UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Haralambos Vavlas

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION

Assignment Date:10/22/2015
Agency: STJ

Patient Initials: ND

Age: 73

Admission Date: 10/16/2015

Gender: Female

Marital Status: Widowed (3 years)

Primary Medical Diagnosis: Right spontaneous

tension pneumothorax

Primary Language: English/Spanish

Level of Education: College level course work (Cuba)

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired Billing receptionist/Medical

assistant.
Number/ages children/siblings: Three children (54,53,46) Two
boys, one girl/ 1 Brother (diseased)

N/A no new medical diagnoses

Served/Veteran:
If yes: Ever deployed? Yes or No

Code Status: Full code

Living Arrangements: Patients lives on her own at her home. She

has two daughters and one son that are present during the interview.
Her children do help her with her activities of daily living such as
grocery shopping, however patient is fully independent and does
take care of herself and is able to take all medications on her own.

Advanced Directives:
If no, do they want to fill them out? Pateints does
not want to fill them out.
Surgery Date:10/20/15

Procedure: Thoracotomy

Culture/ Ethnicity /Nationality: Hispanic or Latino

Religion: Catholic

Type of Insurance: M51 MCR Humana Gold Plus

1 CHIEF COMPLAINT: She had really bad shortness of breath and she got really scared.
We thought it was a really bad asthma attack because she does suffer from asthma, so we took her to see the
doctor. Patient speaks broken English however daughter was at bed side and was able to ask her all my question directly

and translate.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) The patient N.D. is a 73-year-old Hispanic female who presented to her primary care provider on 10/2/2015 with a
chief complaint of shortness of breath accompanied with chest tightness and chest pressure. A chest X-ray (CXR) was
done that illustrated a 20% Pneumothorax (PTX). The patient was treated with nebulizers and a close follow up to
evaluate this treatment. On 10/16/2015 the patient returned to her primary care provider with worsening symptoms and
another CXR was done. The CXR revealed 80-90% PTX with possible tension. The patient was then sent to the
emergency department (ED) for further evaluation and treatment. Upon admission a CXR revealed tension PTX on the
right lung with a mediastinal shift. A CT scan also showed a large emphysematous bleb in the apex of the right lung. the
patient received a chest tube by the ED physician assistant (PA) in order to re-expand the right lung with successful
resolution. Thoracic surgery was consulted and on 10/20/2015 the patient underwent video assisted thoracic surgery
(VATS) for resection of the bleb and talc pleurodesis. After the surgery the patient was admitted to 6W for recovery. The
patient had a chest tube to water seal in place. The patient states her pain began about two weeks before her surgery and
was located on the right side on top of her lung, chest and back area. The patient also described the pain as pressure pain

University of South Florida College of Nursing Revision September 2014

and tightness as if she could not breath. The patient states her pain was worse when she moved and when she walked her
dog. The patient also stated that nothing seem to make the pain better and this is why she went to her primary care
provider. The patient was discharged on 10/26/2015 and given a short course of Percocet to help manage the pain. The
patient will require pulmonary function testing (PFT) outpatient to assess the status of her COPD/asthma. The patient will
also need a follow up with the surgery team in order to remove her staples in addition to the pulmonary team and her
primary care provider.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Operation or Illness
Breast Cancer: Lumpectomy; radiation and chemotherapy
Chronic Obstructive Pulmonary Disease (COPD)

As stated above
As stated above
As stated above
As stated above
As stated above
As stated above
As stated above

Hiatal Hernia; never resolved; present

Rheumatoid Arthritis; Glucosamine
Parathyroid adenoma
Asthma: Fluticasone nasal 1 spray nasal 2x daily; Flovent 220mcg = 1 puff, INH, rt2xdaily
Hypertension: Losartan 12.5mg = .5 tab PO 1x daily
Fibromyalgia: Glucosamine
Edema lower limbs bilaterally; hydrochlorothiazide 12.5 mg/1 cap/ 1xdaily/ PO

Father
Mother
Brother
Sister

5
3
8
6
6
2
N
/
A

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

Gout

(angina,
MI, DVT
etc.)
Heart
Trouble

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable)
Car
accident
Alzheimer
s
Heart
attack

Environmental
Allergies

Anxiety: Alprozolam; .125 mg = .5 tab, PO, 1x daily

Gastroesophageal reflux disease (GERD); Ranitidine 150 mg = 1 tab PO 2x daily; Omeprazole 40mg
= 1 cap PO 1x daily

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Date
1/1/2007
Patient was unable
to recall specifics
and no date
assigned in chart.
As stated above
As stated above

N/A

relationship
relationship
relationship

Comments: Besides causes of death, family is very healthy and patient denies any of these in her family history.

University of South Florida College of Nursing Revision September 2014

 1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Codeine

NO

Type of Reaction (describe explicitly)

Rash, redness of the skin, hallucinations.

Medications

Other (food, tape,

latex, dye, etc.)

