UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDACOLLEGE OF NURSING3137535127000Student: Miguel MartinezPatient Assessment Tool .Assignment Date: 11-21-2014 1 PATIENT INFORMATION Agency: St. Joseph’s Hospital Patient Initials: A.S Age: 53Admission Date: 10/29/14Gender: FemaleMarital Status: Never MarriedPrimary Medical Diagnosis with ICD-10 code:K57.32 DiverticulitisN82.3 Vaginal FistulaPrimary Language: EnglishLevel of Education: High School GraduateOther Medical Diagnoses: (new on this admission)Occupation (if retired, what from?): The patient states she is a "Billing Specialist "Number/ages children/siblings: 1:27 year old male child: 3 Brothers: 55,48,46 3 Sisters: 52, 50, 45Served/Veteran: Patient states “No”Code Status: Full CodeLiving Arrangements: Patient states “I live alone in a house”Advanced Directives: Patient states ”No”If no, do they want to fill them out? Patient states “No”Surgery Date: 10/29/2014 Procedure:Culture/ Ethnicity /Nationality: Non-hispanic White Religion: Roman CatholicType of Insurance: United Healthcare 1 CHIEF COMPLAINT:Patient states “I had a bad stomach pain, fever and I was unable to go to the bathroom for a long time.” 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)The patient presented to the hospital with diverticulitis. During a clinic visit 2 weeks ago, the patient had abdominal pain and constipation. The patient was located in the left lower quadrant and in the right lower quadrant. The pain did not radiate. The patient described the pain as sharp and aching. It was a gradual pain that began 5 years ago. The patient has a history of Diverticulosis. The patient has had 11 previous episode of diverticulitis. Past treatment included higher fiber diet and antibiotics. The patient also stated passing gas through her vagina. The patient also has a history of irritable bowel syndrome, abdominal pain, diverticulitis, thyroid disease and high cholesterol. According to the patient she had a scheduled surgery on 10/29/14 and was admitted to the floor for monitoring after the surgery. Some of the procedures the patient had were resection of sigmoid colon and portion of rectum. An Anastomotic ring was placed on the patient’s full thickness segment of the colon and the patient’s appendix was also removed. When assessed the patient rated a pain of 6 out of 10 in the lower part of her abdomen. Patient stated it was a sharp pain and it was aggravated by pressing on it or bending over on her stomach. Patient stated that lying and getting up carefully reduced the pain. The patient was placed on NPO and was being infused with 1,000 mL of Dextrose 5 Normal Saline at 40 mL/hr after the procedure but since she reported feeling better the doctor came in to assess her and ordered clear fluids for her. The patient is to Turn, Cough and Deep breath q2hr. She is also order to ambulate 4xdaily and sit in chair 3xdaily. She is also on incentive spirometry. 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operationDate Operation or Illness1987Cesarean Section2009Hernia repair10/29/14Appendectomy, Colon Resection, Repaired hernia. 2 FAMILY MEDICAL HISTORYAge (in years)Cause of Death (if applicable)AlcoholismEnvironmental AllergiesAnemiaArthritisAsthmaBleeds EasilyCancerDiabetesGlaucomaGoutHeart Trouble(angina, MI, DVT etc.)HypertensionKidney ProblemsMental Health ProblemsSeizuresStomach UlcersStrokeTumorFatherMultiple Myeloma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX XX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX XMotherCervical Cancer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX X FORMCHECKBOX XX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX XBrother55 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX X 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: Include date of onset: Patient states that the father was diagnosed in 2006 with multiple Myloma and passed away the same year. The patient also states that she cannot recall the onset of her mothers or fathers diseases but that that she passed away in 2000 in the year 2000. The patient cannot recall when the onset of her brother’s asthma occurred. I document each family if they had a previous health disorder. If the family did not have an applicable disease, I simply left that person out. 1 immunization History (May state “U” for unknown, except for Tetanus, Flu, and Pna)YesNoRoutine childhood vaccinationsX FORMCHECKBOX Routine adult vaccinations for military or federal service FORMCHECKBOX XAdult Diphtheria (Date)X FORMCHECKBOX Adult Tetanus (Date) FORMCHECKBOX XInfluenza (flu) (Date) FORMCHECKBOX XPneumococcal (pneumonia) (Date) FORMCHECKBOX XHave you had any other vaccines given for international travel or occupational purposes? Please List FORMCHECKBOX X 1 ALLERGIES OR ADVERSE REACTIONSNAME of Causative AgentType of Reaction (describe explicitly)MedicationsPatient states "none"Other (food, tape, latex, dye, etc.) 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or treatment)Mechanism of Disease: The patient has a history of diverticulosis. This is a disease where pouching forms in the mucosa and sub mucosa layers of muscle layers of the digestive tract (Huether & McCance, 2012). Usually this happens in the sigmoid colon. The mucosa of the colon is the outer portion of the intestine that has direct contact to content within the digestive track. The sub mucosa is the muscle layer beneath the mucosa. The sub mucosa contain the blood vessels and network that feed the mucosa and help the mucosa absorb the nutrients from the digestive contents (Martini, Nath & Bartholomew, 2012.) Diverticulosis is usually an asymptomatic disease, which means that the person with this condition will not see any changes or manifestations that could prompt them to know that they have the disease (Huether & McCance, 2012). . When the out pouching becomes inflamed, the disease is then coined diverticulosis (Huether & McCance, 2012). Diverticula or the out pouching can occur anywhere along the gastrointestinal track but the most common places for this to occur happen in the left sigmoid colon and the right colon (Huether & McCance, 2012).Risk Factors: Diverticulosis is usually seen more steadily in elderly women. Young people who get this disease are usually consuming a diet of refined foods (Huether & McCance, 2012). Diverticula form from an increased in intraluminal pressure and herniation. Consumption of low residue food causes in increase in the bulk of the stool, which leads to a bigger colon diameter and eventually leads to the formation of diverticula (Huether & McCance, 2012). Diagnosis: Some clinical manifestations include having cramping pain of the lower abdomen. Sometimes diarrhea, constipation or flatulence may occur in people with diverticulosis. If the diverticula become inflamed, the patient will present with fever, increased white blood cell or tenderness in their lower abdomen (Huether & McCance, 2012). Usually diverticula are found when other problems are being checked (Huether & McCance, 2012). Sigmoidoscopy or colonoscopy allows the provider to see the formation of the diverticula pouches (Huether & McCance, 2012). An abdominal computed tomography will be used to diagnose a person with diverticulitis (Huether & McCance, 2012). Treatment: The patient may be treated with antibiotics if an infection presents. The patient may a have an increased dietary fiber diet ordered (Huether & McCance, 2012). Medline Plus adds that pain medication and starting a fluid diet may also help treat the disease. The patient may also have a laparoscopic resection of the colon if severe. The course of treatment depends on how progressed the disease is on the patient and other factors regarding the over health status of the patient (Huether & McCance, 2012). Prognosis: According to Medline plus, the patient usually responds well to the treatment of diverticulitis. Again it depends on how the patient's health status is regarding the disease. Surgery will be used but it is common that people will continue to have more episodes of diverticulitis (Medline Plus, n.d). Some complications that may occur with a diverticulitis episode may be a fistula, perforation, stricture or abscess. Genetic factors: As of now, the book states that the etiology of the disease is still unknown. According to a scholarly journal, the most attributable cause to the development of diverticulosis is related to diet and lifestyle (Commane, Asasaradnam, Mills, mathers, &Bradburn, 2009). 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]Name Alvimopan (enterag)Concentration (mg/ml)Dosage Amount 12 MGRoute POFrequency 2xdailyPharmaceutical class Opioid AntagonistsHome Hospital or BothIndicatio: Indicated for this patient to speed time to lower GI recovery following partial resection surgery. Side effects/Nursing considerations Some side effects include, constipation, dyspepsia, flatulence, urinary retention, hypokalemia and a big adverse effect is a myocardial infarction. Some nursing considerations would be to assess this patients lab values to monitor any signs of anemia or hypokalemia. Assess the patient frequently to ensure they are voiding normally or within their usual limits. Assess patient vitals to ensure any underlying issues are investigated further as needed. Name Enoxaprin (Lovenox)Concentration: Dosage Amount 40 mgRoute: Subcut InjFrequency 1xdailyPharmaceutical class Antithrombotic. Low molecular weight heparins.Home Hospital or BothIndication Due to surgery and prolonged bed rest. This patient was administered this medication to help prevent clots and avoid the development of Deep Venous Thrombosis , Pulmonary Embolism, Cerebral Vascular Attack , Cardiac Ischemia and Myocardial Infarctions. Side effects/Nursing considerations: Some side effects include, insomnia, edema, constipation, increased liver enzymes,. Urinary retention, pruritus, urticary, hyperkalemia, bleeding, thrombocytopenia, erythema and fever. Name Famotidine (Pepcid)ConcentrationDosage Amount 20 MgRoute: IV InjFrequency q12 hrPharmaceutical class Histamine h2 antagonistsHome Hospital or BothIndication This was administered to patient to prevent stress ulceration due to recent colon resection. Side effects/Nursing considerations: Some common side effects include confusion, constipation, diarrhea, hallucinations. More adverse side effects include arrhythmias, agranulocytosis, and aplastic anemia. Some nursing considerations would be to assess the patients orientation before and after medication administration. The patient runs risk for infection and all precaution need to be taken into account. Name Levothyroxine (Synthroid)ConcentrationDosage Amount 337 McgRoute POFrequency 1xdailyPharmaceutical class Thyroid Preparations Home Hospital or BothIndication This was used to help in the treatment and suppress goiters, and also given as a thyroid supplement in hypothyroidism. Side effects/Nursing considerations: Some side effects include, insomnia, irritability, angina, arrhythmias, tachycardia, abdominal cramps, diarrhea, vomiting, hyperthyroidism, and weight loss. Some nursing considerations would be to assess the patient and to monitor the patients cardiac rhythm patterns if applicable. The nurse should also assess the patients sleeping pattern and comfort. Additionally the nurse should assess the patients bowel movements along with the consistency of their feces. Name Acetaminophen (Tylenol)ConcentrationDosage Amount 650Route POFrequency qhrPharmaceutical class: Antipyretics nonopioid analgesicsHome Hospital or BothIndication Prn for temperature greater than 101 FSide effects/Nursing