
Nausea/Vomiting

No thrombus
formation occurs

ceftriaxone
(Rocephin)
[cephalosporin
antibiotic]

1-2g IM IV

2Gm= 100mL
IVPB, q24h

Analgesic, antiinflammatory,
antipyretic,
reduces platelet
aggregation
Bactericidal;
inhibits cell wall
synthesis

pyelonephritis

Serum drug
levels in renal
failure patients

Local injection
site reaction
Eosinophilia

S&S of infection
diminish

divalproex
sodium
(Depakote DR)
[antiepileptic;
mood stabilizer]

125, 250, 500 DR

500mg, PO, daily

Exact mechanism
of action
unknown;
increases GABA
effects

Bipolar Disorder

Headaches
Nausea/Vomiting

Mood stabilized,
decreased S&S of
bipolar disorder

heparin
[anticoagulant]

5000 units, SC,

q8-12h

5000 units/mL
Vial 1mL, SC,
q12h

Anticoagulant

Prevent thrombus
formation

LFTs baseline,
coagulation tests
baseline,
behavioral
changes, suicidal
thoughts
PTT, INR, signs of
bleeding

Bleeding
Thrombocytopeni
a

No thrombus
formation occurs

lithium carbonate
cap
(Lithobid)
[mood stabilizer]

150, 300, 600;

300, 450 ER
300/5 mL

150mg, PO,
q other day

Exact mechanism
of action
unknown; alters
neuronal sodium
transport

Bipolar Disorder

CA, CR, US, TSH

at baseline; ECG,
CBC at baseline

Tremor
Polyuria

Mood stabilized,
decreased signs
and symptoms of
bipolar disorder

multivitamin
(Multivitamin
Chew Tab)
[multivitamin]

1 tab daily

1 tab, chew, daily

Health
Supplement

Health Promotion

N/A

Nausea
Headache

N/A

Insulin Type
Onset
Peak
Duration

Generic/Brand
Name and
Class

Normal Dose

Patients Dose
Times to Give

Drug Action

Why ordered
for this patient?

Items to check
before giving;
when to hold

Two common
side effects

You know med

is working
when:

acetaminophenhydrocodone
(Norco)
[analgesic,
opioid]
calcium
carbonate
(Tums)
[antacid]

5/325, 7.5/325,
10/325

10/325, tab, PO,

q 6h, PRN

analgesic

Flank Pain

Pain level
Respirations

N/V
Respiratory
Depression

Pain level
decreased

2-4 tabs PO, PRN

Max: 15 tabs in
24h

1000 mg, PO,

q 4h, PRN

Neutralizes
gastric acid

Heartburn pain?

Caution if renal
impairment

Hypercalcemia
Hypercalciuria

Heartburn pain
relieved

>12 yo: oral

capsule, 50300mg/day PO
divided bid PRN
4, 8; 4/5 mL; IM;
IV

100mg, PO, cap,

PRN

Facilitates
mixture of stool
fat and water

Constipation

Fecal impaction
Last BM
Bowel Sounds?

Diarrhea
Abdominal
cramps

Regular BM

4mg IV push,
q 6h, PRN

Nausea/Vomiting

Nausea?
ECG if electrolyte
abnormalities

Headache
Constipation

Nausea/Vomiting
relieved

promethazine
(Phenergan IM)
[antiemetic]

12.5-25 mg,
PO/IM/IV, q4-6h

12.5 mg, IM Inj.,

q 4h, PRN

Nausea/Vomiting

Nausea?

Drowsiness
Sedation

Nausea/Vomiting
relieved

senna
(Senokot Tab)
[stimulant
laxative]

>12 yo, PO tab,

2-4 tabs, PO qhs,
PRN

8.6 mg tab, PO,

BID, PRN

Selectively
antagonizes
serotonin 5-HT3
receptors
Non-selectively
antagonizes
central and
peripheral
histamine H1
receptors
Increases
peristalsis

Constipation

Fecal impaction
Last BM
Bowel Sounds?

Nausea
Abdominal
cramps

Constipation
relieved

docusate
(Colace)
[sulfonic acid]
ondansetron
(Zofran inj)
[antiemetic]

Insulin Type
Onset
Peak
Duration

Note: You may choose to use hand-written or pre-printed medication cards, but be sure to STUDY and KNOW their
contents!

LAB VALUES SUMMARY

Diagnosis #1
Diagnosis #2
Diagnosis #3

Medical
Diagnosis
List laboratory and
diagnostic tests
found in your text
for admitting and
secondary medical
diagnoses.

