UNIVERSITY OF SOUTH FLORIDA COLLEGE OF NURSING

/tudent9 Mar"ee :riggs

PATIENT ASSESSMENT TOOL . 1 PATIENT INFORMATION

;atient Initia"s9 M.D. :ender9 7ema"e Age9 $% Marita" /tatus9 di.orced

Assignment Date9 '())('+ Agency9 Bay&ront Medica" Center

Admission Date9 '()*('+ ;rimary Medica" Diagnosis with ICD1'* code9 <+-.)' Mi"d intermittent asthma with (acute# e3acerbation Other Medica" Diagnoses9 (new on this admission#

;rimary Language9 =ng"ish Le.e" o& =ducation9 com!"eted ).- years o& co""ege Occu!ation (i& retired2 what &rom>#9 switchboard o!erator at Bay&ront 5umber(ages chi"dren(sib"ings9 %) yo son? $@ yo sister? $$ yo sister

/er.ed(Aeteran9 5o Li.ing Arrangements9 "i.es with a good &riend that she re&ers to as her brother2 they rent a one story house that does not ha.e any stairs. Cu"ture( =thnicity (5ationa"ity9 Caucasian(non1his!anic Re"igion9 Methodist

Code /tatus9 7u"" code Ad.anced Directi.es9 5o I& no2 do they want to &i"" them out> 5o /urgery Date9 5A ;rocedure9 5A

y!e o& Insurance9 BCB/

1 CHIEF COMPLAINT:
I came in because my asthma got worse on Monday.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCAR the sym!toms in addition to the hos!ita" course#
he !atient is a $% year o"d Caucasian &ema"e that was admitted into the emergency de!artment on '()*()*'+ due to worsening asthma sym!toms. he !atient was diagnosed with asthma in ',-, and re!orted that &or the !ast se.era" years she has had .ery good contro" o.er her asthma. On /unday the !atient re!orted she noticed a cough and congestion that became increasing"y worse. he !atient went to a "oca" wa"01in c"inic &or her sym!toms2 but they continued to get worse. On Monday2 the )*th2 she ca""ed ,'' because her sym!toms continued to get worse and she did not ha.e a way to get to the hos!ita". he !atient re!orted that it &e"t as i& she had tightness in her chest2 was easi"y winded2 and had shortness o& breath. he !atient stated that when her asthma sym!toms worsen it causes her b"ood !ressure to increase which causes an increase in her an3iety. he !atient ty!ica""y manages her asthma sym!toms by using Ad.air Dis0us2 a rescue inha"er2 and a nebu"i4er i& needed. he !atient was mo.ed to %5 to recei.e a"butero" and !rednisone treatments in addition to her routine Ad.air Dis0us. he !atient has whee4ing throughout a"" "obes in the "ung2 and the doctor e3!"ained to the !atient that it wi"" ta0e se.era" days &or the whee4ing to subside com!"ete"y. he !"an o& care was &or the !atient to recei.e treatments through res!iratory thera!y and !rednisone to he"! re"a3 the constriction o& the bronchio"es. As o& '())('+2 the !atient began to deny her res!iratory thera!y treatments due to her increase in b"ood !ressure a&ter recei.ing the treatments. he !atient wi"" !otentia""y be discharged on '())()*'+2 but the doctor wanted to obser.e the !atient and determine whether the whee4ing continued to subside.

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

'

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Inc"ude hos!ita"i4ations &or any medica" i""ness or o!eration
Date ',-, ',@)
',@)1',@% he !atient was diagnosed with an3iety.

Operat !" !r I##"e$$ ;atient was diagnosed with asthma. ;atient had a C1section &or the birth o& her son. ;atient had a hysterectomy !er&ormed due to benign &ibroid tumors. he !atients .agina2 cer.i32 and one o.ary were remo.ed. he !atient was diagnosed with B 5. he !atient was diagnosed with A1&ib. :=RD

',@@ )**+ ')()C()*'% un0nown

(angina2 MI2 DA roub"e etc.# Beart

Didney ;rob"ems

=n.ironmenta" A""ergies

Menta" ;rob"ems Bea"th

7ather Mother /ister /ister

re"ationshi! re"ationshi! re"ationshi!

C@ -@ $$ $@

Cause o& Death (i& a!!"icab"e # ;ar0inson Es re"ated Mu"ti!"e /c"erosis

/tomach 6"cers

B"eeds =asi"y

By!ertension

A"coho"ism

:"aucoma

Diabetes

2 FAMILY MEDICAL HISTORY

Age (in years#

Arthritis

/ei4ures

Anemia

Asthma

Cancer

Comments9 Inc"ude date o& onset he !atientEs e"dest sister did not ha.e any o& the abo.e disease !rocesses.

1 IMMUNI%ATION HISTORY (May state 6 &or un0nown2 e3ce!t &or etanus2 7"u2 and ;na# Routine chi"dhood .accinations Routine adu"t .accinations &or mi"itary or &edera" ser.ice Adu"t Di!htheria (Date# Adu"t etanus ()**+# In&"uen4a (&"u# (,()*'%#

YES

NO

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

/tro0e

:out

umor

;neumococca" (!neumonia# (,()*'%# Ba.e you had any other .accines gi.en &or internationa" tra.e" or occu!ationa" !ur!oses> ;"ease List 1 ALLERGIES OR ADVERSE REACTIONS
5AM= o& Causati.e Agent