considerations Some side effects include, agitation, insomnia, dyspnea, hypertension, hypotension, nausea, vomiting, hypokalemia, renal failure muscle spasm and neutropenia. Some more adverse effects include hepatotoxicity, acute generalized exanthematous pustulosis, Stevens-Johnson syndrome and toxic epidermal necrolysis. Ensure the patient is taking medication as prescribed and not going beyond the recommended doses as this could increase the changes of adverse side effects. Assess the patient alcohol use and teach to avoid taking acetaminophen with alcohol as the side effects risk increases. Assess the patient’s labs to see if Bilirubin, LDH, AST, ALT and PT time may have increased as this could indicate hepatotoxicity. Finally ensure that Tylenol is name and not Tylenol PM. Name Naloxone (Narcan)Concentration 0.2 mL= 0.5 mL Dosage AmountRoute IV injection: IM if IV not available.Frequency PRNPharmaceutical classHome Hospital or BothIndication Prn for respiratory distress reduced Respiration rate. If patient unresponsive may repeat in 2 minutes.Side effects/Nursing considerations Some side effects include, HTN, Hypotension, nausea, vomiting, and an adverse effect include ventricular arrhythmias. The nurse should monitor the patient’s vitals and ensure that level of consciousness. The nurse should also be cautious to administer Naloxon and not Lanoxin (digoxin). Finally the patient’s cardiac rhythm should be monitored. Name Ondansetron (Zofran)ConcentrationDosage Amount 4 MGRoute IV InjectionFrequency qhr PRNPharmaceutical class: five ht3 Antagonists.Home Hospital or BothIndication: This is given to prevent nausea and vomiting that the patient may have after the surgery. Side effects/Nursing considerations: Some side effects for this medication include the use headache, weakness, constipation, diarrhea, abdominal pain, extrapyramidal reaction and the most adverse side effect sis Torsade De Pointes. Some nursing considerations would be to let the patient know of potential symptoms. The nurse should monitor the patient cardiac rhythm using an EKG and be knowledgeable as what to look for when assessing for this dysrhythmia.Name Zolpidem (Ambien)ConcentrationDosage Amount 5 mgRoute POFrequency 1xdaily hs PRNPharmaceutical class Sedative/hyponoticsHome Hospital or BothIndication: Use for insomnia.Side effects/Nursing considerations Side effects include daytime drowsiness, dizziness, drugged feeling, hallucinations, nausea, vomiting, diarrhea, hypersensitivity and anaphylaxis as an adverse effect. The nurse should assess the patient level of consciousness. The nurse should also assess the patient for any signs of allergic reaction including difficulty breathing, hives, rashes or any pain verbalized by the patient. Ask the patient about urination pattern and bowel movements and consistency. Name Dextrose 5% Normal SalineConcentration 1000 ml Dosage Amount 40mL/hr infused over 25 hours.RouteFrequency Pharmaceutical class Home Hospital or BothIndicationSide effects/Nursing considerationsName Morphine Patient Controlled Analgesia (PCA)Concentration 50 MgDosage Amount 1mg 7:1:8; 2 mg IV Bolus.Route IVFrequency PRNPharmaceutical class opioid agonistsHome Hospital or BothIndication This was given to the patient to help with the pain associated with her recent surgery. The pain was located almost all near her lower abdomen. Side effects/Nursing considerations: Side effects of this medication include confusion, sedation, dizziness, dysphoria, euphoria, hallucination, blurred vision, diplopia, hypotension, bradycardia, constipation, nausea, vomiting, urinary retention, sweating, dependence, tolerance and most importantly respiratory depression. NameConcentrationDosage AmountRouteFrequencyPharmaceutical classHome Hospital or BothIndicationSide effects/Nursing considerations 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.Diet ordered in hospital? Clear Fluids e Analysis of home diet (Compare to “My Plate” and Diet pt follows at home? Mechanical diet: really chopped food.Consider co-morbidities and cultural considerations):24 HR average home diet:Patients Unmodified diet: Due to the patient medical condition this patient had a deficit in all recommended food group areas. The patient did eat a mechanically soft diet. The patients Grain was at 40z out of 6 oz. The patient’s vegetable was okay at a level of 2 1/2 cup out of 2 1/2 cups. The patient had not fruit in their diet. The patients had 1 cup out of 3 cups for the dairy food group. The patient had 4 oz our of 5 1/2 oz for the protein food group.Breakfast: 2 scrambled eggs with butter and no salt. Cafe con leche beverage. A cup of Cream of the wheat with butter. 2 pancakes with syrup. Patient modified diet: This modification was created with the mindset that the patient has recovered from her diverticulitis episode. In this diet I have adjusted her food intake so that all good group meet their recommended guidelines. I also tried to choose healthier options for the patients, which were also rich in fiber to help her digestive health system maintain stable. Again I maintained the patient's empty calories, oils, saturated fat and sodium to a minimum. Lunch: One cup of Campbell's regular vegetable soup.Dinner: 1 roasted Chicken breast without skin and seasoning. 1 cup of Veggie side composed of green beans, broccoli, cauliflower, and Brussels spouts. Snacks: 11/2 cup of Vanilla Ice Cream. Liquids (include alcohol): 6 to 8 cups of H2Oe per day. Use this link for the nutritional analysis by comparing the patients 24 HR average home diet to the recommended portions, and use “My Plate” as reference.1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)Who helps you when you are ill?Patient states “ Myself and my youngest sister”How do you generally cope with stress? or What do you do when you are upset?Patient states “Crying and eating”Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)The patient states “lately I feel depressed, anxious, overwhelmed with everything and just life in general.”