Pyelonephrosis
Urine
culture/sensitivity
CBC with
diff/indices
Blood Chemistry

Electrolytes

Diagnosis #4

Chronic Kidney
Disease
creatinine

Diverticulitis

Bipolar Disorder

CBC with diff

CBC with diff

BUN

UA

UA

UA

Fecal occult blood

test
ABD x-ray

TSH

Test

Normal
Value

ANALYSIS OF LAB VALUES

Admitting
Follow up
Cause of
date / value
date / value
abnormal
finding

RBC

(4.20-5.40)

3.24

Chronic Infection

Hemoglobin

(12.0-16.0)

10.1

Chronic Kidney
Disease

Hematocrit

(36.0-48.0)

31.9

Chronic Renal
Failure?
Malnutrition?

Platelets
WBC (diff

Implications
for care
Explain to the
patient that
further testing
will be done to
verify test
results
Observe the
patient for S&S
of anemia;
Check hemtocrit
Assess for S&S
of anemia

WNL
(4.0-10.0)

15.4

Pyelonephrosis

Monitor vital
signs

Compare BUN
and creatinine
levels, if both are
high, kidney
disease should
be suspected
Assess renal

prn)

Sodium

WNL

Potassium

WNL

Chloride

WNL

CO2

WNL

BUN

(6-23)

33

Chronic Kidney
Disease/
antibiotics

Creatinine

(0.44-1.03)

1.16

Chronic Kidney

Disease

function

Albumin

(3.2-4.8)

2.8

Chronic Kidney
Disease

Check for
peripheral
edema and
ascites

Calcium

(8.5-10.1)

8.3

Chronic Kidney
Disease,
Diarrhea

Monitor for S&S

of tetany

Protein

(6.1-7.9)

5.9

Chronic Kidney
Disease

MCHC

(32.0-36.0)

31.5

Anemia

Assess urinary
output, Assess
for peripheral
edema in lower
extremities
Monitor RBC,
assess for S&S of
anemia.

ANALYSIS OF LAB VALUES Day 2

List all other pertinent normal or abnormal lab values.

Test

Normal Value

Admitting
date / value

Follow up
date / value

(3.5-5.3)

4.3

5.4

Potassium

Cause of
Abnormal
finding
Chronic

Implications
for care

Kidney

serum and

Disease

urine

Compare

potassium
levels.
(6-23)

33

47

Chronic Kidney
Disease/
antibiotics

Creatinine

(0.44-1.03)

1.16

1.46

Chronic Kidney
Disease

Calcium

(8.5-10.1)

7.8

8.3

Chronic Kidney
Disease,
Diarrhea

Monitor for
S&S of tetany

WBC (diff

(4.0-10.0)

15.4

13.0

Pyelonephrosis

Monitor vital
signs

RBC

(4.20-5.40)

3.24

2.68

Chronic Infection

Hemoglobi
n

(12.0-16.0)

10.1

8.4

Chronic Kidney
Disease

Hematocrit

(36.0-48.0)

31.9

26.7%

MCHC

(32.0-36.0)

31.5

31.5%

Chronic Renal
Failure?
Malnutrition?
Anemia

Explain to the
patient that
further testing
will be done to
verify test
results
Observe the
patient for S&S
of anemia;
Check hemtocrit
Assess for S&S
of anemia

BUN

prn)

Compare BUN
and creatinine
levels, if both
are high, kidney
disease should
be suspected
Assess renal
function

Monitor RBC,
assess for S&S
of anemia.

Student Name __Sarah

Jones____________________________Date___02/07/15__Time_1100_______________
Patient Age/Sex __92/F__________ Medical Diagnosis __Pyelonephrosis_________ Code Status
___DNAR_________
MENTAL STATUS
LOC and orientation X3
Appearance
Cognition
PAIN
Location, severity, quality, radiation,
duration, precipitating/alleviating
factors, associated symptoms
HEAD AND NECK
Hair and skin
Eyes: sclerae, conjunctivae, pupil
reactivity
Eyes: vision/aids
Ears: lesions, hearing/aids
Nose: symmetry, mucosa, drainage
Mouth: mucosa, tongue, dentation,
lesions
Swallowing/ Appetite
Trachea position
JVD at 45 degrees
UPPER EXTREMITIES
Skin
Pulses (brachial, radial)
Capillary refill
Strength/ROM
Turgor/edema
CHEST/BACK
Shape
Respiratory effort/SpO2
Cough/sputum
Lung sounds anterior and posterior
Skin condition/integrity
Heart sounds
Apical pulse rate/rhythm (auscultate
full min)
ABDOMEN/PERINEAL AREA
Contour, symmetry
Bowel sounds in 4 quadrants
Tenderness
Urinary pattern/color
Bowel pattern/character/last BM
Perineum (if appropriate)
LOWER EXTREMITIES
Skin color/integrity
Edema