y!e o& Reaction (describe e3!"icit"y#

Medications

5DA

Other (&ood2 ta!e2 "ate32 dye2 etc.#

5DA

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

 & PATHOPHYSIOLOGY: (inc"ude A;A re&erence and in te3t citations# (Mechanics o& disease2 ris0 &actors2 how to diagnose2 how to treat2 !rognosis2 and inc"ude any genetic &actors im!acting the diagnosis2 !rognosis or treatment#
Asthma is a chronic disease that a&&ects the bronchio"es in the "ungs. he bronchio"es branch o&& &rom the bronchi and e.entua""y "ead to the a".eo"i. he bronchio"es are "ined with smooth musc"e and are ab"e to constrict or di"ate based on the needs o& the body. his a""ows the body to contro" how much air is de"i.ered to the a".eo"i. Asthma causes the bronchio"es o& the "ung to become in&"amed which causes bronchoconstriction2 or a narrowing o& the !assageway. his "eads to whee4ing2 shortness o& breath2 chest tightness2 and coughing. Fhen an asthma attac0 occurs2 the in&"ammatory res!onse in the bronchio"es "eads to swe""ing and a tightening o& the musc"es that surround the bronchio"e which drastica""y reduces the amount o& air that is ab"e to &"ow through the bronchio"es and be de"i.ered to the a".eo"i. Asthma can o&ten be triggered by breathing in a""ergens2 being e3!osed to a""ergens2 or changes in the en.ironment. Common triggers &or asthma inc"ude !et hair or dander2 dust mites2 medications2 changes in weather2 chemica"s in the air or in &ood2 e3ercise2 mo"d2 !o""en2 strong emotions such as stress2 tobacco smo0e2 or res!iratory in&ections such as a common co"d. It is not c"ear as to why some !eo!"e ha.e asthma2 and others do not2 but it is be"ie.ed to be a combination o& en.ironmenta" and genetic &actors. /ome ris0 &actors that increase a !ersonEs "i0e"ihood o& ha.ing asthma inc"ude ha.ing a &irst degree re"ati.e with asthma2 ha.ing another a""ergic condition such as hay &e.er2 being o.erweight2 being a smo0er2 e3!osure to second hand smo0e2 ha.ing a mother who smo0ed whi"e !regnant2 e3!osure to e3haust &umes or other ty!es o& !o""ution2 e3!osure to occu!ationa" triggers such as chemica"s used in &arming2 hairdressing2 or manu&acturing2 and a "ow birth weight. here are se.era" tests that may be used to diagnose asthma. he doctor wi"" most "i0e"y com!"ete a !hysica" e3am to ru"e out chronic obstructi.e !u"monary disorder (CO;D# or res!iratory in&ection and wi"" as0 Guestions about sym!toms that ha.e been e3!erienced and any other hea"th !rob"ems and the doctor wi"" a"so obser.e &or signs o& what a !atient is e3!eriencing. /!irometry and !ea0 &"ow meter tests may a"so be used to he"! aid in the diagnosis o& asthma. /!irometry measures how much air you can e3ha"e a&ter ta0ing a dee! breath and it a"so measures how &ast you can breathe out. he s!irometry test is used to estimate how much the bronchio"es ha.e constricted and narrowed. he !ea0 &"ow meter is a de.ice that a""ows the !ractitioner to see how hard you can e3ha"e. I& the !ea0 &"ow meter reading is "ow it can be a signa" to the hea"thcare !ro.ider that the !atientEs "ungs may not be wor0ing as we"" and that the asthma is getting worse. he "ung &unction tests are o&ten conducted be&ore and a&ter a bronchodi"ator is gi.en to determine i& the &unction o& the "ungs im!ro.es a&ter recei.ing medication that o!ens the airways o& the "ungs. I& "ung &unction im!ro.es a&ter recei.ing treatment with a bronchodi"ator then there is a high !robabi"ity that the diagnosis is asthma. A combination o& treatments is usua""y necessary to he"! contro" asthma and !re.ent acute asthma attac0s. It is im!ortant &or indi.idua"s to be aware o& their triggers and the necessary ste!s to a.oid the triggers. It is a"so recommended to trac0 oneEs breathing to ensure that the current asthma medications are 0ee!ing the sym!toms under contro". Medications are an im!ortant as!ect o& contro""ing oneEs asthma sym!toms and the right medications are de!endent on oneEs age2 sym!toms2 indi.idua" triggers2 and what combination wor0s best to 0ee! oneEs asthma under contro". he two main categories o& asthma medications inc"ude the "ong1term asthma contro" medications and Guic01re"ie& rescue medications. here are mu"ti!"e ty!es o& medications that &a"" under those two ty!es o& treatments2 but the "ong1term asthma contro" medications are genera""y ta0en e.ery day and he"! 0ee! asthma sym!toms at bay on a dai"y basis. he Guic01re"ie& or rescue medications are ta0en on an as needed basis and are used &or short1term2 .ery Guic0 sym!tom re"ie& during an asthma attac0. /ome o& the medications in this category can a"so be used be&ore e3ercise i& it is recommended by the hea"thcare !ro.ider. Asthma is a chronic disease that cannot be cured2 but with !ro!er treatment and a thorough understanding o& triggers and how to !re.ent e3!osure to triggers2 its sym!toms can be managed and contro""ed. (Mayo C"inic2 )*')#. :enetic &actors contributing to the de.e"o!ment o& asthma in an indi.idua" is estimated between %*H and -*H. he research conducted thus &ar has shown that asthma is autosoma" dominant2 meaning that on"y one !arent needs to !ass down the gene in order &or the chi"d to inherit the disease. here are se.era" candidate genes that are being studied with .ariations in ; :DR2 :;RA2 IRAD%2 CBI%L'2 B5M 2 and ADRB). here are se.era" other "oci that ha.e been associated with an increased susce!tibi"ity to asthma and inc"ude '!%'2 )!2 and 'CG)'. he inter!"ay o& genetic and en.ironmenta" &actors is com!"e32 but an increase in gene .ariation and the strong !ercentage o& the contribution o& genetic &actors can increase oneEs chance o& being diagnosed with asthma. (5ursing Centra"2 )*'%#.

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

 & MEDICATIONS: IInc"ude both !rescri!tion and O C? home (reconci"iation#2 routine2 and ;R5 medication. :i.e trade and
generic name.J
Na'e: am"odi!ine R!,te: ;O P/ar'a(e,t (a# (#a$$: ca"cium channe" b"oc0ers 0!t/

(5or.asc#

C!"(e"trat !" )'*/'#+ Fre-,e"(.: BID

D!$a*e A'!,"t: - mg

I"1 (at !": 6sed a"one or with other agents in the management o& hy!ertension2 angina !ectoris2 and .asos!astic angina. S 1e e22e(t$: headache2 di44iness2 &atigue2 peripheral edema2 angina2 bradycardia2 !a"!itations2 hy!otension2 ginigi.a" hy!er!"asia2 nausea2 &"ushing. N,r$ "* (!"$ 1erat !"$: Monitor B; and !u"se be&ore thera!y2 during dose titration2 and !eriodica""y during thera!y. Monitor =C: !eriodica""y during !ro"onged thera!y. Monitor inta0e and out!ut ratios and dai"y weight. Assess &or signs o& B7 (!eri!hera" edema2 ra"es(crac0"es2 dys!nea2 weight gain2 Kugu"ar .enous distention#. Assess "ocation2 duration2 intensity2 and !reci!itating &actors o& !atientLs angina" !ain. Na'e: ;ARo3etine (;a3i"# R!,te: ;O P/ar'a(e,t (a# (#a$$: se"ecti.e serotonin reu!ta0e inhibitors I"1 (at !": ;a3i" is used to treat genera"i4ed an3iety disorder. S 1e e22e(t$: : 5=6ROL=; IC MALI:5A5 /M5DROM=2 /6ICIDAL 0!t/ C!"(e"trat !" Fre-,e"(.: '3(day D!$a*e A'!,"t: )* mg

BO6:B /2 anxiety2 dizziness2 drowsiness2 headache2 insomnia2 weakness2 agitation2 amnesia2 con&usion2 emotiona" "abi"ity2 hango.er2 im!aired concentration2 ma"aise2 menta" de!ression2 synco!e b"urred .ision2 rhinitis cough2 !haryngitis2 res!iratory disorders2 yawning chest !ain2 edema2 hy!ertension2 !a"!itations2 !ostura" hy!otension2 tachycardia2 .asodi"ation constipation2 diarrhea2 dry mouth2 nausea2 abdomina" !ain2 N(O a!!etite2 dys!e!sia2 &"atu"ence2 taste disturbances2 .omiting2 ejaculatory disturbance2 N "ibido2 genita" disorders2 in&erti"ity2 urinary disorders2 urinary &reGuency2
sweating2 !hotosensiti.ity2 !ruritus2 rash2 weight gain("oss2 bac0 !ain2 bone &racture2 mya"gia2 myo!athy !aresthesia2 tremor2 /=RO O5I5 /M5DROM=2 chi""s2 &e.er N,r$ "* (!"$ 1erat !"$: Monitor a!!etite and nutritiona" inta0e. Feigh wee0"y. 5oti&y hea"th care !ro&essiona" o& continued weight "oss. AdKust diet as to"erated to su!!ort nutritiona" status. Monitor menta" status (orientation2 mood2 beha.ior#. In&orm hea"th care !ro&essiona" i& !atient demonstrates signi&icant increase in an3iety2 ner.ousness2 or insomnia. Assess &or serotonin syndrome (menta" changes Iagitation2 ha""ucinations2 comaJ2 autonomic instabi"ity Itachycardia2 "abi"e B;2 hy!erthermiaJ2 neuromuscu"ar aberations Ihy!er re&"e3ia2 incoordinationJ2 and(or :I sym!toms Inausea2 .omiting2 diarrheaJ#2 es!ecia""y in !atients ta0ing other serotonergic drugs (//RIs2 /5RIs2 tri!tans#. Assess &reGuency and se.erity o& e!isodes o& an3iety and assess the "e.e" o& an3iety be&ore(a&ter ta0ing the drug. Na'e: !rednisone R!,te: ;O P/ar'a(e,t (a# (#a$$: corticosteroid H!$p ta# C!"(e"trat !" Fre-,e"(.: '3(day D!$a*e A'!,"t: +* mg

