UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDACOLLEGE OF NURSINGStudent: Emily MorganPatient Assessment ToolLONG FORM FUNDAMENTALSAssignment Date: 06/38/13Agency: Sarasota MemorialPatient Initials: G.G. Age: 79Admission Date: 6/26/13Gender: F Martial Status: MarriedOccupation: Retired NursePrimary Language: EnglishLevel of Education: Bachelor’s of ScienceNumber/ages children/siblings: 1 Son: 52 1 Daughter: 48Primary Medical Dx with ICD-10 code: Myasthenia Gravis G70.0Living Arrangements: Lives at home with husband. Advanced Directive: Yes.Immunizations: Yes.Code Status: Full.Culture/ Ethnicity /Nationality: Swedish Surgery Date: N/A Procedure: N/AReligion: Catholic Type of Insurance: BCBS, Medicare± 2CC: “Weakness” “Seeing double, headache” “Dizziness”+3 HPI: OLD CART Onset: Patient started to experience her symptoms 5-6 months ago. Location: Patient states that she felt weak “all over my body.” The right side of her head was in pain and she claims her eyes were seeing double. Duration: According to the patient her symptoms were constant. Characteristics: The patient described her symptoms as “painful and sharp.” The pain in her head would radiate down theright side and lead to trouble swallowing and locked jaw. Associated/Aggravating Factors: According to the patient her symptoms would “worsen as the day progressed.”Relieving Factors: The patient claims that nothing would make her symptoms improve. Treatments: Because we can only relieve the symptoms of Myasthenia Gravis and not cure it, the patient is being treated To reduce the impact it has on her body. She is receiving Prednisone to suppress her immune system’s response as well As intravenous immunoglobulin therapy which temporarily changes the way the patient’s immune system operates. The Patient claimed that “I already feel 30% better” after she had been receiving a couple rounds of treatment. 2 PMH/PSH Hospitalizations for any medical illness or operationDate Operation or IllnessManagement/Treatment2013Anxiety Lorazepam 2013Mild DepressionNot managed 3-4 years agoTIAAnticoagulants 6/26/13Myasthenia GravisPrednisone/IgG 2 FMHAge (in years)Cause of Death (if applicable)AlcoholismEnvironmental AllergiesAnemiaArthritisAsthmaBleeds EasilyCancerDiabetesGlaucomaGoutHeart Trouble(angina, MI, DVT etc.)HypertensionKidney ProblemsMental Health ProblemsSeizuresStomach UlcersStrokeTumorFather54Alcoholism FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mother?TB FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Brother72Cancer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Brother74Alcoholism FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Son52N/A 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: Patient couldn’t recall exactly how old her mother was when she passed away. Patient couldn’t recall what kind of cancerher brother died from. 1 immunization HistoryYesNoRoutine childhood vaccinations FORMCHECKBOX FORMCHECKBOX Routine adult vaccinations for military or federal service FORMCHECKBOX FORMCHECKBOX Adult Diphtheria (Date) Patient can’t recall date. FORMCHECKBOX FORMCHECKBOX Adult Tetanus (Date) Over 5 years ago. FORMCHECKBOX FORMCHECKBOX Influenza (flu) (Date) Last Flu Season. FORMCHECKBOX FORMCHECKBOX Pneumococcal (pneumonia) (Date) Patient can’t recall 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)MedicationsLiptorPatient couldn’t recallZocorPatient couldn’t recall“Others I can’tUnknownRemember”Other (food, tape, dye, etc.)No known allergies 5 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis, prognosis or treatment) According to Heuther and McCance (2012, pp. 399), more common in women, Myasthenia gravis is an acquired chronic autoimmune disease mediated by antibodies fighting the acetylcholine Receptor (AChR) at the neuromuscular junction. The disease is characterized by muscle weakness and fatigability. Ocular myasthenia involves weakness of the eyelids and eye muscles, and, as in my patient, may include swallowing Difficulties. A defect in nerve impulse transmission at the neuromuscular junction leads to the post synaptic AChRs on The muscle cell’s plasma membrane to no longer be recognized as “self” which elicits the production of autoantibodies. Therefore, the binding of acetylcholine is blocked by IgG antibodies that fix themselves onto the AChR sites. This Ultimately leads to the destruction of receptor sites. The resulting destruction of sites then progresses to diminished Transmission of the nerve impulse across the neuromuscular junction and lack of