Oriented x4
Appropriate
Answers questions appropriately
Back/Flank, 6/10, worsens with movement, pain present
past 24 hrs

Clean, shiny, white, evenly distributed

White, pink, no exudate noted, PERRLA
Wears reading glasses only
No lesions noted, no hearing aids
Symmetrical, pink, moist, no drainage noted
Pink, moist, midline, no lesions noted, minimal dental
work noted, teeth in good condition
No dysphasia, appetite good
Midline
No JVD noted @ 45 degrees
Pink, some excessive dryness, warm, no lesions noted
+2, regular, equal bilaterally
> 3 seconds
Strong, equal bilaterally
Elastic, no edema noted
AP: Transverse Diameter 1:2, symmetrical
No use of accessory muscles, non labored breathing,
91% RA
No cough noted
Clear and equal bilaterally in all lobes
Pink, excessive dryness, no varicosities noted, warm
S2>S1 in aortic and pulmonic areas; S1>S2 in tricuspid
and mitral areas; loud murmur noted
62, regular, strong
Flat, symmetrical
BS present in all 4 quadrants
Non-tender upon palpation, no facial grimacing noted
Some urge incontinence, dark yellow, cloudy
Ileostomy present in LLQ, diarrhea
N/A
Pink, excess dryness, warm, no lesions noted
No edema noted

Pulses (femoral, popliteal, PT, DP)

Capillary refill
Strength/ROM
EQUIPMENT
Pumps
Tubes
DURING SHIFT
Vital signs/time

Blood glucose monitoring

results/insulin
Intake and output
Food intake/Appetite/Nausea
IV solution and rate/hourly checks
Significant lab results
Support system/SO involvement
Patient education completed

All: 1+, regular, equal bilaterally

>3 seconds
Dorsiflexion, plantar flexion Strong, equal bilaterally
IV present in R forearm, patent

0800: HR: 62, RR: 16, BP: 133/73, Temp: 98.3 oral, Pain
4/10
N/A

Ate 100% of breakfast, good appetite, no complaint of

nausea
100% NS
High BUN and Creatinine, WBC; Low RBC, Protein,
Albumin
Daughter and Son in law visit frequently

NURSING DIAGNOSIS
Acute pain, r/t pyelonephrosis, aeb: patient states pain is at a 6/10 on the pain scale.

SOAP NOTE (on above nursing diagnosis only)

S: Client states bilateral flank pain is at a 4/10 on the numerical pain scale, worsens with movement, feels sharp, past
24 hrs.
O: VS: BP: 133/73, Apical Pulse: 62 BPM (regular, strong) RR: 16, Temp: 98.3 oral, Pain level 4/10. CV: No edema noted.
Capillary refill > 3 seconds in upper and lower extremities. Carotid, brachial, and radial pulses +2, regular, equal
bilaterally. Femoral, popliteal, dorsalis pedis, and posterior tibialis pulses 1+, regular, equal bilaterally. Negative
Homans. No JVD noted @ 45 degrees. RESP: O2 sat: 91% RA. Lung sounds clear and equal bilaterally to all fields,
breathing is non-labored, no use of accessory muscles noted. GI: bowel sounds present X4. Abdomen is flat,
symmetrical, and non-tender upon palpation, denies any nausea today. Ileostomy present in the LLQ. Normal diet, 75100% food eaten. GU: 100ml dark yellow, cloudy urine voided. MUSC: Client has a tremor while walking and uses a
walker which stabilizes her sufficiently. Upper and lower extremity strength: strong, equal bilaterally. Client is a high fall
risk. SKIN: pink, warm, excessively dry on back, legs, and feet. No lesions or breakdown noted. NEUR: Client oriented
X4, PERRLA. Grasps strong and equal bilaterally. Cranial Nerves grossly intact. Positive Babinski.

A: Client is progressing towards discharge. Pain is being controlled well, infection is being treated with IV antibiotics.