+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? Patient states “No”Have you ever been talked down to? Patient states “yes” Have you ever been hit punched or slapped?? Patient states “ Slapped”Have you been emotionally or physically harmed in other ways by a person in a close relationship with you??Patient states “No” If yes, have you sought help for this?? ______________________Are you currently in a safe relationship? Patient states “Yes, alone” 4 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 DespairCheck one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your patient’s age group:The patient is a 53 year old Caucasian female. She is in the Generativity vs Self Absorption/Stagnation phase. This phase is for people who are in the age group of 40 to 65. The Generativty stage refers to people who give back to society through raising children, being productive at work and becoming involved in community activities and organizations. (McLeod S. A., 2008). People who fail at achieving what those who are in the generativity stage are in the self-absorption or stagnation stage. In this stage people feel unproductive and in this stage people will lead to the virtue of care (McLeod S. A., 2008). Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:The patient finds herself in the Stagnation stage. This patient indicated never being married and only has one child. The patient lives alone and states that her youngest sister is the only helping her. The patient also verbalized feeling depressed, anxious and overwhelmed with life in general. Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:I think the patient has been hospitalized many times before. The patient lives alone and this patient is now again in the hospital. The patient indicated living alone and never being married. The patient verbalized being overwhelmed and depressed and I think it may be due to the patient chronic health problems. I think if she were to be educated properly and taught on how to prevent future episodes of her diverticulosis disease, she may be able to feel less overwhelmed and depressed. I think everyone gets down when they continue to have problems especially if they are health problems that prevent you form living a normal life.+3 CULTURAL ASSESSMENT: “What do you think is the cause of your illness?”Patient states “too many laxatives (OTC).” Additionally patient states “ My history of hemmoriods led me to use laxatives” What does your illness mean to you?Patient states, “it’s scary”.+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? Patient states “back in the day” Do you prefer women, men or both genders? Patient states “ men”Are you aware of ever having a sexually transmitted infection?? Patient states “no” Have you or a partner ever had an abnormal pap smear? Patient states “no” Have you or your partner received the Gardasil (HPV) vaccination? Patient states “no”Are you currently sexually active??? Patient states “no”When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?? Patient states “no” How long have you been with?your current partner? Patient states “ I don’t have one.”Have any medical or surgical conditions changed your ability to have sexual activity?? Patient states “no” Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? Patient states “I do worry about that”±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)What importance does religion or spirituality have in your life? Patient states “I believe in god but I don’t go to church, however I do talk to him”_____________________________________________Do your religious beliefs influence your current condition? Patient states "No"________________________________________________________________________________________________________________________________+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?(specify daily amount)For how many years? 36 yearsPatient states "I smoke cigarettes" Patients states " two packs a week."(age 17 thru 53 )Pack Years: 4If applicable, when did the patient quit?Patient states" I quit a couple weeks ago"Does anyone in the patient’s household smoke tobacco? If so, what, and how much?Has the patient ever tried to quit?Patients states "no"2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No What?How much? (give specific volume)For how many years? Patient states " since I was a teenager."Patient states" On special occasions" Patient states " 1 or 2 glasses of wine"(age thru ) If applicable, when did the patient quit?3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No If so, what?Patient states " No"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/RisksPatient states "No" 10 Review of SystemsGeneral ConstitutionGastrointestinalImmunologicX Recent weight loss or gain FORMCHECKBOX Nausea, vomiting, or diarrhea FORMCHECKBOX Chills with severe shakingIntegumentary FORMCHECKBOX Constipation X Irritable BowelX Night sweats FORMCHECKBOX Changes in appearance of skin FORMCHECKBOX GERD X Cholecystitis FORMCHECKBOX Fever FORMCHECKBOX Problems with nails FORMCHECKBOX Indigestion FORMCHECKBOX Gastritis / Ulcers FORMCHECKBOX HIV or AIDS FORMCHECKBOX DandruffX Hemorrhoids FORMCHECKBOX Blood in the stool FORMCHECKBOX Lupus FORMCHECKBOX Psoriasis FORMCHECKBOX Yellow jaundice FORMCHECKBOX Hepatitis FORMCHECKBOX Rheumatoid ArthritisX Hives or rashes FORMCHECKBOX Pancreatitis FORMCHECKBOX Sarcoidosis FORMCHECKBOX Skin infections FORMCHECKBOX Colitis FORMCHECKBOX TumorX Use of sunscreen Patient states "I don’t use suncreen" SPF:X Diverticulitis FORMCHECKBOX Life threatening allergic reactionBathing routine: 2X days FORMCHECKBOX Appendicitis FORMCHECKBOX Enlarged lymph nodesOther: FORMCHECKBOX Abdominal AbscessOther: X Last colonoscopy? 