ࡱ> )+"#$%&'( hbjbj זlh h )))))T}}}}}$E5"g5g5g5:* IOXfhhhhhhGhE)$Sz:|:$S(Sh|Y))g5g5|Y|Y|Y,S)g5)g5f|Y$Sf|Y|Y2g|))>hݠ}VgZh &Î0g~|Y$>h|Y)>h$S$S$Sh :   UNIVERSITY OF SOUTH FLORIDA COLLEGE OF NURSING Student: Jaymie McAllisterPatient Assessment Tool .Assignment Date: 1/28/13 Agency: BMC UDPatient Initials: A.P. Age: 23Admission Date: 1/5/2013Gender: MaleMarital Status: SinglePrimary Medical Diagnosis with ICD-10 code: Open skull fracture. Primary Language: EnglishLevel of Education: Bachelors Degree (USF Accounting)Other Medical Diagnoses: Pneumocephalus and skull fracture with small right-sided subdural hematoma. Forehead laceration (10cm). Occupation (if retired, what from?): Currently unemployed, beginning graduate school at the University of South Florida for forensic accounting in the Fall. Number/ages children/siblings: N/A Code Status: Full CodeLiving Arrangements: Lives in an second story apartment with 2 roommates in Tampa, FL. Advanced Directives: N/A Surgery Date: 1/05/2013 Procedure: Sutures placed in 10 cm forehead laceration through three layers: galea, subcutaneous tissues, and the skin. Culture/ Ethnicity /Nationality: Hispanic (Cuban) and Caucasian Religion: Catholic Type of Insurance: Unknown ( 2 CC: I was laying in the back seat of my dads car and I guess we got t-boned and next thing I knew I was in an ambulance on my way to the emergency room, I dont really remember exactly what happened. ( 3 HPI: This is a pleasant, 23-year-old male who was involved in a motor vehicle accident crash. The car was hit on the side. His father was driving the car and he was laying down in the back seat, asleep. He came to the E.R. as a non-trauma alert. He had an open head fracture of his skill, a visible laceration on the forehead measuring 10 cm with the fracture site visible. Upon arrival he was alert and oriented and reported that he did experience a loss of consciousness at the scene and does not remember the accident. He had CT scans of his head, neck, abdomen and pelvis performed. The CT of the head reveals evidence of a pneumocephalus and a skull fracture as well as bilateral maxillary facial factures, there is also a small right-sided subdural hematoma. The 10 cm laceration was sutured in the E.R. completely through three layers: the galea, the subcutaneous and the skin. This patients past medical history is otherwise unremarkable. The patient has been prescribed PRN acetaminophen (650 mg PO Q6hr), PRN oxycodone (5-10 mg PO Q4hr), and PRN morphine (4mg=1 mL IVPush Q1hr) for pain and minimal activity.  ( 2 PMH/PSH Hospitalizations for any medical illness or operationDate Operation or IllnessManagement/Treatment1/05/13Open forehead laceration (10cm)Sutured completely in the E.R. ( 2 FMHAge (in years)Cause of Death (if applicable)AlcoholismEnvironmental AllergiesAnemiaArthritisAsthmaBleeds EasilyCancerDiabetesGlaucomaGoutHeart Trouble (angina, MI, DVT etc.)HypertensionKidney ProblemsMental Health ProblemsSeizuresStomach UlcersStrokeTumorFather58 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Mother56 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Brother FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Sister FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX relationship FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX relationship FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX relationship FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Comments:Draw Genogram Here: (See instructions for genogram in Jarvis textbook)  ( 1 immunization HistoryYesNoRoutine childhood vaccinations FORMCHECKBOX  FORMCHECKBOX Routine adult vaccinations for military or federal service FORMCHECKBOX  FORMCHECKBOX Adult Diphtheria (Date) FORMCHECKBOX  FORMCHECKBOX Adult Tetanus (Date) FORMCHECKBOX  FORMCHECKBOX Influenza (flu) (Date) FORMCHECKBOX  FORMCHECKBOX Pneumococcal (pneumonia) (Date) FORMCHECKBOX  FORMCHECKBOX Have you had