I"1 (at !": 6sed systemica""y and "oca""y in a wide .ariety o& chronic diseases inc"uding9 In&"ammatory2 A""ergic2 Bemato"ogic2 5eo!"astic2 and Autoimmune disorders. S 1e e22e(t$: depression2 euphoria2 headache2 O intracrania" !ressure (chi"dren on"y#2 !ersona"ity changes2 !sychoses2 rest"essness2 cataracts2 O intraocu"ar !ressure2 hypertension, ;=; IC 6LC=RA IO52 anorexia2 nausea2 .omiting acne2 wound healing2 ecchymoses2 fragility2 hirsutism2 petechiae, adrenal suppression2 hy!erg"ycemia &"uid retention ("ong1term high doses#2 hy!o0a"emia2 hy!o0a"emic a"0a"osis2 BROMBO=MBOLI/M2 thrombo!h"ebitisweight gain2 weight "oss2 muscle wasting2 osteoporosis2 a.ascu"ar necrosis o& Koints2 musc"e !ain cushingoid appearance (moon face, buffalo hump)2 O susce!tibi"ity to in&ection N,r$ "* (!"$ 1erat !"$:. Assess in.o".ed systems (res!iratory# be&ore and !eriodica""y during thera!y. Assess !atient &or signs o& adrena" insu&&iciency (hy!otension2 weight "oss2 wea0ness2 nausea2 .omiting2 anore3ia2 "ethargy2 con&usion2 rest"essness# be&ore and !eriodica""y during thera!y. Monitor inta0e and out!ut ratios and dai"y weights. Obser.e !atient &or !eri!hera" edema2 steady weight gain2 ra"es(crac0"es2 or dys!nea. 5oti&y hea"th care !ro&essiona" i& these occur. Assess the !atient be&ore beginning thera!y to ensure there are no signs o& in&ection as corticosteroids can mas0 s(s o& in&ection. =ducate the !atient on the im!ortance o& s"ow"y discontinuing the medication as sudden disuse can "ead to adrena" insu&&iciency. Na'e: a"!ra4o"am (Pana3# C!"(e"trat !" D!$a*e A'!,"t: *.)- mg R!,te: ;O P/ar'a(e,t (a# (#a$$: ben4odia4a!enes 0!t/ Fre-,e"(.: ID

I"1 (at !": he medication is used &or genera"i4ed an3iety disorder2 !anic disorder2 and an3iety associated with de!ression. S 1e e22e(t$: dizziness2 drowsiness2 lethargy2 con&usion2 hango.er2 headache2 menta" de!ression2 !arado3ica" e3citation2 b"urred .ision2 consti!ation2 diarrhea2 nausea2 .omiting2 weight gain2 rash2 !hysica" de!endence2 !sycho"ogica" de!endence2 to"erance N,r$ "* (!"$ 1erat !"$: Assess degree and mani&estations o& an3iety and menta" status (orientation2 mood2 beha.ior# !rior to and !eriodica""y during thera!y. Assess !atient &or drowsiness2 "ight1headedness2 and di44iness. hese sym!toms usua""y disa!!ear as thera!y !rogresses but dose shou"d be reduced i& these sym!toms !ersist. Instruct !tEs to not drin0 gra!e&ruit Kuice whi"e ta0ing Pana32 a"coho" and C5/ de!ressants shou"d not be used concurrent"y with Pana3. Discuss with !t other non1!harmaco"ogica" techniGues to decrease an3iety2 such as e3ercise2 su!!ort grou!2 re"a3ation techniGues.

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

Na'e: !ante!ra4o"e (;rotoni3# R!,te: ;O P/ar'a(e,t (a# (#a$$: !roton1!um! inhibitors

C!"(e"trat !" Fre-,e"(.: '3(day 0!t/

D!$a*e A'!,"t: +* mg

I"1 (at !": 6sed &or the &o""owing conditions9 =rosi.e eso!hagitis associated with :=RD2 decrease re"a!se rates o& daytime and nighttime heartburn sym!toms on !atients with :=RD2 and !atho"ogic gastric hy!ersecretory conditions. S 1e e22e(t$: headache2 abdomina" !ain2 diarrhea2 eructation2 &"atu"ence2 hy!erg"ycemia2 hy!omagnesemia (es!ecia""y i& treatment duration Q% mo#2 bone &racture . N,r$ "* (!"$ 1erat !"$: Assess !atient routine"y &or e!igastric or abdomina" !ain and &or &ran0 or occu"t b"ood in stoo"2 emesis2 or gastric as!irate2 May cause hy!omagnesemia. Monitor serum magnesium !rior to and !eriodica""y during thera!y. Ad.ise !atient to a.oid a"coho"2 !roducts containing as!irin or 5/AIDs2 and &oods that may cause an increase in :I irritation. Ad.ise !atient to re!ort onset o& b"ac02 tarry stoo"s? diarrhea? or abdomina" !ain to hea"th care !ro&essiona" !rom!t"y. Na'e: &"uticasone1sa"metero"2 Ad.air Dis0us )-*(-* R!,te: ;O inha"ation C!"(e"trat !" Fre-,e"(.: ' !u&& BID D!$a*e A'!,"t: &"uticasone )-* mcg? sa"metero" -* mcg

P/ar'a(e,t (a# (#a$$: &"uticasone9 corticosteroids? sa"metero"9 0!t/ adrenergics I"1 (at !": &"uticasone9 maintenance and !ro!hy"actic treatment o& asthma. /a"metero"9 as concomitant thera!y &or the treatment o& asthma and the !re.ention o& bronchos!asm in !atients who are current"y ta0ing but are inadeGuate"y contro""ed on a "ong1term asthma1contro" medication (e.g. inha"ed corticosteroid#. S 1e e22e(t$ )2#,t (a$!"e+: headache, di44iness2 dys!honia2 hoarseness2 oro!haryngea" &unga" in&ections2 nasa" stu&&iness2 rhinorrhea2 sinusitis2 bronchos!asm2 cough2 u!!er res!iratory tract in&ection2 whee4ing2 diarrhea2 adrena" su!!ression2 decreased bone minera" density2 decreased growth in chi"dren2 CushingEs syndrome.2 musc"e !ain2 BM;=R/=5/I IAI M R=AC IO5 I5CL6DI5: A5A;BMLAPI/2 LARM5:=AL =D=MA2 6R ICARIA2 A5D BRO5CBO/;A/M2 CB6R:1/ RA6// /M5DROM=2 &e.er. N,r$ "* (!"$ 1erat !"$: Monitor res!iratory status and "ung sounds. Monitor &or signs and sym!toms o& hy!ersensiti.ity reactions !eriodica""y during thera!y. Ad.ise !atient to sto! using medication and noti&y hea"th care !ro&essiona" immediate"y i& signs and sym!toms o& hy!ersensiti.ity reactions occur. Instruct !atient in the !ro!er use o& the metered1dose inha"er. Instruct !atient when using inha"ation corticosteroids and bronchodi"ator to use bronchodi"ator &irst and to a""ow min to e"a!se be&ore administering the corticosteroid. S 1e e22e(t$ )$a#'eter!#+: headache, ner.ousness2 !a"!itations2 tachycardia2 abdomina" !ain2 diarrhea2 nausea2 musc"e cram!s(soreness2 tremb"ing2 A/ BMA1R=LA =D D=A B2 !arado3ica" bronchos!asm2 cough. N,r$ "* (!"$ 1erat !"$: Assess "ung sounds2 !u"se2 and B; be&ore administration and !eriodica""y during thera!y. Obser.e &or !arado3ica" bronchos!asm and hy!ersensiti.ity reaction Na'e: ri.aro3aban (Pare"to# R!,te: ;O P/ar'a(e,t (a# (#a$$: antithrombotic2 &actor 3a inhibitors 0!t/ C!"(e"trat !" Fre-,e"(.: R;M D!$a*e A'!,"t: )* mg