muscle depolarization. MyastheniaGravis manifests clinically as muscle fatigue and general weakness. The muscles that tend to be affected first are in the Eyes, face, mouth, throat, and neck. Weakness of the throat muscles can make swallowing difficult. In my patient’s case,She lost 30 pounds over the last couple of months due to the difficulty of swallowing. Myasthenia gravis can be diagnosedSeveral ways. In the case of my patient, her blood work detected the presence of anti-AChR antibodies. The disease can Relapse and patients may experience symptom-free intervals ranging from weeks to months. Over time the disease can Progress, leading to death. Myasthenia gravis is treated using steroids, anticholinesterase drugs, and immunosuppressant Drugs. In my patient’s case, she is receiving immunosuppressants to alter her immune response (Heuther and McCance, 2012, p. 400).Heuther, S & McCance, K. (2012) Understanding Pathophysiology. 5thEdition.(pp.399-400) St. Louis, MO: Elsevier Mosby Inc. 5 Medications: (Include both prescription and OTC)Name Enoxaparin/Lovanox ConcentrationDosage Amount: 40mgRoute: Subcu InjectionFrequency: Daily Pharmaceutical class: Antithrombotic/LMWHHome Hospital or Both: Hospital Indication: Prevention of VTESide effects/Nursing considerations: Dizziness, nausea Name: Prednisone ConcentrationDosage Amount: 20mgRoute: POFrequency: DailyPharmaceutical class: Anti-inflammatory Home Hospital or Both: HospitalIndication: Variety of chronic diseases esp. neoplasticitySide effects/Nursing considerations: Give with food. Name: TemazepamConcentrationDosage Amount: 15mgRoute: POFrequency: Daily at nightPharmaceutical class: Benzodiazepines Home Hospital or Both: BothIndication: Short term management of insomniaSide effects/Nursing considerations: Dizziness, drowsiness. Name: Immune Globulin Concentration: 10% in 200mLDosage Amount: 0.4gm/kg/dayRoute: IVFrequency: DailyPharmaceutical class: Immune Globulins Home Hospital or Both: Hospital Indication: Pts with immunodeficiency syndromes who are unable to produce IgG antibodies Side effects/Nursing considerations: Malaise, light-headedness 4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis)Diet ordered in hospital? Low Cholesterol, Low Saturated Analysis of home diet (Compare to food pyramid and FatConsider co-morbidities and cultural considerations):Diet pt follows at home?Fruits: My patient did not mention any consumption of Breakfast: Coffee and a muffin. Spinach or oatmeal. Fruits in her diet. At her age she needs 11/2 cups daily. Fruits can greatly decrease the risk of MI and stroke. I would recommend she incorporate more in her diet especially since she has had a stroke in the past. Vegetables: 2 cups is recommended daily for my patient. Lunch: Ham sandwich with lettuce. Although she eats spinach in the morning sometimes, I am not convinced that she meets her requirements of vegetables. Eating more of this food group also decreases the chance of heart disease. Grains: 5 ounces daily is needed. If she has oatmeal for Dinner: Sometimes nothing. Sometimes milk and cookies. Breakfast and has her ham sandwich than she meets her requirement. Perhaps she could have her ham sandwich on whole wheat bread instead of white. Protein: Although she has ham on her sandwich for lunch, I Snacks: Applesauce/pudding/ensure. Do not think she meets her proteins requirements with that. She does occasionally consume ensure which has protein in it, although if she incorporated more high-protein foods in her diet she may have more strength, especially considering her diagnosis. Dairy: 3 cups daily are recommended. Because she does not meet this standard, she could incorporate more into her diet by eating yogurt, having a cup of milk a day, etc. Dairy is high in calcium so it is especially important to prevent osteoporosis in her old age. Oils: Her recommended “allowance” is 5 tsps daily. Too much oil in her diet can cause an increase caloric intake. However, since she has recently lost 30 lbs perhaps including more oils in her diet could be beneficial to her Overall strength. 2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)Who helps you when you are ill? “Friends” “Doctors”How do you generally cope with stress? or What do you do when you are upset? “Used to talk, then we stopped” “I couldn’t cope eventually” Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)“Overwhelmed with my health”+2 DOMESTIC 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?____No___________ 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??