any other vaccines given for international travel or occupational purposes? Please List FORMCHECKBOX  FORMCHECKBOX  ( 1 Allergies or Adverse ReactionsNAME of Causative AgentType of Reaction (describe explicitly)MedicationsNo known drug allergiesOther (food, tape, dye, etc.)No known food allergiesPollen, oak treesAllergic rhinitis (itchy eyes, coughing, sneezing) ( 3 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis, prognosis or treatment)The typical mechanism that produces an acute subdural hematoma is a high-speed impact to the skull. This causes the brain to accelerate from its fixed position within the skull, tearing the blood vessels. These tears cause blood to pool in the outer brain tissues. This pooled blood is visible on a CT scan. Subdural hematomas may cause an increase in intracranial pressure. Because this patients skull fracture was open, this was not as great of a concern. Richard J Meagher, MD. (Oct 4, 2011). Subdural Hematoma. In Medscape. Retrieved 1/28/2013, from http://emedicine.medscape.com/article/1137207-overview#a0104. ( 5 Medications: (Include both prescription and OTC) Name Bacitracin topicalConcentrationDosage Amount: 1 applicationRoute: topicalFrequency: BID (2 x daily)Pharmaceutical class: none assignedHome Hospital or BothReason for taking: To be used prevent/treat localized infectionTo be used on the suture line of the patients foreheadAdverse effects: Pswudomembranous colitis, n/v, rash Name: ColaceConcentrationDosage Amount: 100 mgRoute: POFrequency: BIDPharmaceutical class: Stool softenerHome Hospital or BothReason for taking: prevention of constipations in patientstaken counteract the risk for constipation associated with pain medications and immobilityAdverse effects: cramps, diarrhea, throat irritation Name: acetaminophenConcentrationDosage Amount: 650 mgRoute: POFrequency: Q6HrPharmaceutical class: nonopiod analgesicsHome Hospital or BothReason for taking: Used with opioid analgesics for the treatment of moderate to severe pain. Adverse effects: Hepatoxicity, fatigue, constipation, n/v  Name: MorphineConcentration: 4 mg= 1mLDosage Amount: 1 mLRoute: IVPushFrequency: Q1hrPharmaceutical class: opioid agonist Home Hospital or BothReason for taking: severe painAdverse effects: Respiratory depression, confusion, sedation, hypotension, constipation, n/v, bradycardia , dry mouth Name: PercoloneConcentrationDosage Amount: 5-10 mLRoute: POFrequency: Q4hrPharmaceutical class: opioid agonistHome Hospital or BothReason for taking: moderate to severe painAdverse effects: Respiratory depression, confusion, sedation, constipation, dry mouth, n/v  ( 4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis)Diet ordered in hospital? Regular Analysis of home diet (Compare to food pyramid and Consider co-morbidities and cultural considerations):Diet pt follows at home? RegularPatients home diet consists of: Breakfast: cereal with whole milk and a banana Lunch: Frozen pizza bagels and French fries Dinner: Protein (chicken or beef), with potatoes and vegetables (typically broccoli or zucchini) Compared ChooseMyPlate.gov, this patients diet is lacking healthy grains and fruits. Though breakfast and dinner are fairly balanced, the patients typical lunch consists of empty calories and fats. This patient has been advised to increase their intake of lean proteins, vegetables and fruits. Breakfast: Cheese omelette, orange juice, sausage patty Lunch: Turkey and cheese sandwich on white bread, 6oz. cola, jello Dinner: Turkey and gravy, mashed potatoes, green beans, chocolate puddingSnacks:(2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)Who helps you when you are ill? My mom and dad. How do you generally cope with stress? or What do you do when you are upset?When Im stressed I like to listen to music and go for a runRecent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)Since the accident, I have been a little overwhelmed by having to put my life on hold in order to recoverDOMESTIC VIOLENCE ASSESSMENT Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are safe. Have you ever felt unsafe in a close relationship? No. Have you ever been talked down to? Have you ever been hit punched or slapped? No. Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? If yes, have you sought help for this? No. Are you currently in a safe relationship? I am not currently in a relationship.( 5 DEVELOPMENTAL CONSIDERATIONS:Eriksons stage of psychosocial development:  FORMCHECKBOX Trust vs.  FORMCHECKBOX Mistrust  FORMCHECKBOX Autonomy vs.  FORMCHECKBOX Doubt & Shame  FORMCHECKBOX Initiative vs.  FORMCHECKBOX Guilt  FORMCHECKBOX Industry vs.  FORMCHECKBOX Inferiority  FORMCHECKBOX Identity vs.  FORMCHECKBOX Role Confusion/Diffusion  FORMCHECKBOX Intimacy vs.  FORMCHECKBOX Isolation  FORMCHECKBOX Generativity vs.  FORMCHECKBOX Self absorption/Stagnation  FORMCHECKBOX Ego Integrity vs.  FORMCHECKBOX DespairGive the textbook definition of both parts of Ericksons developmental stage for your patients age group:The Intimacy vs. Isolation stage takes place during the ages 19 to 40 years old. During this time, forming intimate, loving relationships with others is at the center of conflict. Erikson believed that having a formed sense self is essential in being able to form these loving relationships. Failure to form successful and strong relationships results in loneliness and isolation. Describe the characteristics that the patient exhibits that led you to your determination:Though I did not get into the personal details of this patients relationships, it was obvious that he had a loving and supportive family, as they were present the entire time I was on the floor. I found him to be in the intimacy stage because he didnt appear lonely or isolated and said that he was excited to be able to see his friends again. Although he wasnt in a committed relationship at the time, he had a strong support system of friends and family that keep him from becoming isolated during his recovery. Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:This patient has stayed very positive during my time spent with him. He was unable to begin graduate school in January but the accident left him unable to begin. Through his recovery, he has had a strong support system, so there hasnt been a change in his developmental stage because of his injury. Cultural Assessment: What do you think is the causes of your illness?A car accidentWhat does your illness mean to you?This means I wont be able to go grad school this semester as I planned on and have to wait until the fall, but otherwise I am just trying to get better.  (2 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)What importance does religion or spirituality have in your life?Religion is not very important to me at this point.Do your religious beliefs influence your current condition?No, they dont influence this situation. +3 Smoking, Chemical use, Occupational/Environmental Exposures:1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No If so, what? How much?For how many years?n/an/a(age thru )For cigarette use, what is the number of pack years?If applicable, when did the patient quit?n/a Does anyone in the patients household smoke tobacco? If so, what, and how much?No. 2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No What?How much?For how many years?Occasional beer and liquor. 1-3 drinks a few times a month(age 18 thru 23 ) If applicable, when did the patient quit? n/a3. 