2 procedures: Early august and one at TGH July, 6, 2014.HEENTOther:Hematologic/OncologicX Difficulty seeing Genitourinary FORMCHECKBOX Anemia FORMCHECKBOX Cataracts or GlaucomaX nocturiaX Bleeds easily FORMCHECKBOX Difficulty hearing FORMCHECKBOX dysuriaX Bruises easily FORMCHECKBOX Ear infections FORMCHECKBOX hematuria FORMCHECKBOX Cancer FORMCHECKBOX Sinus pain or infectionsX polyuria FORMCHECKBOX Blood TransfusionsX Nose bleeds FORMCHECKBOX kidney stonesBlood type if known: Patient "no"X Post-nasal dripNormal frequency of urination: 4x/dayOther: FORMCHECKBOX Oral/pharyngeal infection FORMCHECKBOX Bladder or kidney infections X Dental problemsMetabolic/EndocrineX Routine brushing of teeth 2/day FORMCHECKBOX Diabetes Type:X Routine dentist visits N.A /yearX Hypothyroid /HyperthyroidX Vision screening-once a year.X Intolerance to hot or coldOther: FORMCHECKBOX OsteoporosisOther:PulmonaryX Difficulty BreathingCentral Nervous SystemX Cough - dry or productiveWomen Only FORMCHECKBOX CVA FORMCHECKBOX AsthmaX Infection of the female genitalia: Patient states "NO" FORMCHECKBOX Dizziness FORMCHECKBOX BronchitisX Monthly self breast exam: Patient states "NO" FORMCHECKBOX Severe Headaches FORMCHECKBOX EmphysemaX Frequency of pap/pelvic exam FORMCHECKBOX Migraines FORMCHECKBOX Pneumonia Date of last gyn exam? Patient states "a couple of years ago" FORMCHECKBOX Seizures FORMCHECKBOX TuberculosisX menstrual cycle regular irregular FORMCHECKBOX Ticks or Tremors FORMCHECKBOX Environmental allergiesX menarche age? Patient states "when I was in middle school" FORMCHECKBOX Encephalitis FORMCHECKBOX last CXR?X menopause age? Patient states "Now, I think when I turned 50" FORMCHECKBOX MeningitisOther:Date of last Mammogram &Result: Patient states "Patient states February 2014 and it was good"Other:Date of DEXA Bone Density & Result: Patient states "CardiovascularMen OnlyMental Illness FORMCHECKBOX Hypertension FORMCHECKBOX Infection of male genitalia/prostate? X DepressionX Hyperlipidemia FORMCHECKBOX Frequency of prostate exam? FORMCHECKBOX Schizophrenia FORMCHECKBOX Chest pain / Angina Date of last prostate exam?X Anxiety Patient states "every now and then" FORMCHECKBOX Myocardial Infarction FORMCHECKBOX BPH FORMCHECKBOX Bipolar FORMCHECKBOX CAD/PVD FORMCHECKBOX Urinary RetentionOther: FORMCHECKBOX CHFMusculoskeletalX Murmur FORMCHECKBOX Injuries or FracturesChildhood Diseases FORMCHECKBOX Thrombus FORMCHECKBOX WeaknessX Measles FORMCHECKBOX Rheumatic Fever FORMCHECKBOX PainX Mumps FORMCHECKBOX Myocarditis FORMCHECKBOX Gout FORMCHECKBOX Polio FORMCHECKBOX Arrhythmias FORMCHECKBOX Osteomyelitis FORMCHECKBOX Scarlet FeverX Last EKG screening, when? Friday FORMCHECKBOX ArthritisX Chicken PoxOther:Other:Other:Is there any problem that is not mentioned that your patient sought medical attention for with anyone? Patient States "NO"Any other questions or comments that your patient would like you to know?Patient States "NO"±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) General Survey: Patient is a 53 year old female, who is obese with physical pain to her lower abdomen related to a recent colon resection. The patient moves slow to avoid painful abdominal pain.Height: 5 '4Weight:105.45 kg or 232lb BMI: 40Pain: (include rating & location)Patient states a dull pain level of 7 in her lower abdomen. She states sitting up fast or moving a lot aggravates the pain. Slowly getting up and holding her abdomen help alleviate the pain. Pulse: 81BloodPressure: 136/83(include location)Temperature: (route taken?) Oral: 98°FRespirations: 18SpO2 99Is 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 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:Integumentary4023360-1841500 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: 22 Gauge Location: Left Forarm. Date inserted: 10/29/14 FORMCHECKBOX no redness, edema, or discharge Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what? 1,000 mL Dextrose 5% with 0.9% Normal saline at a rate of 40mL/hr 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 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- 6 inches & left ear- 6 inches FORMCHECKBOX Nose without lesions or discharge FORMCHECKBOX Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesionsDentition: teeth are okay. A little out of ments: I could not assess the patients Pupils as a light was not available on my floor. I also could not measure the pupil size due to the lack of proper equipment. In this case it was the small disposable flashlights.Pulmonary/Thorax: FORMCHECKBOX Respirations regular and unlabored FORMCHECKBOX Transverse to AP ratio 2:1 FORMCHECKBOX Chest expansion symmetric -1384305778500 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 Sputum production: thick thin Amount: scant small moderate large CR - Crackles Color: white pale yellow yellow dark yellow green gray light tan brown redRH – Rhonchi D – Diminished S – Stridor Ab - AbsentCardiovascular: FORMCHECKBOX No lifts, heaves, or thrills PMI felt at: Heart 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 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP:3 PT:3 FORMCHECKBOX No temporal or carotid bruits Edema: [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]Location of edema: 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 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: mLs N/A FORMCHECKBOX Foley Catheter FORMCHECKBOX Urinal or Bedpan FORMCHECKBOX Bathroom Privileges without assistance or with assistance FORMCHECKBOX CVA punch without rebound tenderness Last BM: (date 10 / 31 / 14 ) Formed Semi-formed Unformed Soft Hard Liquid Watery Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red Hemoccult