I"1 (at !": ;re.ention o& dee! .ein thrombosis that may "ead to !u"monary embo"ism &o""owing 0nee or hi! re!"acement thera!y. ( his is the indication "isted in Da.is Drug :uide2 a"though she did not ha.e 0nee or hi! re!"acement surgery# S 1e e22e(t$: : synco!e2 b"ister2 !rutitus2 BL==DI5:2 wound secretion2 e3tremity !ain2 musc"e s!asm N,r$ "* (!"$ 1erat !"$: Assess &or signs o& b"eeding and hemorrhage (b"eeding gums? noseb"eed? unusua" bruising? b"ac02 tarry stoo"s? hematuria? &a"" in hematocrit or B;? guaiac1!ositi.e stoo"s#? b"eeding &rom surgica" site. 5oti&y hea"th care !ro&essiona" i& these occur. Instruct !atient not to drin0 a"coho" or ta0e other R32 O C2 or herba" !roducts2 es!ecia""y those containing as!irin or 5/AIDs2 or to start or sto! any new medications during thera!y without ad.ice o& hea"th care !ro&essiona". Na'e: 4o"!idem (Ambien# R!,te: ;O P/ar'a(e,t (a# (#a$$: nonben4odia4e!ene :ABAa rece!tor agonist I"1 (at !": 6sed &or insomnia S 1e e22e(t$: daytime drowsiness2 dizziness2 abnorma" thin0ing2 amnesia2 beha.ior changes2 SdruggedS &ee"ing2 ha""ucinations2 s"ee!1dri.ing2 diarrhea2 nausea2 .omiting2 A5A;BMLAC IC R=AC IO5/2 hy!ersensiti.ity reactions2 !hysica" de!endence2 !sycho"ogica" de!endence2 to"erance N,r$ "* (!"$ 1erat !"$: Assess menta" status2 s"ee! !atterns2 and !otentia" &or abuse !rior to administration. ;ro"onged use o& TC8'* days may "ead to !hysica" and !sycho"ogica" de!endence. Limit amount o& drug a.ai"ab"e to the !atient .Assess a"ertness at time o& !ea0 e&&ect. 5oti&y hea"th care !ro&essiona" i& desired sedation does not occur. Assess !atient &or !ain. Medicate as needed. 6ntreated !ain decreases sedati.e e&&ects. Instruct !t to not dri.e or !arta0e in other acti.ities that reGuire a"ertness unti" the res!onse to the medication is 0nown. H!$p ta# C!"(e"trat !" Fre-,e"(.: B/ D!$a*e A'!,"t: - mg

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

 & NUTRITION: Inc"ude ty!e o& diet2 )+ BR a.erage home diet2 and your nutritiona" ana"ysis with recommendations.
Diet ordered in hos!ita"> Regu"ar diet Diet !t &o""ows at home> Regu"ar diet )+ BR a.erage home diet9 Brea0&ast9 one banana Lunch9 banana2 sandwich made o& )1% ounces o& rotisserie chic0en2 ' ts!. o& mustard2 and ) s"ices o& who"e wheat bread2 and ) ounces o& cut u! cheese Ana"ysis o& home diet (Com!are to My ;"ate and Consider co1morbidities and cu"tura" considerations#9 According to My;"ate there are a "ot o& im!ortant nutrients that the !atient is not consuming in her diet. he !atient is not consuming enough who"e grains2 .egetab"es2 who"e &ruit2 or dairy. he !atient cou"d increase her who"e grains by eating cerea" or who"e wheat toast &or brea0&ast2 and cou"d increase her who"e &ruit inta0e by adding in another sma"" ser.ing o& &ruit as a snac0 in the morning or a&ternoon. he !atient cou"d incor!orate some o& her &a.orite .egetab"es into her dinner or snac0 on raw ones throughout the day. =ating &oods "i0e yogurt or drin0ing mi"0 wi"" a"so he"! increase the amount o& dairy the !atient is consuming.

Dinner9 $ ounce sir"oin2 ba0ed !otato with '1) ts! o& butter /nac0s9 )1% dar0 choco"ate candies LiGuids (inc"ude a"coho"#9 he !atient on"y drin0s water and stated she consumes about )+ ounces(day.
6se this "in0 &or the nutritiona" ana"ysis by com!aring the !atients )+ BR a.erage home diet to the recommended !ortions2 and use My ;"ate as re&erence.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are !rom!ts designed to he"! guide your discussion#
Fho he"!s you when you are i""> My UbrotherE and my son. Bow do you genera""y co!e with stress> or Fhat do you do when you are u!set> he !atient re!orted that she used to ha.e better co!ing s0i""s when she was seeing a counse"or2 but now she re"ies a "ot on her an3iety medications. Recent di&&icu"ties (7ee"ings o& de!ression2 an3iety2 being o.erwhe"med2 re"ationshi!s2 &riends2 socia" "i&e# he !atient stated that her recent i""nesses ha.e caused a "ot o& an3iety &or her. he !atient wor0s &or Bay&ront and is ner.ous that she cou"d !otentia""y "ose her Kob because o& a"" the time she has had to ta0e o&& o& wor0. he !atient stated that she was .ery an3ious o.er her high b"ood !ressure and she a"so did not "i0e the &act that they were not gi.ing her the same medications that she too0 at home. he !atient re!orted that she &ee"s as i& her inabi"ity to s"ee! has a"so made her &ee" more an3ious.

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

32 DOMESTIC VIOLENCE ASSESSMENT Consider beginning with: !nfortunately many, children, as well as adult women and men ha"e been or currently are unsafe in their relationships in their homes# $ am going to ask some %uestions that help me to make sure that you are safe#& Ba.e you e.er &e"t unsa&e in a c"ose re"ationshi!> Mes2 many years ago. Ba.e you e.er been ta"0ed down to> Mes. Ba.e you e.er been hit !unched or s"a!!ed> Mes2 my &iancV !unched me in the &ace2 but I ended u! not marrying him. Ba.e you been emotiona""y or !hysica""y harmed in other ways by a !erson in a c"ose re"ationshi! with you> 5o. I& yes2 ha.e you sought he"! &or this> WWWWWWWWWWWWWWWWWWWWWW Are you current"y in a sa&e re"ationshi!> IEm not current"y in a re"ationshi!.