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? n/an/an/a(age thru ) Is the patient currently using these drugs? Yes NoIf not, when did he/she quit?n/a 4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risksn/a  ( 10 Review of Systems General ConstitutionGastrointestinalImmunologic FORMCHECKBOX  Recent weight loss or gain FORMCHECKBOX  Nausea, vomiting, or diarrhea FORMCHECKBOX  Chills with severe shakingIntegumentary FORMCHECKBOX  Constipation  FORMCHECKBOX  Irritable Bowel FORMCHECKBOX  Night sweats FORMCHECKBOX  Changes in appearance of skin (Brusing) FORMCHECKBOX  GERD  FORMCHECKBOX  Cholecystitis FORMCHECKBOX  Fever FORMCHECKBOX  Problems with nails FORMCHECKBOX  Indigestion  FORMCHECKBOX  Gastritis / Ulcers FORMCHECKBOX  HIV or AIDS FORMCHECKBOX  Dandruff FORMCHECKBOX  Hemorrhoids  FORMCHECKBOX  Blood in the stool FORMCHECKBOX  Lupus FORMCHECKBOX  Psoriasis FORMCHECKBOX  Yellow jaundice  FORMCHECKBOX  Hepatitis FORMCHECKBOX  Rheumatoid Arthritis FORMCHECKBOX  Hives or rashes FORMCHECKBOX  Pancreatitis FORMCHECKBOX  Sarcoidosis FORMCHECKBOX  Skin infections FORMCHECKBOX  Colitis FORMCHECKBOX  Tumor FORMCHECKBOX  Use of sunscreen SPF: FORMCHECKBOX  Diverticulitis FORMCHECKBOX  Life threatening allergic reactionBathing routine: FORMCHECKBOX Appendicitis FORMCHECKBOX  Enlarged lymph nodesOther: Advised to wear SPF 30 daily FORMCHECKBOX  Abdominal AbscessOther: Advised to report any changes in immunological function.  FORMCHECKBOX  Last colonoscopy? N/AHEENTOther: Advised to report changes in GI functionHematologic/Oncologic FORMCHECKBOX  Difficulty seeing Genitourinary FORMCHECKBOX  Anemia FORMCHECKBOX  Cataracts or Glaucoma FORMCHECKBOX  nocturia FORMCHECKBOX  Bleeds easily FORMCHECKBOX  Difficulty hearing  FORMCHECKBOX  dysuria FORMCHECKBOX  Bruises easily FORMCHECKBOX  Ear infections FORMCHECKBOX  hematuria FORMCHECKBOX  Cancer FORMCHECKBOX  Sinus pain or infections FORMCHECKBOX  polyuria FORMCHECKBOX  Blood Transfusions FORMCHECKBOX Nose bleeds  FORMCHECKBOX  kidney stonesBlood type if known: FORMCHECKBOX  Post-nasal dripNormal frequency of urination: 3 x/dayOther: Patient encouraged to report any signs of hematological changes to her primary care doctor immediately FORMCHECKBOX  Oral/pharyngeal infection FORMCHECKBOX  Bladder or kidney infections  FORMCHECKBOX  Dental problemsAdvised to watch for changes in urinary function, such as inability to urinate or pain with urination. Metabolic/Endocrine FORMCHECKBOX  Routine brushing of teeth 2 x/day FORMCHECKBOX  Diabetes Type: FORMCHECKBOX  Routine dentist visits 2x/year FORMCHECKBOX  Hypothyroid /Hyperthyroid FORMCHECKBOX Vision screening Biannually  FORMCHECKBOX  Intolerance to hot or coldOther: Advised pt. to continue to visit the dentist and optometrist regularly. FORMCHECKBOX  OsteoporosisOther: Patient was encouraged to report any signs of metabolic change to her primary care provider immediately.Pulmonary FORMCHECKBOX  Difficulty BreathingCentral Nervous System FORMCHECKBOX  Cough - dry or productiveWomen Only FORMCHECKBOX  CVA FORMCHECKBOX  Asthma FORMCHECKBOX  Infection of the female genitalia FORMCHECKBOX  Dizziness  FORMCHECKBOX  Bronchitis FORMCHECKBOX  Monthly self breast exam FORMCHECKBOX  Severe Headaches FORMCHECKBOX  Emphysema FORMCHECKBOX  Frequency of pap/pelvic exam FORMCHECKBOX  Migraines FORMCHECKBOX  Pneumonia Date of last gyn exam? FORMCHECKBOX  Seizures FORMCHECKBOX  Tuberculosis FORMCHECKBOX  menstrual cycle regular irregular FORMCHECKBOX  Ticks or Tremors FORMCHECKBOX  Environmental allergies FORMCHECKBOX  menarche age? FORMCHECKBOX  Encephalitis FORMCHECKBOX last CXR?  FORMCHECKBOX  menopause age? FORMCHECKBOX  MeningitisOther: Advised to report any shortness of breath or changes in pulmonary functionDate of last Mammogram &Result:Other: Encouraged patient to report any changes or increasing of headaches/dizziness to a doctor immediately. Patient taught to sit on the edge of the bed before getting up to prevent dizziness related falls.Date of DEXA Bone Density & Result:CardiovascularMen OnlyMental Illness FORMCHECKBOX Hypertension FORMCHECKBOX  Infection of male genitalia/prostate FORMCHECKBOX  Depression FORMCHECKBOX  Hyperlipidemia FORMCHECKBOX  Frequency of prostate exam? n/a FORMCHECKBOX  Schizophrenia FORMCHECKBOX  Chest pain / Angina Date of last prostate exam? N/s FORMCHECKBOX  Anxiety FORMCHECKBOX Myocardial Infarction FORMCHECKBOX  BPH FORMCHECKBOX  Bipolar FORMCHECKBOX  CAD/PVD FORMCHECKBOX Urinary RetentionOther: Encourage patient to watch for signs and symptoms of depression associated with hospitalization/immobility. FORMCHECKBOX CHFMusculoskeletal FORMCHECKBOX Murmur FORMCHECKBOX  Injuries or FracturesChildhood Diseases FORMCHECKBOX  Thrombus FORMCHECKBOX  Weakness FORMCHECKBOX  Measles FORMCHECKBOX Rheumatic Fever FORMCHECKBOX  Pain FORMCHECKBOX  Mumps FORMCHECKBOX  Myocarditis  FORMCHECKBOX  Gout FORMCHECKBOX  Polio FORMCHECKBOX  Arrhythmias FORMCHECKBOX  Osteomyelitis FORMCHECKBOX  Scarlet Fever FORMCHECKBOX  Last EKG screening, when? 1/05/13 FORMCHECKBOX Arthritis FORMCHECKBOX  Chicken PoxOther: Advised to report any changes in cardiac functionOther: Advised to properly maintain pain control and report any changes in musculoskeletal system or changes in pain level. Other: Review of Systems Narrative General ConstitutionPts perception of health: Patient is taking a realistic approach to his injury and is taking every precaution necessary to decrease\ his recovery time. The patient is able to return home to the care of his parents until he is fully able to care for himself. He understands that his parents need to assist him with certain activities until a full recovery is made. Sexuality Assessment: (the following prompts may help to guide your discussion)Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life. All of these questions are confidential and protected in your medical recordHave you ever been sexually active? Do you prefer women, men or both genders? Are you aware of ever having a sexually transmitted infection? Have you or a partner ever had an abnormal pap smear? Have you or your partner received the Gardasil (HPV) vaccination? Did not ask. Are you currently sexually active? When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? Did not ask. How long have you been with your current partner? Did not ask. Have any medical or surgical conditions changed your ability to have sexual activity? Did not ask. Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? Did not ask.  Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No. Any other questions or comments that your patient would like you to know? No.  10 PHYSICAL EXAMINATION:Orientation and level of Consciousness: Patient is alert and oriented x3 (person, place, time)General Survey: This is a well-nourished 23 year old male laying comfortably in bed.Height: 69in. Weight: 61.82kg BMI:Pain: (include rating & location) Pt. states his pain level is a 5 and is located at the back of his head. Pulse: 72Blood Pressure: 122/80 (include location) Right armTemperature: (route taken?) 98.2Respirations: 18SpO2: 98%Is the patient on Room Air or O2: Room airOverall Appearance: [Dress/grooming/physical handicaps/eye contact] FORMCHECKBOX  clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicapsNo obvious handicaps, maintains eye contact, patients head is bandaged and he is wearing a neck collar. Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] FORMCHECKBOX  awake, calm, relaxed, interacts well with others, judgment intactSpeech: [e.g.: clear/mumbles /rapid /slurred/silent/other] FORMCHECKBOX  clear, crisp dictionMood and Affect:  FORMCHECKBOX  pleasant  FORMCHECKBOX  cooperative  FORMCHECKBOX  cheerful  FORMCHECKBOX  talkative  FORMCHECKBOX  quiet  FORMCHECKBOX  boisterous  FORMCHECKBOX  flat FORMCHECKBOX  apathetic  FORMCHECKBOX  bizarre  FORMCHECKBOX  agitated  FORMCHECKBOX anxious  FORMCHECKBOX tearful  FORMCHECKBOX withdrawn  FORMCHECKBOX aggressive  FORMCHECKBOX hostile  FORMCHECKBOX loud Integumentary FORMCHECKBOX  Skin is warm, dry, and intact Skin is warm, dry, skin has several abrasions (hips, elbows, knees) and a sutured laceration on his forehead.  