positive / negative (leave blank if not done)Genitalia: 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 FORMCHECKBOX Strength bilaterally equal at _______ RUE _______ LUE _______ RLE & _______ in LLE [rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] FORMCHECKBOX vertebral column without kyphosis or scoliosis (Although not assessed the patient states she does have curvature to her back.) FORMCHECKBOX Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesiasNeurological: 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: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative Could not assess the patients DTR due to lack of equipment. Reflux hammer was not available on floor. ±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):LabDatesTrendAnalysisWBC14.410.6Normal (4.5-10)(10/30/14)(10/31/14)Upon admit, the patients WBC were in the high range. However, WBC are trending downward indicating either an infection or inflammatory process is being treated properly with the prescribed medications. High WBC indicates the presence of an infection or inflammation. High WBC is often indicated in an exacerbation of the patient’s diverticulitis. However because she was put on antibiotics, her WBC count was going down indicating that the infection was going down.HgB12.511.1Normal (13.8-17.2)(10/30/14)(10/31/14)Upon admission the patients Hemoglobin(HGB) was below the normal range. A second evaluation of the patients HGB was also below the normal range.The patients lower than normal HGB value may be due to bleeding from her digestive track and her poor nutrition. The patient stated not being able to eat normally.Plts302273Normal (150-400)(10/30/14)(10/31/14)The patients Platelet (Plts) was within the normal range value. However the first lab reading indicating a higher value than the second value. A higher Plts value may have been due to the infection that the patient was undergoing. Prophylaxis medication was administered to help the patient prevent a thrombolytic episode.HCT37%32.8%Normal (36.1% -44.3%)(10/30/14)(10/31/14)The Patients Hemocrit (HCT) was within the normal range. The second reading indicated lower than normal value.The patient's (HCT) may be due to the patient poor diet. The patient was also on an NPO status and they may have lead to the patients HCT to drop below the normal range.NA142145Normal (135-145)(10/30/14)(10/31/14)The patients Sodium (NA) lab value was within the normal range for the both lab test that were performed on the patient. NA is within the normal limits. NA is one of the substances the body needs to work properly.Cl108 Meq/L112 Meq/LNormal (96-106 Meq/L)(10/30/14)(10/31/14)The Chloride (CL) lab value was within the normal range but elevated past the normal range when assessed for the second time.Higher than normal CL may be due to the patients diarrhea that has been occurring with her current disease process. The patient verbalized a watery stool formation and this may due to her NPO diet and her recent transition to clear fluid diet.BUN64Normal (6-20 mg/dl)(10/30/14)(10/31/14)THe patients Blood Urea Nitrogen (BUN) blood value was within the normal limits for the first test. The second lab value indicated a lower than normal lab value.The BUN in this patient may be due to a potential over-hydration with her infusing fluids that were started after surgery another reason for the second low value reading may be due to malnutrition in the patient.K4.04.0Normal (3.7-5.2)(10/30/14)(10/31/14)The lab value of potassium (K) was within the normal range for both lab test.The K is needed in the body to help nerves and muscle communicated. It also helps nutrient into cells and waste products out of cells in the body.HCo32722Normal 23-29(10/30/14)(10/31/14)The Carbon dioxide lab value within the normal range. The second value was below the normal range. In the body most of the CO2 is in the form of bicarbonate. Most of the time this test is done as part of an electrolyte or basic metabolic panel. This may tell the provider whether the patient may be losing or retaining fluids. Creat.54.48Normal (0.7-1.3 mg/dl)(10/30/14)(10/31/14)Both of the lab values are below the normal range.Creatinine is used to assess the how kidneys are functioning. Some reasons the lab values may be low may be due to the medication the patient is using. Glucose145131Normal (70 to 100 mg/dL)(10/30/14)(10/31/14)Both lab results are above the normal lab value. The patients elevated glucose level also referred to as hyperglycemia may be due too little food as the patient was on an NPO diet. CT of the abdomenWas not on the patient chart.The images from the CT of the abdomen could have resulted in abnormal pouching of the colon or somewhere along the digestive tract .This would help diagnose the patient with diverticulitis. This procedure is done by getting an image of what the patient organs look like. ColonoscopyNot listed on patient chartIf a CT of the abdomen came back positive for pouching, the provider could have investigated further by a colonoscopy.A colonoscopy lets the provider see how the disease if progressing. This allows a clear visual about the pouching that are taking place inside of the patient. Finally this will give more insight on the deciding the best course of treatment for this patient.