P: Continue nursing care, administration of PRN narcotics and antibiotic TX. Educate patient about importance of
reporting pain prior to it becoming uncontrolled.

END OF SHIFT CHECK-OUT

Patient safe and comfortable

Meds administered

Reported off to RN

and instructor
I&O documented
______________________________

MAR signed

Student signature

DAY TWO PREPARATION

EVALUATION
Did you choose the appropriate nursing diagnosis for Day One?

Yes

No

What would have been a better choice?

Were your objectives and interventions appropriate?

Yes

No

What would have been more appropriate?

Nursing Care Plan for SECOND PRIORITY Nursing Diagnosis

Nursing Diagnosis in PES Format
Patient Expected Outcome
Individualized & Prioritized Nursing
(Measurable and with time
Interventions with Referenced
Evidence/Rationale
frame)
P Impaired urinary elimination
Client will report an absence or reduction
1. Assess:
of urgency during urination, as well as a
reduction in incontinence by 02/09/15.

Inquire about urgency, daytime frequency, nocturia,

involuntary leakage, leakage accompanied by or preceded by
urgency, and whether the amount of urine loss is a moderate
or large volume. Rationale: A history of urine loss associated
with urgency is the most helpful criterion for diagnosing urge
urinary incontinence (Ladwig, Ackley, 2014. P 465.)
E r/t chronic UTI

2.

Intervene:
Gradually increase the time between urinations to the
negotiated goal of voiding q 3h during the day is achieved.
Rationale: with bladder training, the goal is to restore normal
bladder function through the use of a voiding schedule, the
woman voids at predetermined intervals rather than in
response to urgency, progressively increasing the intervals
between voiding (Ladwig, Ackley, 2014. P467.)
S AEB: patient states I often have the urge to
urinate suddenly and sometimes dont make it
in time.

3.
Defining Characteristics (from book
did you pick the correct
diagnosis?)

AEB:

Dysuria, incontinence; retention, urgency

(Ladwig, Ackley, 2014. pg 826.)

Client will report a reduction in feeling the

sudden urge urinate and will demonstrate
decreased incontinence by 02/09/15.

Teaching:
Teach the client to recognize symptoms UTI: dysuria that
crescendos as the bladder nears complete evacuation;
urgency to urinate followed by micturition of only a few drops;
suprapubic aching discomfort; malaise; voiding frequency,
sudden exacerbation of urinary incontinence with or without
fever, chills, and flank pain. Rationale: There are a variety of
typical and unexpected symptoms in women with a history of
recurring UTI (Ladwig, Ackley, 2014. P 827.)

4.

Discharge Planning:
Teach the client the following measures pertinent to women to
decrease the incidence of urinary tract infections:
- Urinate at appropriate intervals, do not ignore the need to
void, which can result in stasis of urine.
-Drink plenty of liquids, especially water. Rationale: Drinking
water helps dilute the urine and ensures more frequent
urination..etc (Ladwig, Ackley, 2014. P 828.)
-Wipe from front to back. Rationale: This helps prevent
bacteria in the anal region from spreading to the vagina and
urethra.
Avoid potentially irritating feminine products. Rationale:
Using deodorant sprays, bubble baths, or other feminine
products such as douches and powders, in the genital area
can irritate the urethra (Ladwig, Ackley, 2014. P 828.)

Student Name ___Sarah Jones________________________________________ Date

__02/08/15_____________
Patient Age/Sex __92/F______ Medical Diagnosis __Pyelonephrosis_______________ Code Status
__DNAR__________
MENTAL STATUS
LOC and orientation X3
Appearance
Cognition
PAIN
Location, severity, quality, radiation,
duration, precipitating/alleviating
factors, associated symptoms
HEAD AND NECK
Hair and skin
Eyes: sclerae, conjunctivae, pupil
reactivity
Eyes: vision/aids
Ears: lesions, hearing/aids
Nose: symmetry, mucosa, drainage
Mouth: mucosa, tongue, dentation,
lesions
Swallowing/ Appetite
Trachea position
JVD at 45 degrees
UPPER EXTREMITIES
Skin
Pulses (brachial, radial)
Capillary refill
Strength/ROM
Turgor/edema
CHEST/BACK
Shape
Respiratory effort/SpO2
Cough/sputum
Lung sounds anterior and posterior
Skin condition/integrity
Heart sounds
Apical pulse rate/rhythm (auscultate
full min)
ABDOMEN/PERINEAL AREA
Contour, symmetry
Bowel sounds in 4 quadrants
Tenderness
Urinary pattern/color
Bowel pattern/character/last BM
Perineum (if appropriate)
LOWER EXTREMITIES
Skin color/integrity
Edema

Oriented X4
Appropriate
Answers questions appropriately
1/10, bilateral flank, worsens upon movement, sharp,
Norco is controlling the pain well as well as laying still.