4 DEVELOPMENTAL CONSIDERATIONS:
=ri0sonEs stage o& !sychosocia" de.e"o!ment9
In&eriority Identity .s. Ro"e Con&usion(Di&&usion rust .s. Mistrust Autonomy .s. Doubt X /hame Initiati.e .s. :ui"t Industry .s. Intimacy .s. Iso"ation :enerati.ity .s. /e"& absor!tion(/tagnation =go Integrity .s. Des!air

Chec0 one bo3 and gi.e the te3tboo0 de&inition (with citation and re&erence# o& both !arts o& =ric0sonEs de.e"o!menta" stage &or your !atientEs age grou!9 he stage o& :enerati.ity .s. /e"&1absor!tion(/tagnation is &or indi.idua"s that are in their +*Es1$*Es. <anet Be"s0y ()**C# de&ines =ri0sonEs stage o& generati.ity as the !hase in which indi.idua"s &ind meaning in their "i&e through the care and enrichment o& others. his can be through &ostering the ne3t generation2 ta0ing care o& others2 or he"!ing others through oneEs Kob. Fhen someone has not achie.ed generati.ity2 it causes &ee"ings o& stagnation2 and a "oss o& a sense o& !ur!ose in oneEs "i&e. Describe the stage your !atient is in and gi.e the characteristics that the !atient e3hibits that "ed you to your determination9 I be"ie.e the !atient is in the stage o& generati.ity. he !atient to"d me se.era" times about how she wor0ed &or Bay&ront and that she rea""y enKoys her Kob. he !atient was ho!e&u" that this year wou"d be a better year and that she wou"dnEt ha.e to be in and out o& the hos!ita" as much. he !atient seems to ta0e !ride in her wor02 her a!!earance2 and in her son. /he s!ent a "ot o& time te""ing me about her son and that she was going to ha.e a grandson soon. here was nothing that the !atient said that made it seem as i& she &e"t "i0e she had "ost a sense o& !ur!ose in her "i&e. Describe what im!act o& disease(condition or hos!ita"i4ation has had on your !atientEs de.e"o!menta" stage o& "i&e9 he !atient has a diagnosis o& an3iety2 so I thin0 her being in the hos!ita" and not s"ee!ing we"" has caused her to &ee" more an3ious2 but I donEt be"ie.e that has changed her de.e"o!menta" stage to se"&1absor!tion(stagnation. he !atient said se.era" times that she 0nows i& she cou"d get home and get some s"ee! that she wou"d &ee" a "ot better.

Fhat do you thin0 is the cause o& your i""ness> My asthma is not !sychosomatic2 I donEt be"ie.e itEs r(t my an3iety. Fhat does your i""ness mean to you> ItEs a !ain in the ass. Fhen I got used to ta0ing Ad.air2 my asthma was !retty we"" managed2 but itEs been getting worse.

33 SE5UALITY ASSESSMENT: )t/e 2!##!6 "* prompts 'a. /e#p t! *, 1e .!,r 1 $(,$$ !"+
Consider beginning with: $ 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 %uality of life# (ll of these %uestions are confidential and protected in your medical record& Ba.e you e.er been se3ua""y acti.e> Mes. Do you !re&er women2 men or both genders> Men2 on"y men. Are you aware o& e.er ha.ing a se3ua""y transmitted in&ection> Mes2 but I was dating a doctor at the time and had it ta0en care o&. Ba.e you or a !artner e.er had an abnorma" !a! smear> 5o. Ba.e you or your !artner recei.ed the :ardasi" (B;A# .accination> 5(A

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

Are you current"y se3ua""y acti.e> 5o2 but not necessari"y by choice. Fhen se3ua""y acti.e2 what measures do you ta0e to !re.ent acGuiring a se3ua""y transmitted disease or an unintended !regnancy> I usua""y 0now the !erson .ery we"" be&ore I am with them in that way. Bow "ong ha.e you been with your current !artner> 5(A Ba.e any medica" or surgica" conditions changed your abi"ity to ha.e se3ua" acti.ity> 5o. Do you ha.e any concerns about se3ua" hea"th or how to !re.ent se3ua""y transmitted disease or unintended !regnancy> 5o.

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

71 SPIRITUALITY ASSESSMENT: (inc"uding but not "imited to the &o""owing Guestions#

Fhat im!ortance does re"igion or s!iritua"ity ha.e in your "i&e> My re"igion has become rea""y im!ortant to me2 es!ecia""y the o"der I get. IE.e a"ways grown u! going to church2 and it is a source o& com&ort. Do your re"igious be"ie&s in&"uence your current condition> 5o2 I wou"d ne.er re&use he"! &or my medica" condition.

33 SMO8ING9 CHEMICAL USE9 OCCUPATIONAL/ENVIRONMENTAL E5POSURES:

'. Does the !atient current"y2 or has he(she e.er smo0ed or used chewing tobacco> I& so2 what> Bow much>(s!eci&y dai"y amount# Mes 5o 5 7or how many years> P years
(age thru #

;ac0 Mears9 Does anyone in the !atientEs househo"d smo0e tobacco> I& so2 what2 and how much> 5o

I& a!!"icab"e2 when did the !atient Guit> Bas the !atient e.er tried to Guit>

). Does the !atient drin0 a"coho" or has he(she e.er dran0 a"coho"> Mes 5 5o Fhat> Bow much> (gi.e s!eci&ic .o"ume# 7or how many years> (age )* thru !resent # Fhite 4in&ande" '$ ounces(day2 e.eryday I& a!!"icab"e2 when did the !atient Guit> %. Bas the !atient e.er used street drugs such as mariKuana2 cocaine2 heroin2 or other> Mes 5o 5 I& so2 what> Bow much> 7or how many years>
(age thru #

Is the !atient current"y using these drugs> Mes 5o

I& not2 when did he(she Guit>

+. Ba.e you e.er2 or are you current"y e3!osed to any occu!ationa" or en.ironmenta" Ba4ards(Ris0s he !atient re!orted that she wor0ed &or /t. ;ete imes and !eo!"e used to smo0e in the o&&ice and she was e3!osed to a "ot o& second hand smo0e.

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

'*

 1: REVIE; OF SYSTEMS
Ge"era# C!"$t t,t !"
Recent weight "oss or gain

Ga$tr! "te$t "a#

5ausea2 .omiting2 or diarrhea Consti!ation Irritab"e Bowe" :=RD Cho"ecystitis Indigestion :astritis ( 6"cers Bemorrhoids B"ood in the stoo" Me""ow Kaundice Be!atitis ;ancreatitis Co"itis Di.erticu"itis A!!endicitis Abdomina" Abscess Last co"onosco!y> )*'* Other9

I'',"!#!* (
Chi""s with se.ere sha0ing 5ight sweats (a&ter hysterectomy# 7e.er BIA or AID/ Lu!us Rheumatoid Arthritis /arcoidosis umor (benign &ibroid tumors# Li&e threatening a""ergic reaction =n"arged "ym!h nodes Other9

I"te*,'e"tar.
Changes in a!!earance o& s0in ;rob"ems with nai"s Dandru&& ;soriasis Bi.es or rashes /0in in&ections 6se o& sunscreen no /;79 Bathing routine9 shower e.eryday Other9

HEENT
Di&&icu"ty seeing Cataracts or :"aucoma Di&&icu"ty hearing =ar in&ections /inus !ain or in&ections 5ose b"eeds ;ost1nasa" dri! Ora"(!haryngea" in&ection Denta" !rob"ems (teeth e3tracted# Routine brushing o& teeth ) 3(day Routine dentist .isits '3(year Aision screening Other9

He'at!#!* (/O"(!#!* (
Anemia B"eeds easi"y Bruises easi"y Cancer B"ood rans&usions B"ood ty!e i& 0nown9 OY Other9

Ge" t!,r "ar.

nocturia dysuria hematuria !o"yuria 0idney stones 5orma" &reGuency o& urination9 B"adder or 0idney in&ections

- 3(day

Meta<!# (/E"1!(r "e

Diabetes y!e9 By!othyroid (By!erthyroid Into"erance to hot or co"d Osteo!orosis Other9

P,#'!"ar.
Di&&icu"ty Breathing Cough 1 dry or !roducti.e Asthma Bronchitis =m!hysema ;neumonia ubercu"osis =n.ironmenta" a""ergies "ast CPR> '()*()*'+ Other9