___________No_______________________________ If yes, have you sought help for this?? ______________________Are you currently in a safe relationship? Yes 5 DEVELOPMENTAL CONSIDERATIONS:Erikson’s 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 Erickson’s developmental stage for your patient’s age group:Older adults need to look back on life and feel a sense of fulfillment. Success at this age leads to feelings of wisdom, while failure results in regret, bitterness, and despair. Describe the characteristics that the patient exhibits that led you to your determination: I had to check both for my patient because she Is in limbo between the two. She would go from describing her happy life and all the things she has accomplished to alsoTelling me, very bitterly, about her hardships. I think that she is currently conflicted; however, now that she is on her roadto “recovery” I truly believe that she will start to look at the bright side of life more than not. She was very reminiscent When I was talking to her and I could feel her sort out her issues and accept her situation as we talked. Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: The impact of this Disease on my patient is very intense. For a while she did not want to live anymore. It was hard for her to cope with beingtold nothing was wrong for so long. Now that she is being treated, she is appearing to be more optimistic about life. Shehas a great support system at home. +3Cultural Assessment: “What do you think is the cause of your illness?” “Disease, I don’t know”What does your illness mean to you? “It meant that my life was over, and I was going to die” +3 Sexuality Assessment: (the following prompts may help to guide your discussion)Consider beginning with:? “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.? All of these questions are confidential and protected in your medical record”Have you ever been sexually active?____Yes_____________________________________________________ Do you prefer women, men or both genders? __Men_____________________________________________________Are you aware of ever having a sexually transmitted infection??No____________________________________________ Have you or a partner ever had an abnormal pap smear?_________ No_______________________________ Have you or your partner received the Gardasil (HPV) vaccination? ___No________________________________________ Are you currently sexually active??? _______No____________________When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?? ____________N/A______________________How long have you been with?your current partner?______32 years__________________________________________________Have any medical or surgical conditions changed your ability to have sexual activity?? ________No___________________Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?No+3 Smoking, Chemical use, Occupational/Environmental Exposures:1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? No If so, what? How much?For how many years?(age thru )If applicable, when did the patient quit?Does anyone in the patient’s household smoke tobacco? If so, what, and how much?Has the patient ever tried to quit?No2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes What?How much?For how many years?WineVery little on special occasions(age thru )N/A If applicable, when did the patient quit?3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No If so, what?How much?For how many years?(age thru ) Is the patient currently using these drugs? Yes NoIf not, when did he/she quit?4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/RisksAlthough this patient feels weak and jittery, she is an independent walker and can ambulate with little assistance. Review of Systems (TO BE USED FOR DATA COLLECTION ONLY)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 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: 45 FORMCHECKBOX Diverticulitis FORMCHECKBOX Life threatening allergic reactionBathing routine: 1x daily FORMCHECKBOX Appendicitis FORMCHECKBOX Enlarged lymph nodesOther: FORMCHECKBOX Abdominal AbscessOther: FORMCHECKBOX Last colonoscopy? Pt couldn’t recallHEENTOther:Hematologic/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: 4 x/dayOther: FORMCHECKBOX Oral/pharyngeal infection FORMCHECKBOX Bladder or kidney infections FORMCHECKBOX Dental problemsMetabolic/Endocrine FORMCHECKBOX Routine brushing of teeth 2 x/day FORMCHECKBOX Diabetes Type: FORMCHECKBOX Routine dentist visits 1-2 x/year FORMCHECKBOX Hypothyroid /Hyperthyroid FORMCHECKBOX Vision screening FORMCHECKBOX Intolerance to hot or coldOther: Slight right facial droop FORMCHECKBOX OsteoporosisOther: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? 