FORMCHECKBOX  Skin turgor elastic FORMCHECKBOX  No rashes, lesions, or deformities Lesions on hips, elbows, knees FORMCHECKBOX  Nails without clubbing FORMCHECKBOX  Capillary refill < 3 seconds FORMCHECKBOX  Hair evenly distributed, clean, without vermin Evenly distributed, head was shaved in ER to visualizeHead wounds. FORMCHECKBOX  Peripheral IV site Type: 20 gauge Location: Right wrist Date inserted: 1/5/13   FORMCHECKBOX  no redness, edema, or discharge Fluids infusing?  FORMCHECKBOX  no  FORMCHECKBOX  yes - what? 0.9% saline flushHEENT:  FORMCHECKBOX  Facial features symmetric  FORMCHECKBOX  No pain in sinus region  FORMCHECKBOX  No pain, clicking of TMJ  FORMCHECKBOX  Trachea midline FORMCHECKBOX  Thyroid not enlarged  FORMCHECKBOX  No palpable lymph nodes  FORMCHECKBOX  sclera white and conjunctiva clear; without discharge  FORMCHECKBOX  Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness Functional vision: right eye - 20/20 left eye - 20/20  FORMCHECKBOX  without corrective lenses right eye - left eye -  FORMCHECKBOX  with corrective lensesFunctional vision both eyes together:  FORMCHECKBOX  with corrective lenses or  FORMCHECKBOX  NA FORMCHECKBOX  PERRLA pupil size 3 / 3 mm  FORMCHECKBOX  Peripheral vision intact  FORMCHECKBOX  EOM intact through 6 cardinal fields without nystagmus FORMCHECKBOX  Ears symmetric without lesions or discharge  FORMCHECKBOX  Whisper test heard: right ear- inches & left ear- inches FORMCHECKBOX  Weber test, heard equally both ears Rinne test, air time(s) longer than bone  FORMCHECKBOX  Nose without lesions or discharge  FORMCHECKBOX  Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesionsDentition: Patient has all his teeth intact.Comments: Facial features are not symmetric due to swelling of the right side of the face (eye region), and swelling of the maxillary area. Sclera of right eye is reddened related to head injury.Orbital area has slight edema and tenderness.  Pulmonary/Thorax:  FORMCHECKBOX  Respirations regular and unlabored  FORMCHECKBOX Transverse to AP ratio 2:1  FORMCHECKBOX Chest expansion symmetric  FORMCHECKBOX  Lungs clear to auscultation in all fields without adventitious soundsCL Clear FORMCHECKBOX Percussion resonant throughout all lung fields, dull towards posterior bases WH Wheezes FORMCHECKBOX Tactile fremitus bilaterally equal without overt vibrationCR - Crackles FORMCHECKBOX Sputum production: thick thin Amount: scant small moderate large RH Rhonchi Color: white pale yellow yellow dark yellow green gray light tan brown redD Diminished S Stridor Ab - Absent Cardiovascular:  FORMCHECKBOX No lifts, heaves, or thrills PMI felt at: 5th intercostal space, midclavicular lineHeart sounds: S1 S2 Regular Irregular  FORMCHECKBOX No murmurs, clicks, or adventitious heart sounds  FORMCHECKBOX No JVDRhythm (for patients with ECG tracing tape 6 second strip below and analyze) FORMCHECKBOX  Calf pain bilaterally negative  FORMCHECKBOX Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]Apical pulse: 3-normal Carotid: 3-normal Brachial: 3-normal Radial: 3-normal Femoral: 3-normal Popliteal: 3-normal DP: 3-normal PT: 3-normal FORMCHECKBOX No temporal or carotid bruits Edema: +1 (1-2mm [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]Location of edema: minimal swelling of orbital area pitting non-pitting  FORMCHECKBOX Extremities warm with capillary refill less than 3 secondsGI/GU:  FORMCHECKBOX Bowel sounds active x 4 quadrants; no bruits auscultated  FORMCHECKBOX No organomegaly Liver span cm FORMCHECKBOX Percussion dull over liver and spleen and tympanic over stomach and intestine  FORMCHECKBOX Abdomen non-tender to palpationUrine output:  FORMCHECKBOX Clear  FORMCHECKBOX Cloudy Color: Previous 24 hour output: mLs N/A FORMCHECKBOX Foley Catheter  FORMCHECKBOX Urinal or Bedpan  FORMCHECKBOX Bathroom Privileges without assistance or with assistance--minimal FORMCHECKBOX CVA punch without rebound tenderness Last BM: (date 1/ 4 / 2012) 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 / negativeGenitalia:  FORMCHECKBOX Clean, moist, without discharge, lesions or odor  FORMCHECKBOX Not assessed, patient alert, oriented, denies problems Other Describe: Musculoskeletal: ( Full ROM intact in all extremities without crepitus patient  FORMCHECKBOX Strength bilaterally equal at _4-against some resistance ______ in UE & _4-against some resistance ______ in LE [rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] FORMCHECKBOX vertebral column without kyphosis or scoliosis FORMCHECKBOX Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesiasSoreness is felt throughout the body related to MVA.Neurological:  FORMCHECKBOX Patient awake, alert, oriented to person, place, time, and date  FORMCHECKBOX Confused; if confused attach mini mental exam FORMCHECKBOX CN 2-12 grossly intact  FORMCHECKBOX Sensation intact to touch, pain, and vibration  FORMCHECKBOX Rombergs Negative  FORMCHECKBOX Stereognosis, graphesthesia, and proprioception intact  FORMCHECKBOX Gait smooth, regular with symmetric length of the strideDTR: [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 10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):Pertinent Hematology: WBC (H 12.9), RBC (L 4.23), Hgb (L 13.5), Hct (L 38.5), Platelet (293) General Chemistry: Na (140), K (L 3.2), Cl (104), Glucose (H 147), BUN (8), Creatinine (0.8), Ca (9.0), Albumin (4.4), Lactic acid (H 3.1) Coagulation: PT (H 13.2), PTT (L 24.1) Labs drawn (1/1/13) For a patient that experienced a head injury that subsequently led to a subdural hematoma, hematology labs are very important. This patients lab values indicate a high WBC as a result of the body fighting infection and as part of the healing process. Low RBC, hgb and hct may indicate poor oxygenation of the body tissues, however this was not something being specifically treated by the doctors. It may just be a result of the body tissues healing process. For this patients general chemistry, the K is low. This could be related to nausea and vomiting that results from a head injury. The blood glucose is high, but it was not part of fasting blood glucose, therefore it is normal. The high lactic acid may be a result of the large amounts of acetaminophen this patient is currently taking. +2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:This patient is currently being treated for an open skull fracture and subdural hematoma as a result of a motor vehicle accident. He had a 10 cm. forehead laceration that was sutured in the Emergency Department. He is being treated for pain using oxycodone, morphine and acetaminophen. He has a collar on his neck for stabilization and has been told to use caution when getting out of bed and when ambulation to avoid dizziness and decrease his risk for falls.  ( 8 Nursing Diagnoses (actual and potential - listed in order of priority)1. Risk for falls related to head injury. 2. Acute pain related to altered brain and/or skull tissue3. Risk for injury related to complications of head injury.4. Anxiety related to the threat of permanent neurological injury or impairment.  15 for Care Plan Nursing Diagnosis: Risk for falls Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for Interventions Provide ReferencesEvaluation of Interventions on Day care is ProvidedRemain free from falls during shift.1.Complete a high fall risk assessment upon admission and reevaluate as condition improves or worsens(such as the Hendrich II Model upon arrival and as the patients condition changes. 2. Assist the patient with ambulation and movement. 3. Place a high fall risk band on the patient and a fall risk sign in the room. 4.Place call light near the patient at all times. 