Clean, shiny, white, evenly distributed

White, pink, no exudate noted, PERRLA
Wears reading glasses only
No lesions noted, no hearing aids
Symmetrical, pink, moist, no drainage noted
Pink, moist, midline, no lesions noted, minimal dental
work noted, teeth in good condition
No dysphasia, appetite good
Midline
No JVD noted @ 45 degrees
Pink, some excessive dryness, warm, no lesions noted
+2, regular, equal bilaterally
> 3 seconds
Strong, equal bilaterally
Elastic, no edema noted
AP: Transverse Diameter 1:2, symmetrical
No use of accessory muscles, non labored breathing,
96% RA
No cough noted
Clear and equal bilaterally in all lobes
Pink, excessive dryness, no varicosities noted, warm
S2>S1 in aortic and pulmonic areas; S1>S2 in tricuspid
and mitral areas; loud murmur noted
63, regular, strong
Flat, symmetrical
BS present in all 4 quadrants
Non-tender upon palpation, no facial grimacing noted
Some urge incontinence, yellow, cloudy
Ileostomy present in LLQ, diarrhea present
N/A
Pink, excess dryness, warm, no lesions noted
No edema noted

Pulses (femoral, popliteal, PT, DP)

Capillary refill
Strength/ROM
EQUIPMENT
Pumps
Tubes
DURING SHIFT
Vital signs/time
Blood glucose monitoring
results/insulin
Intake and output
Food intake/Appetite/Nausea
IV solution and rate/hourly checks
Significant lab results
Support system/SO involvement
Patient education completed

All: 1+, regular, equal bilaterally

>3 seconds
Dorsiflexion, plantar flexion Strong, equal bilaterally
IV present in R forearm, patent
BP: 123/65, HR: 63, RR: 16, Temp: 97.9 oral, Pain: 1/10
N/A

100% NS
High Potassium, BUN, Creatinine, and WBC; Low
Calcium, RBC, HBG, Hematocrit
Daughter and Son-In-Law frequently visit

NURSING DIAGNOSIS
Impaired urinary elimination, R/T chronic UTI, AEB patient states I often have the urge to urinate suddenly and
sometimes dont make it in time.

SOAP NOTE (on above nursing diagnosis only)

S: Patient states I often have the urge to urinate suddenly and sometimes dont make it in time. Reports chronic
UTIs.
O: VS: BP: 123/65, Apical Pulse Rate: 63 BPM, regular, strong. RR: 16, Temp: 97.9 oral. CV: No edema noted, capillary
refill >3 seconds X4. Carotid, brachial, and radial pulses +2, regular, equal bilaterally. Femoral, popliteal, dorsalis
pedis, and posterior tibialis pulses 1+, regular, equal bilaterally. Negative Homans. No JVD noted @ 45 degrees. RESP:
O2 Sat: 96% RA, Lungs sounds clear and equal bilaterally to all fields, non-labored breathing, no use of accessory
muscles noted. GI: Bowel sounds present in all 4 quadrants. No abdominal distention noted, abdomen is symmetrical
and non-tender upon palpation, no facial grimacing noted upon palpation. Ileostomy present in the LLQ, diarrhea
noted. Client doesnt report any nausea or vomiting today. GU: Urine output roughly 100 mL, cloudy, yellow. Some urge
incontinence present. MUSC: Patient has noticeable tremor with gait and relies on walker to ambulate. Client is a high
fall risk. SKIN: pink, warm, excess dryness on back, legs, and feet. Temperature equal bilaterally. No lesions or
breakdown noted. NEUR: Oriented X4, PERRLA, Strong grasps equal bilaterally. Dorsiflexion and Plantar flexion strong
and equal bilaterally. Positive Babinski.

A: Patient progressing toward discharge.

P: Continue with PRN analgesics, educate regarding voiding schedule and S&S of UTI/prevention methods.

END OF SHIFT CHECK-OUT

Patient safe and comfortable

Meds administered

Reported off to RN

and instructor
I&O documented
______________________________

MAR signed

Student signature