2012 FORMCHECKBOX Seizures FORMCHECKBOX Tuberculosis FORMCHECKBOX menstrual cycle regular irregular FORMCHECKBOX Ticks or Tremors FORMCHECKBOX Environmental allergies FORMCHECKBOX menarche age? 13 FORMCHECKBOX Encephalitis FORMCHECKBOX last CXR? FORMCHECKBOX menopause age? 50 FORMCHECKBOX MeningitisOther:Date of last Mammogram &Result: 2-3 yrs ago. Negative.Other:Date of DEXA Bone Density & Result: Pt counldn’t tell me. CardiovascularMen OnlyMental Illness FORMCHECKBOX Hypertension FORMCHECKBOX Infection of male genitalia/prostate? FORMCHECKBOX Depression FORMCHECKBOX Hyperlipidemia FORMCHECKBOX Frequency of prostate exam? FORMCHECKBOX Schizophrenia FORMCHECKBOX Chest pain / Angina Date of last prostate exam? FORMCHECKBOX Anxiety FORMCHECKBOX Myocardial Infarction FORMCHECKBOX BPH FORMCHECKBOX Bipolar FORMCHECKBOX CAD/PVD FORMCHECKBOX Urinary RetentionOther: 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? 6/26 FORMCHECKBOX Arthritis FORMCHECKBOX Chicken PoxOther:Other:Other:PHYSICAL EXAMINATION(TO BE USED FOR DATA COLLECTION ONLY)Orientation and level of Consciousness: Alert General Survey:Height: 64 inchWeight:117.8 BMI: 20.21Pain: (include rating & location)1, headPulse: 84BloodPressure: 104/69, right arm(include location)Temperature: (route taken?)97.8o F, oral Respirations: 17SpO2: 98Is the patient on Room Air or O2: RAOverall Appearance: [Dress/grooming/physical handicaps/eye contact] FORMCHECKBOX clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicapsOverall 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 Other:Integumentary FORMCHECKBOX Skin is warm, dry, and intact FORMCHECKBOX Skin turgor elastic FORMCHECKBOX No rashes, lesions, or deformities FORMCHECKBOX Nails without clubbing FORMCHECKBOX Capillary refill < 3 seconds FORMCHECKBOX Hair evenly distributed, clean, without vermin FORMCHECKBOX Peripheral IV site Type: 18 Location: Left peripheral atecubital fossa Date inserted: 06/26/13 FORMCHECKBOX no redness, edema, or discharge Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what? FORMCHECKBOX Peripheral IV site Type: Location: Date inserted: FORMCHECKBOX no redness, edema, or discharge Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what? FORMCHECKBOX Central access device Type: Location: Date inserted: Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what?HEENT: 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 - left eye - 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 / 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:Comments: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 RH – Rhonchi Color: clearD – Diminished S – Stridor Ab - AbsentCardiovascular: FORMCHECKBOX No lifts, heaves, or thrills PMI felt at: Heart sounds: S1 S2 Regular 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 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3 FORMCHECKBOX No temporal or carotid bruits Edema: +1 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]Location of edema: ankles 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: yellow Previous 24 hour output: N/A FORMCHECKBOX Foley Catheter FORMCHECKBOX Urinal or Bedpan FORMCHECKBOX Bathroom Privileges with assistance FORMCHECKBOX CVA punch without rebound tenderness Last BM: (date 06 / 28 / 13 ) Liquid Color: Light brown Hemoccult: 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- weakness in extremities FORMCHECKBOX Strength bilaterally equal at __4_____ in UE & __4_____ 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 parathesiasPatient experiencing numbness in feet. 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 Romberg’s 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: 1 Biceps: 1 Brachioradial: 1 Patellar: 1 Achilles: 1 Ankle clonus: positive negative Babinski: positive negative +10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS: (include rationale and analysis)-CT of the brain showed chronic microangiopathic disease. This is actually a somewhat normal finding as we Age. However, since my patient has a history of a stroke, this could be a complication. -Chest x-ray showed no acute cardiopulmonary disease. It is important to know everything that is going on witha patient, so this result confirms that she has no acute cardiopulmonary disease process going on. +2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:To manage the patient’s Myasthenia Gravis, she is receiving treatments that suppress her immune system’s Response to her disease. She is receiving prednisone and immunoglobulin treatment to alter how her body’sImmune system operates. When she is discharged she will require intensive physical therapy and occupationalTherapy. 