Ce"tra# Ner=!,$ S.$te'

;OMEN ONLY In&ection o& the &ema"e genita"ia Month"y se"& breast e3am 7reGuency o& !a!(!e".ic e3am Date o& "ast gyn e3am> ) years ago menstrua" cyc"e regu"ar irregu"ar menarche age> ') meno!ause age> 5A (!artia" hysterectomy# Date o& "ast Mammogram XResu"t9 )*'%2 negati.e Date o& D=PA Bone Density X Resu"t9 )*'*2 no osteo!orosis MEN ONLY In&ection o& ma"e genita"ia(!rostate> 7reGuency o& !rostate e3am> Date o& "ast !rostate e3am> B;B 6rinary Retention CAA Di44iness /e.ere Beadaches Migraines /ei4ures remors (right hand# =nce!ha"itis Meningitis Other9

Car1 !=a$(,#ar
By!ertension By!er"i!idemia Chest !ain ( Angina Myocardia" In&arction CAD(;AD CB7 Murmur hrombus Rheumatic 7e.er Myocarditis Arrhythmias

Me"ta# I##"e$$
De!ression /chi4o!hrenia An3iety Bi!o"ar Other9

M,$(,#!$>e#eta#
InKuries or 7ractures Fea0ness ;ain :out Osteomye"itis

C/ #1/!!1 D $ea$e$
Meas"es Mum!s ;o"io /car"et 7e.er

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

''

Last =D: screening2 when> '()'()*'+ Other9

Arthritis Other9

Chic0en ;o3 Other9

Is there any !rob"em that is not mentioned that your !atient sought medica" attention &or with anyone> 5o.

Any other Guestions or comments that your !atient wou"d "i0e you to 0now> 5o.

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

')

71: PHYSICAL E5AMINATION:(Describe abnorma" assessment be"ow non chec0ed bo3es#

:enera" /ur.ey9 he !atient is Beight9 -E- Feight9 )'+ BMI9 %-.$ ;ain9 (inc"ude rating X "ocation# a $% year o"d woman that is ;u"se9 $* B"ood *('* c"ean and dressed ;ressure9 '@)(@* Le&t &orearm (inc"ude "ocation# a!!ro!riate"y. /he is .ery concerned about her a!!earance and made se.era" remar0s in regards to not being ab"e to ta0e care o& herse"& the !ast se.era" days and a!o"ogi4ing &or her a!!earance. em!erature9 (route ta0en># Res!irations9 '$ ,C.C2 ora" /!O)? ,% Is the !atient on Room Air or O)9 RA O.era"" A!!earance9 IDress(grooming(!hysica" handica!s(eye contactJ c"ean2 hair combed2 dress a!!ro!riate &or setting and tem!erature2 maintains eye contact2 no ob.ious handica!s O.era"" Beha.ior9 Ie.g.9 a!!ro!riate(rest"ess(odd mannerisms(agitated("ethargic(otherJ awa0e2 ca"m2 re"a3ed2 interacts we"" with others2 Kudgment intact he !atient interacted we""2 but she was an3ious throughout the inter.iew !rocess. he !atient o&ten com!"ained o& being tired2 but did not want me to "ea.e so that she cou"d rest. /he a"so re!eated herse"& se.era" times in regards to &ee"ing an3ious and wanting her medications. /!eech9 Ie.g.9 c"ear(mumb"es (ra!id (s"urred(si"ent(otherJ c"ear2 cris! diction Mood and A&&ect9 !"easant coo!erati.e cheer&u" a!athetic bi4arre agitated an3ious tear&u" Other9 I"te*,'e"tar. /0in is warm2 dry2 and intact /0in turgor e"astic 5o rashes2 "esions2 or de&ormities 5ai"s without c"ubbing Ca!i""ary re&i"" Z % seconds Bair e.en"y distributed2 c"ean2 without .ermin ta"0ati.e withdrawn Guiet boisterous aggressi.e hosti"e &"at "oud

;eri!hera" IA site y!e9 )) gauge no redness2 edema2 or discharge 7"uids in&using> no yes 1 what> ;eri!hera" IA site y!e9 no redness2 edema2 or discharge 7"uids in&using> no yes 1 what> Centra" access de.ice y!e9 7"uids in&using> no yes 1 what>

Location9 R wrist Location9 Location9

Date inserted9 '()*('+ Date inserted9 Date inserted9

HEENT: 7acia" &eatures symmetric 5o !ain in sinus region 5o !ain2 c"ic0ing o& M< rachea mid"ine hyroid not en"arged 5o !a"!ab"e "ym!h nodes sc"era white and conKuncti.a c"ear? without discharge =yebrows2 eye"ids2 orbita" area2 eye"ashes2 and "acrima" g"ands symmetric without edema or tenderness

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

'%

;=RRLA !u!i" si4e + (+ mm ;eri!hera" .ision intact =OM intact through $ cardina" &ie"ds without nystagmus =ars symmetric without "esions or discharge Fhis!er test heard9 right ear1 $ inches X "e&t ear1 $ inches 5ose without "esions or discharge Li!s2 bucca" mucosa2 &"oor o& mouth2 X tongue !in0 X moist without "esions Dentition9 he !atient has se.era" teeth that are missing due to e3traction. Otherwise2 dentition is intact. Comments9

6ni.ersity o& /outh 7"orida Co""ege o& 5ursing 8 Re.ision August )*'%

'+

P,#'!"ar./T/!ra?:

Res!irations regu"ar and un"abored rans.erse to A; ratio )9' Chest e3!ansion symmetric Lungs c"ear to auscu"tation in a"" &ie"ds without ad.entitious sounds? FB in a"" "obes CL 8 C"ear ;ercussion resonant throughout a"" "ung &ie"ds2 du"" towards !osterior bases
FB 8 Fhee4es CR 1 Crac0"es RB 8 Rhonchi D 8 Diminished / 8 /tridor Ab 1 Absent

/!utum !roduction9 thic0 thin Amount9 scant sma"" moderate "arge Co"or9 white !a"e ye""ow ye""ow dar0 ye""ow green gray "ight tan brown red

Car1 !=a$(,#ar: 5o "i&ts2 hea.es2 or thri""s ;MI &e"t at9 -th IC/2 MCL Beart sounds9 /' /) Regu"ar Irregu"ar 5o murmurs2 c"ic0s2 or ad.entitious heart sounds Rhythm (&or !atients with =C: tracing 8 ta!e $ second stri! be"ow and ana"y4e#

5o <AD

Ca"& !ain bi"atera""y negati.e ;u"ses bi"atera""y eGua" Irating sca"e9 *1absent2 '1bare"y !a"!ab"e2 )1wea02 %1norma"2 +1boundingJ A!ica" !u"se9 % Carotid9 % Brachia"9 ) Radia"9 % 7emora"9 ;o!"itea"9 ) D;9 ) ; 9 ) 5o tem!ora" or carotid bruits =dema9 Irating sca"e9 *1none2 Y' ('1)mm#2 Y) (%1+mm#2 Y% (-1$mm#2 Y+(C1@mm# J Location o& edema9 !itting non1!itting =3tremities warm with ca!i""ary re&i"" "ess than % seconds

GI/GU: Bowe" sounds acti.e 3 + Guadrants? no bruits auscu"tated 5o organomega"y ;ercussion du"" o.er "i.er and s!"een and tym!anic o.er stomach and intestine Abdomen non1tender to !a"!ation 6rine out!ut9 C"ear C"oudy Co"or9 ;re.ious )+ hour out!ut9 mLs 5(A 7o"ey Catheter 6rina" or Bed!an Bathroom ;ri.i"eges without assistance or with assistance CAA !unch without rebound tenderness Last BM9 (date *' ( )* ()*'+ # 7ormed /emi1&ormed 6n&ormed /o&t Bard LiGuid Fatery Co"or9 Light brown Medium Brown Dar0 Brown Me""ow :reen Fhite Co&&ee :round Maroon Bright Red
Bemoccu"t !ositi.e ( negati.e ("ea.e b"an0 i& not done#