+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)The patient was placed on an NPO diet while she awaited the surgery set for 10/29/2014. The patient was being infused with Dextrose 5 in Normal saline to continue to provide fluids for the patient. After surgery the patient was to ambulate 4x per day. The patient was also instructed to get out of bed and into a chair next to her bed 3x per day. The nurse would have the patient turn, deep breathe and cough to allow any post-surgical secretions to expel from the body. The nurse was also responsible to teach the patient to do the incentive spirometery at least 3x per day. The patient was then placed on clear fluids. This was to help the patient begin to get her normal diet back. The clear fluids will help the patient jumpstart he digestive tract without it being too big of a load for the digestive system. The patients Input and output were to be measured q12 hours. If the patient had respiratory depression, the provider would need to be contacted. The patient dressing was to be changed every 3days. 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)1.Deficeint Knowledge related to diet needed to control disease, medication regiment as evidence by a recurrence of diverticulitis.2. Imbalanced nutrition status related to patient clear liquid diet related to recent surgery and lower abdominal pain. 3.Risk of deficient fluid volume related to diarrheas as evidence by the patient’s verbalization of watery stool.4. 5.± 15 CARE PLANNursing Diagnosis: Deficient Knowledge related to diet needed to control disease, medication regiment as evidence by a recurrence of diverticulitis.Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Goal on Day care is ProvidedAssess patient level of education and provide resources for the patient to read about tips to prevent the recurrence of hospitalization and assess patient understanding of the material providing.Assessing the patients’ level of education would allow the nurse to see what materials to provide to the patient. If the patient cannot read, this may be a non-therapeutic attempt to educate the patient.The provider will explain the patient’s diagnosis. Finally with consent of the provider, the nurse will explain any questions within the nurse's scope of practice. Quiz the patient to see if they truly understand. Anything regarding the prognosis of the disease should be answered by the provider and the nurse should reinforce the education of the patient. Having the provider explain the disease to the patient will allow the patient to begin to understand why they are having problems. Then the nurse will help reinforce what the provider explained regarding the disease the patient is experiencing. It is important to not which resources to use. Using image props will help explain things better to the patient and increase their comprehension (Moorman, 2012).This did not happen during my care of the patient. I did try to explain things such as the reason for insulin but as far at diverticulitis, I did not assess the patient to ensure she understand the pathology of her disease and risk factors that could lead her to being hospitalized againProvide the patient with an opportunity to have counseling by expert nurses and other health care professionals to learn and help manage the patient’s disease.I would ask patient if they would like to follow up with a dietician or educator. I could find courses that talk about the patient’s disease and ways to manage her disease. I could also try to find a dietician to help manage her disease also. If possible I would see if telephone follow up could help the patient keep in contact with the dietician via phone so that the patient does not have to come to appointment, which could be discouraging for the patient if she had to come to a physical location. Depending on the individual. Some may be able to understand their disease progress and manage it without to much help. Others may require follow-up consultations. Its really important to evaluate and follow-up with patient to ensure that their health outcomes improve (Brand, P, L P & Stiggelbout, A. M., 2013) Its important to assess weather a patient is on a positive track to recovery. This may also allow the patient to ask questions that may have not occurred during the initial patient education lesson.The provider explained the procedure to the patient and the things that would occur after the surgery of her colon resection. I would offer the patient a consultation with a dietician to try to help her with a new diet to prevent further exacerbation of her illness. Following up after the patients discharge will also ensure the patient is on the right track to recovery. After asking the patient if she could follow up with a provider I would work to have her follow-up fit her schedule even if it meant that she followed-up with a phone call with health professionals within her area of need.The nurse would ensure to administer the medication as ordered. Whether it be within the one hour before or one hour after rule. The nurse should assess the patient level of pain before and after administration.Assessing the patient before a medication administration using a zero to ten rating pain scale. Zero being no pain and ten being the worst pain ever felt. After a pharmacological intervention, the patient should be reassessed.Assessing the patient's pain level will help decrease and prevent the under treatment of pain and resulting harmful effects (Wells, pasero, McCaffery, 2008). This will help the nurse establish a baseline of the patient before the medication. This will let the nurse or health provider know whether the intervention worked or not. If it does work, this intervention can be reused and if it fails the intervention can be modified until a positive affect occurs.Every time the patients was given her medication, her pained was assessed before and after. The patient did indicate that the medication was helping relieve her pain. Also the provider came into to see the patient and ensured that the medication was helping relieve her pain. ±2 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 ± 15 CARE PLANNursing 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 ± 15 CARE PLANNursing Diagnosis: Imbalanced nutrition status related to patient clear liquid diet related to recent surgery colon resection.Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Interventions on Day care is ProvidedEnsure the patient maintains a healthy steady weight within their expected weight measure.I would weigh the patient daily and teach the patients to weigh themselves daily after they have been discharged from the hospital.Sometimes a sudden or abnormal change in a patient's weight can indicate a problem. For example, if a patient begins to gain some weight and is unable to have a bowel movement. This could indicate that the patient is constipated. Especially for this patient, this needs to have high importance because this could complicate the illness of the patient even further.I did not weight the patient. However I would keep and eye on the input and output of the patient. I would ask the patient to see if they do not have any recent weight gain. If so I would realistically measure the patient at least once every week to see if the patient has gained weight or not. I will measure the patient's intake and output to ensure the patient is not constipated or developing edema caused by her recent digestive track resection.Determine the patient's realistic recommended intake with a dietician to ensure the patient is consuming the proper types of foods and the correct amounts. I will check the patient’s lab values to assess for any electrolyte imbalance. I will record the patient's response to clear fluids and ensure the patient progresses positively to get the patient on a high fiber diet before the patient is discharged from the hospital.I will assess the patient stool and check for consistency and color.Research indicated that stool consistency is a key tool in determining the function of the digestive track in a patient's with gastrointestinal diseases (Pares, D, Vallverdue, H, Monroy, G., Amigo, P., Romagosa, C., Toral, M., hermoso, J., Saen-de-Navarrete, G, & 2012). In the hospital sometimes, the provider will ask for stool sampling to check for any internal bleeding. This can also tell the patient, nurse, doctor and other health professionals the status of the patients digestive tract health. I did ask the patient for her last bowel movement. I further asked her about the consistency of her stool and the color of her stool. She indicated it was watery and light brown. This was expected as the patient was on a clear fluid diet. The doctor wanted to tapper the patients diet back to normal slowly to ensure that the patient was recovering. Start the patient’s nutrition diet ordered by the doctor or administered via IV if the patient is order an NPO diet as ordered by the doctor.I will check the patient’s food before and then after eating. I will ask the patient what she ate and keep a journal of her eating habits. I will inquire about any food request to ensure the patient is eating as much as she can. I will work with dietician to help improve the patient’s digestive track's health.If the patient is ordered an NPO diet. The patient cannot consume food orally. This leads the patient to be in a nutritional deficient dilemma. Sometimes the provider will order fluids to be administered to the patient to prevent post-operative complications (Conchin, S., Muirhead, R., Ferrie, S., & Carey, S, (2013). Even IV fluids can help a patient begin to progress toward a normal diet.The patient is on a clear fluid diet. The nurse did not really record the patient’s intake. The nurse probably did not want to record the diet yet because the patient was just transitioning from an NPO diet to a clear fluid diet. Ideally I would record what the patient has consumed and ensure the output is relatively equal to the input. The patient is ordered a diet that is unique to them. Yes, doctors along with other health professional counterparts know that a patient after surgery needs energy in order to recover. As a nurse it is of the most importance that the patient is given IV fluids during any special diet, especially if the patient is on an NPO diet.± 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 ReferencesBrand, P. L P., & Stiggelbout, A. M. (2013) Effective follow-up consultations: the importance of patient-centered communication and shared decision making. Paediatric respiratory mane, D. M., Arasaradnam, R. P., Mills, S., Mathers, J. C., & Bradburn, M. (2009) Diet, ageing, and genetic factors in pathogenesis of diverticular disease. World J gastroenterology, 15, 2479-2488. doi: 10.3748/wjg.15.2479Conchin, S., Muirhead, R., Ferrie, S., & Carey, S. (2013). Can’t we just let them eat? Defining and addressing under-use of the oral route in a post-surgical ward. Asia Pacific Journal of Clinical nutrition, 22. Retrieved from ’s Drug Guide. (Acetominophen, Alvimopan, Dextrose, Enoxaprin, Famotidine, Levotyroxine, Morphine, Naloxone, Ondansetron, Zolpidem, ). Nursing Central.Retrieved from , S. A. (2008). Erik Erikson. Retrieved from , F. H., Nath, J. L., &Bartholomew, E. F. (2012) Fundamentals of Anatomy and Physiology. San Francisco, CA: Pearson Education, Inc. Moorman, S. (2012) Help Patients Defy diverticular disease. Journal of Christian Nursing, 29, 82-87. doi:10.109Pares, D, Vallverdue, H, Monroy, G., Amigo, P., Romagosa, C., Toral, M., hermoso, J., & Saen-de-Navarrete, G. (2012). Bowel Habits and Fecal Incontinence in Patients with Obesity Undergoing Evaluation for Weight Loss: The importance of stool consistency. Disease of the Colon & Rectum, 55. Retrieved from 9d2d2320efe7%40sessionmgr4003&hid=4210&bdata=JnNpdGU9ZWRzLWxpdmU%3D#db=edswsc&AN=000303056300016Wells, N., Pasero, C., & McCaffery. (2008). Improving the Quality of Care Through Pain Assessment and Management. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Hughes RG. ................
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