2 Medical Diagnoses (as listed on the chart) 8 Nursing Diagnoses(actual and potential - listed in order of priority)1.Myasthenia Gravis1. Imbalanced nutrition less than body requirements related to dysphagia as evidence by recent drop in weight. 2.2. Self-care deficit related to muscle weakness, general fatigue as evidence by need of assistance. 3.3.4.4.5.5.± 15 for Care PlanNursing Diagnosis: Imbalanced Nutrition…Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Interventions on Day care is Provided-Caloric intake will be adequate -Measure the patient’s body weight-Tracking of body weight daily -Patient’s body weight was taken To meet the metabolic needs. Every day. Helps to evaluate the success of And it seems that she is gaining -Improved energy due to increased-Perform nutritional consultation toThe interventions. Weight slowly. Intake of food. Evaluate calories. -Nutritional consultation to -The healthcare team was aware-Assess cough reflex and Evaluate calories gives the health-Of how many more calories she Swallowing disorders before Care team an idea of how manyShould be consuming and is Administration by mouth. Calories the patient needs.Continually working of increasing-Give small meals eaten per--Assessing cough reflex and Her intake. Interval if there is dysphagia. Swallowing disorders is extremely -The patient’s cough reflex is intactImportant to that the patient’s planAnd she has problems swallowing Of care is tailored for them. At night time. The healthcare team-Small meals several times a day Tries to avoid giving her meds tooCan be easier and more achievable Late.For the patient. -Smaller meals are being given, Although the patient continues to Not eat very much of her food. ± 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: No*□Dietary Consult: Yes *□PT/ OT: Yes □Pastoral Care: No□Durable Medical Needs: No□F/U appts: Yes. □Med Instruction/Prescription: Yes□ are any of the patient’s medications available at a discount pharmacy? □Yes □Rehab/ HH: No□Palliative Care: NoNursing Diagnosis: Self-care deficit…Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Interventions on Day care is Provided-Patient will be able to do at least-Give a patient a break in between -A break between events allows -Breaks were giving to the patient25% of the activities themselvesEvents.For the patient to rest and regainAnd she was allowed to rest and And dress up. -Demonstrate energy saving Some energy that was lost duringRelax. -Patient will be able to plan when Techniques.Exertion. -The patient was educated aboutIs the best time to perform -Perform self-care for the patient-By teaching the patient energy The timing of her exertion and howActivities and when it is time to During a very excessive muscleSaving techniques, the healthcareTo plan out her days.Rest. Weakness or include family. Team is providing the patient with-The patient was assisted the -Create maintenance schedule A strategy to improve their Bathroom when she was feeling To the interval. Conservation of energy. Rather weak. Other than that she-In the event of intense weakness,Was able to do most everythingIt is important to assist the patient Else.When they cannot do it themselves. -It was discussed with the patient -If a schedule is created that How creating a schedule for herIncludes when to exert and when toDaily activities can work to her Relax, the patient will have an Advantage in managing her Easier time managing their Weakness. Weakness. ± 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: No*□Dietary Consult: Yes*□PT/ OT: Yes □Pastoral Care: No□Durable Medical Needs: No□F/U appts: Yes□Med Instruction/Prescription: Yes □ are any of the patient’s medications available at a discount pharmacy? □Yes □Rehab/ HH: No□Palliative Care: NoNursing Diagnosis: Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Interventions on Day care is Provided± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)Consider the following needs:□SS Consult □Dietary Consult □PT/ OT□Pastoral Care □Durable Medical Needs □F/U appts □Med Instruction/Prescription □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No □Rehab/ HH □Palliative Care ................
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