:enita"ia9 C"ean2 moist2 without discharge2 "esions or odor Other 8 Describe9

5ot assessed2 !atient a"ert2 oriented2 denies !rob"ems

M,$(,#!$>e#eta#: 5 7u"" ROM intact in a"" e3tremities without cre!itus1yes /trength bi"atera""y eGua" at WWWW+WWW R6= WWWWW+WW L6= WWWW-WWW RL=

X WWWW-WWW in LL=

Irating sca"e9 *1absent2 '1trace2 )1not against gra.ity2 %1against gra.ity but not against resistance2 +1against some resistance2 -1against &u"" resistanceJ

.ertebra" co"umn without 0y!hosis or sco"iosis 5euro.ascu"ar status intact9 !eri!hera" !u"ses !a"!ab"e2 no !ain2 !a""or2 !ara"ysis or !arathesias

Ne,r!#!* (a#: ;atient awa0e2 a"ert2 oriented to !erson2 !"ace2 time2 and date Con&used? i& con&used attach mini menta" e3am C5 )1') gross"y intact /ensation intact to touch2 !ain2 and .ibration RombergEs 5egati.e1unab"e to assess2 !atient didnEt &ee" com&ortab"e standing u! /tereognosis2 gra!hesthesia2 and !ro!rioce!tion intact :ait smooth2 regu"ar with symmetric "ength o& the stride1 didnEt assess2 !atient didnEt want to stand u!# D R9 Irating sca"e9 *1absent2 Y' s"uggish(diminished2 Y) acti.e(e3!ected2 Y% s"ight"y hy!eracti.e2 Y+ By!eracti.e2 with intermittent or transient c"onusJ
rice!s9 Bice!s9 Brachioradia"9 ;ate""ar9 Achi""es9 An0"e c"onus9 !ositi.e negati.e Babins0i9 !ositi.e negati.e

1didnEt ha.e re&"e3 hammer to test D R

71: PERTINENT LA0 VALUES AND DIAGNOSTIC TEST RESULTS (inc"ude !ertinent norma"s as we"" as abnorma"s2 inc"ude rationa"e and ana"ysis. List dates with a"" "abs and diagnostic tests#9

A"a#.$ $ he administration o& '()*()*'+ corticosteroids '()'()*'+ (!rednisone# can cause an increase in b"ood g"ucose "e.e"s. he corticosteroids stimu"ate the "i.er to !roduce more g"ucose and they b"oc0 insu"inEs abi"ity to remo.e g"ucose &rom the b"ood into the ce"". T/e pat e"t a#$! /a1 a (/e$t ?@ra. 1!"e 6/ (/ 6a$ t! <e (!'pare1 t! !"e pre= !,$#. (!'p#ete1 !" 1/1A/2:14. T/e rep!rt "!te1 t/at t/ere 6a$ r */t <a$ #ar a r$pa(e 1 $ea$e t/at 'a. re2#e(t $,<$e*'e"ta# ate#e(ta$ $ =er$,$ p"e,'!" a 2 t/ $ $ "1 (ate1 (# " (a##.. 32 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet2 .ita"s2 acti.ity2 schedu"ed diagnostic tests2 consu"ts2 accu chec0s2 etc. A"so !ro.ide rationa"e and &reGuency i& a!!"icab"e.# he !atient is on a regu"ar diet and her .ita"s are to be ta0en !er nursing unit standard. he standard on %5 is to ta0e the .ita"s twice during each shi&t. he !atient is to ha.e continuous ;u"se O3 monitoring to determine whether o3ygen is needed. he !atient is to recei.e o3ygen !.r.n. he !atient was to recei.e IA /o"u1Medro" as we"" as IA &"uid hydration. he /o"u1Medro" was discontinued on '()'()*'+. he !atient was to recei.e breathing treatments through res!iratory thera!y and a !u"monary consu"t was ordered. he !atientEs home medications were to be continued !er medication reconci"iation. he !atient is a"so !"aced on a te"emetry machine due to a recent diagnosis o& A1&ib.

La< :"ucose '%$ mg(dL 'CC mg(dL 5orma" Random g"ucose test Z)** mg(dL

Date$

Tre"1 he !atientEs b"ood g"ucose "e.e"s are trending u!2 but they are sti"" within the norma" range &or a random g"ucose test.

 B NURSING DIAGNOSES (actua" and !otentia" 1 "isted in order o& !riority#

'. Ine&&ecti.e airway c"earance r(t tracheobronchia" narrowing A=B ins!iratory and e3!iratory whee4es ). Acti.ity into"erance r(t &atigue A=B the !atient &ee"ing "ightheaded &rom sitting u! &or a &ew minutes. %. /"ee! de!ri.ation r(t ine&&ecti.e breathing !attern A=B !atientEs com!"aint o& not being ab"e to s"ee! the !ast two nights due to whee4ing and being in the hos!ita". +. -.

7 1& CARE PLAN N,r$ "* D a*"!$ $: Ine&&ecti.e airway c"earance r(t tracheobronchia" narrowing A=B ins!iratory and e3!iratory whee4es. (Ac0"ey X Ladwig2 )*'%# Pat e"t G!a#$/O,t(!'e$ N,r$ "* I"ter=e"t !"$ t! A(/ e=e Rat !"a#e 2!r I"ter=e"t !"$ E=a#,at !" !2 G!a# !" Da. (are $ G!a# Pr!= 1e Re2ere"(e$ Pr!= 1e1 '. he !atient wi"" maintain a '. ;osition the c"ient to o!timi4e '. An u!right !osition a""ows &or '. he !atientEs BOB was e"e.ated !atent airway at a"" times during res!iration (BOB e"e.ated %*1+ma3ima" "ung e3!ansion? "ying &"at to %*1+- degrees. my shi&t. degrees2 and i& !atient unab"e to get causes abdomina" organs to shi&t ). AB:Es were not com!"eted on u!2 re!osition G) hours#. toward the chest2 which crowds the the !atient2 but the !atientEs !u"se ). Monitor b"ood gas .a"ues and "ungs and ma0es it more di&&icu"t to o3 was monitored to ensure "e.e"s !u"se o3ygen saturation "e.e"s as breathe. abo.e ,*H. a.ai"ab"e ). An o3ygen saturation o& "ess %. I chec0ed the !atientEs %. Monitor res!iratory !atterns2 than ,*H (norma"9 ,-H to '**H# res!iratory !atterns inc"uding2 rate2 inc"uding rate2 de!th2 and e&&ort. or a !artia" !ressure o& o3ygen o& de!th and e&&ort2 and the !ct a"so +.[ Administer medications such as "ess than @* (norma"9 @* to '**# chec0ed the !atientEs res!iratory bronchodi"ators or inha"ed steroids indicates signi&icant o3ygenation rate as !art o& the .ita"s. as ordered. Fatch &or side e&&ects !rob"ems. his a""ows the nurse to +. he nurse administered Ad.air such as tachycardia or an3iety with monitor the !atientEs o3ygen dis0us and !rednisone to the bronchodi"ators. saturation "e.e"s. !atient. -. Administer o3ygen as ordered. %. A norma" res!iratory rate &or an -. he doctor ordered o3ygen !rn2 adu"t without dys!nea is ') to '$. but the !atient was doing &ine on I& secretions are !resent in the RA. airway2 the res!iratory rate wi"" increase. +. Bronchodi"ators decrease airway resistance and im!ro.e the e&&iciency o& res!iratory mo.ements. -. O3ygen administration has been shown to correct hy!o3emia. ). he !atient wi"" demonstrate '. Auscu"tate breath sounds G '1+ '. Breath sounds are norma""y c"ear '. he doctor2 nurse2 and I a"" e&&ecti.e coughing and c"ear breath hours. or scattered &ine crac0"es at bases2 "istened to the !atientEs breath sounds by the end o& my shi&t. ).[ Be"! the c"ient dee! breathe which c"ear with dee! breathing? sounds2 but I donEt thin0 they were and !er&orm contro""ed coughing. whee4ing indicates an airway being auscu"tated e.ery '1+ hours. Ba.e the c"ient inha"e dee!"y2 ho"d obstruction. ). his did not ha!!en during my breath &or se.era" seconds2 and ). he techniGue can he"! increase shi&t.