1.This assessment tool helps to identify the patients level of fall risk severity by combining information about the patients history of falls, levels of depression/confusion, level of dizziness/orthostatic hypotension, altered mobility level, etc. 2. Lock the bed/chair before ambulation, steady the patient at the edge, verbalize commands and ask the patient how they feel. This can prevent orthostatic hypotension and improves nurse/patient communication to prevent falls. 3. This alerts other staff members and visitors to be aware of the patients risk for falls. 4. Ensures that the patient can ask for assist at all times when attempting to ambulate.The patient was assisted out of bed by his mother and was asked to sit on the edge of the bed before standing up. Upon standing with some assist, the patient ambulated with the student nurse from his room to the end of the hall and back to the room with no assist. Patient was free of falls during the shift. Change patient environment to minimize fall risk.Free the room of clutter to prevent a compromising situation for the patient. Ensuring clear pathways and removing all objects from the floor allows for the patient to have an unobstructed view of the distance they need to ambulate. This also prevents the patient from tripping over an object, reducing the fall risk significantly. Patients floor remained clear of clutter, including monitor cords and other objects, and the patient did not have any trips or falls during the shift.  Patient will be able to explain the methods of injury prevention to use at the hospital and at home. 1.Provide information to the patient about wearing non-skid footwear, provide/use adequate lighting, toilet frequently to avoid urgency, always seek assistance when ambulating until he is feeling better.  Giving a patient information and asking them to repeat and provide feedback about these ideas helps the nurse to ensure the patient is actually retaining and learning this information. Patient stated that they understood and have been practicing methods of fall prevention and will continue doing so at home.  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 X Dietary Consult X PT/ OT %Pastoral Care X Durable Medical Needs X F/U appts X Med Instruction/Prescription % are any of the patient s medications available at a discount pharmacy? %Yes % No %Rehab/ HH %Palliative Care Nursing Diagnosis: Acute pain related to altered brain and/or skull tissue Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for Interventions Provide ReferencesEvaluation of Interventions on Day care is ProvidedPerform a comprehensive assessment of pain in order to form a plan of care. Have patient identify characteristics of pain such as: location, onset, frequency, quality, intensity, severity and precipitating factors.Pain is subjective and individual to each patient. It must be described by the client in order for effective treatment to be planned.Patient described their pain to the nurse before their pain medication was given, which helped the client and nurse determine which PRN medication would be best at that time. Lowered pain level after administration of pain medicationsProvide effective pain relief using prescribed medicationsMaximum pain relieve for patients is a top nursing priority. Analgesics prescribed on a PRN basis should be offered when the next dose is available. When offered medication, the patient chose to take the acetaminophen to help relieve his pain. Teach patient about the use of non-pharmacological techniques of pain relief. Teach patient about pain management strategies such as relaxation, guided imagery, music therapy, etc. to use before and after painful activities, while pain is occurring or to prevent pain. The use of non-pharmacologic pain reducers helps to relax the patient, release endorphins and possibly enhance the effects of pain relief medications.The patient stated that he understood these other interventions and already tries to incorporate them into his pain management to avoid being overly medicated.  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