cough two or three times with mouth o!en whi"e tightening the u!!er abdomina" musc"es. %. [=ncourage acti.ity and ambu"ation as to"erated.

s!utum c"earance and decrease cough s!asms. Contro""ed coughing uses the dia!hragmatic musc"es2 ma0ing the cough more &orce&u" and e&&ecti.e. %. Body mo.ement he"!s mobi"i4e secretions.

%. he nurse encouraged the !atient to get u! and use the restroom with assistance. I a"so !"anned on ha.ing the !atient sit u! so I cou"d !er&orm !art o& my e3am but she was unab"e due to &ee"ing "ightheaded.

72 DISCHARGE PLANNING: (!ut a [ in &ront o& any !t education in abo.e care !"an that you wou"d inc"ude &or discharge teaching#
C!"$ 1er t/e 2!##!6 "* "ee1$: P // Consu"t1the !atient may need assistance in com!"eting the 7MLA !a!erwor0 to submit to her em!"oyer? a"so may need re&erra" &or thera!y due to an3iety P Dietary Consu"t1the !atient is obese and is not eating enough o& the reGuired nutrients2 dietary cou"d assist her in mea" !"anning2 etc. \; ( O \;astora" Care \Durab"e Medica" 5eeds \7(6 a!!ts \Med Instruction(;rescri!tion \ are any o& the !atientEs medications a.ai"ab"e at a discount !harmacy> \Mes \ 5o \Rehab( BB \;a""iati.e Care

7 1& CARE PLAN N,r$ "* D a*"!$ $: /"ee! de!ri.ation r(t ine&&ecti.e breathing !attern A=B !atientEs com!"aint o& not being ab"e to s"ee! the !ast two nights due to whee4ing and being in the hos!ita". (Ac0"ey X Ladwig2 )*'%#. Pat e"t G!a#$/O,t(!'e$ N,r$ "* I"ter=e"t !"$ t! A(/ e=e Rat !"a#e 2!r I"ter=e"t !"$ E=a#,at !" !2 I"ter=e"t !"$ !" G!a# Pr!= 1e Re2ere"(e$ Da. (are $ Pr!= 1e1 '. he !atient wi"" awa0en '. Obtain a s"ee! history inc"uding '. Assessment o& s"ee!1wa0e '. his inter.ention was not re&reshed and be "ess &atigued bedtime routines2 s"ee! !atterns2 beha.ior !atterns is an im!ortant initiated as &ar as I 0now. during the day by the time o& use o& medications and stimu"ants2 !art o& any hea"th status ). he doctor e3!"ained to the discharge. use o& com!"ementary(a"ternati.e e3amination. !atient that because she sti"" has medica" !ractices. ). /ym!tomato"ogy o& disease whee4ing it wi"" !robab"y be ).C Assess &or under"ying states can cause insomnia. di&&icu"t &or her to s"ee! we"". !hysio"ogica" i""nesses causing %. Attention to en.ironmenta" noise %. his wou"d be a great s"ee! "oss. can e"iminate or mar0ed"y reduce inter.ention &or the night shi&t %. Dee! the s"ee! en.ironment noise and !romote e&&ecti.e s"ee! nurse to uti"i4eI donEt thin0 this Guiet (a.oid use o& intercoms2 and minimi4e s"ee! de!ri.ation. was used. "ower the .o"ume on radio and +. Regu"ar s"ee! schedu"es that +. I encouraged the !atient to try te"e.ision2 antici!ate a"arms on IA inc"ude strategica""y !"aced na! and rest and ta0e a short na! during !um!s2 ta"0 Guiet"y on unit#. !eriods can su!!"ement tota" the day. I am not sure whether the +. C=ncourage na!!ing as a way to amounts o& s"ee! obtained. !atient was e.er ab"e to &a"" as"ee! com!ensate &or s"ee! de!ri.ation and ta0e a na!. when se.ere"y restricted s"ee! cannot be a.oided. he !atient wi"" &a"" as"ee! without '. 7rom the history2 assess &actors '. 7or the in!atient the most '. his was not com!"eted. di&&icu"ty tonight. "eading to s"ee! de!ri.ation. &reGuent causes o& s"ee! "oss are ) and %. his wou"d be something ). Minimi4e &actors that disturb the medica" condition2 treatment2 and to discuss with the nurse wor0ing !atientEs s"ee!. Conso"idate care. en.ironmenta" stimu"i in the the o.ernight shi&t. It wou"d be %. Mas0 noise in s"ee! area i& noise treatment setting. im!ortant &or the day shi&t nurse to cannot be e"iminated ). /e.era" researchers ha.e &ound re!ort the !atientEs inabi"ity to that the high &reGuency o& s"ee! and their subseGuent &atigue nocturna" care interaction a""ows during the day. !atients &ew uninterru!ted !eriods this was not done2 the nurses &or s"ee! that are "ong enough &or seemed annoyed by the !atientEs them to com!"ete e.en one ,*1''* com!"aints o& not s"ee!ing the night minute s"ee! cyc"e. be&ore and wanting her Ambien %.C Listening to music resu"ted in increased. better s"ee! Gua"ity2 "onger s"ee! duration2 greater s"ee! e&&iciency2

shorter s"ee! "atency2 "ess s"ee! disturbance2 and "ess daytime dys&unction. 7 DISCHARGE PLANNING: (!ut a [ in &ront o& any !t education in abo.e care !"an that you wou"d inc"ude &or discharge teaching# C!"$ 1er t/e 2!##!6 "* "ee1$: \// Consu"t \Dietary Consu"t \; ( O \;astora" Care \Durab"e Medica" 5eeds \7(6 a!!ts \Med Instruction(;rescri!tion \ are any o& the !atientEs medications a.ai"ab"e at a discount !harmacy> \Mes \ 5o \Rehab( BB \;a""iati.e Care

Re&erences Ac0"ey2 B. <.2 X Ladwig2 :.B. ()*''#. )ursing diagnosis handbook: (n e"idence*based guide to planning care (,th ed.## /t. Louis2 MO9 Mosby2 ="se.ier. Be"s0y2 <. ()**C#. +xperiencing the lifespan. 5ew Mor02 5M9 Forth ;ub"ishers. Mayo C"inic (-()$()*')#. ,iseases and conditions: (sthma# Retrie.ed &rom htt!9((www.mayoc"inic.org(diseases1conditions(asthma(basics(de&inition(con1)**)$,,) 5ursing Centra" ('*(@()*'%#. ,iseases and disorders: (sthma# Retrie.ed &rom htt!9((nursing.unboundmedicine.com(nursingcentra"(ub(.iew(Diseases1and1 Disorders(C%-)@(a""(Asthma>G]asthma