No food allergies
present

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)

Pneumothorax (PTX) is the presence of air or gas in the pleural space caused by a rupture in the visceral pleura
(which surrounds the lungs) or the parietal pleura and chest wall (Huether & McCance, 2012, p. 682). When air
enters the pleural space it begins to separate the visceral and parietal pleura, altering the negative pressure
located within the lung (Huether & McCance, 2012). This negative pressure within the pleural space is essential
because it prevents the lungs from collapsing during inhalation and exhalation (Huether & McCance, 2012). In
patients diagnosed with a PTX the presence of air in the pleural cavity causes a build up of pressure resulting in
lung collapse which compromises normal respiration (Huether & McCance, 2012).
A PTX can be classified into two categories either primary (spontaneous) PTX or a secondary
(nonspontaneous) PTX (Huether & McCance, 2012). A primary PTX occurs with no known lung disease and it
is found much more common in young to middle aged men (Huether & McCance, 2012). Although there is no
underlying cause to a primary PTX, it is normally caused by small air filled sacs known as blebs that form on
the lungs and rupture (Luh, 2010). Bleb ruptures are mostly located on the top of the patients lungs and are
very unpredictable and can occur at any time including during sleep, exercise, and rest (Huether & McCance,
2012). Although there is no clear etiology of bleb formation, emphysema like changes in the lungs have been
found in a majority of patients with bleb formation (Huether & McCance, 2012). Although there is no clear
evidence that a PTX has a genetic relationship, a small percent (10%) of diagnosed individuals have at least one
family member who has had a primary PTX with a mutation in the folliculin gene (Huether & McCance, 2012).
A secondary PTX is caused by any type of trauma to the chest wall which may include an internal trauma such
as as fractured rib, or an external trauma such as a stab or gunshot wound (Huether & McCance, 2012).
Both primary and secondary PTX can be further classified into either open or tension PTX. In an open
University of South Florida College of Nursing Revision September 2014

PTX a wound or trauma creates an open passage between the external environment and pleural cavity (Huether
& McCance, 2012). Air can then pass in and out of the chest cavity through the opening in the chest (Huether &
McCance, 2012). With the loss of the negative pressure that is normally in the pleural space to hold the lung in
an expanded state, the lung begins to collapse (Huether & McCance, 2012). This differs from patients who are
diagnosed with a tension PTX. At the site of the pleural rupture air is brought in from the external environment
during inhalation however it is unable to expel during exhalation, acting as a one-way valve (Huether &
McCance, 2012). By trapping the air into the pleural cavity more and more air begins to accumulate which
places tension on the affected lung and in turn pushes against the heart and the major vessels (Huether &
McCance, 2012). Most patients who suffer from a PTX have a diminished vital capacity, a decease in PaO2, and
an increase in alveolar-arterial oxygen tension (Physiopedia).
Patients diagnosed with a PTX present with sudden pleural pain, rapid breathing or respirations, and
difficulty breathing (Huether & McCance, 2012). Findings that are common upon physical assessment include
diminished breath sounds in addition to hyperresonance on the lung which has collapsed (Huether & McCance,
2012). In addition to these findings those who are diagnosed with a tension PTX may present with a deficiency
of oxygen reaching the tissues, tracheal deviation opposite of the collapsed lung, and low blood pressure
(Huether & McCance, 2012).
The prevalence of a PTX occurs much more often in males then in females (Physiopedia).
Cigarette smoking is also a key player in the development of a PTX, increasing the risk of developing a PTX 20
fold and the majority (90%) of patients diagnosed with a PTX are or have smoked in their life time
(Physiopedia). In addition to cigarette smoking there is an increasing amount of evidence that genetics may play
a role in the development of PTX (Physiopedia). Genetic disorders that are associated with PTX include,
Marfan Syndrome and Homocystinuria dn Birt-Hogg-Dube (BHD) Syndrome (Physiopedia). Premature infants
who require mechanical ventilation are also a major population in which PTX is commonly found
(Physiopedia).
PTX is diagnosed by physical examination by a provider (Physiopedia). A provider may observe
diminished breath sounds in addition to hyperressonance upon percussion over the collapsed or partially
collapsed lung (Physiopedia). Following this physical exam, the patient will then be taken and observed by
more sophisticated methods such as chest x-ray and computed tomography (CT) scans to finalize the diagnosis
(Physiopedia).
The objective of treatment of a PTX is to decrease the pressure and to reinflate the collapsed lung
(Physiopedia). There are multiple methods of treatment of a PTX depending on the severity (Physiopedia). A
PTX that is less than 20% deflated may only warrant X-ray monitoring in addition to supplemental oxygen until
the lung has reinflated (Physiopedia). A patient diagnosed with a PTX that is greater than 20% may undergo
more invasive treatment including insertion of a chest tube to empty the unwanted air in the pleural space and
allow the rupture to heal (Huether & McCance, 2012). If the PTX does not heal and there is a continuous air
leak, the patient will undergo other treatment options including surgery, pleurodesis, endobronchial
embolization, or thoracoscopic gluing techniques (Huether & McCance, 2012).
The mortality rate of patients who are diagnosed with a PTX is very low, and when treated properly
patients may resume their normal lives with no to very few complications. However, the majority of patients
may return with a recurring PTX (Physiopedia).
References:
Huether, S., McCance, K. (Ed. 5). (2012). Understanding Pathophysiology. St. Louis, Missouri: Elsevier Mosby.
Pneumothorax (- Physiopedia, universal access to physiotherapy knowledge.)
Retrieved from http://www.physio-pedia.com/Pneumothorax#Causes_and_risk_factors
University of South Florida College of Nursing Revision September 2014

 5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.
Name: ranitidine (Zantac)

Concentration

Dosage Amount: 150 mg tablet

Route: PO

Frequency: 1 tab 2x daily

Pharmaceutical class: Histamine2 Blocker

Home

Hospital

or

Both

Indication: Used for GERD

Adverse/ Side effects: Headache, confusion, nausea, vertigo, diarrhea or constipation, depression, rash, blurred vision, malaise, decrease libido. Adverse: hepatotoxicity,
cardiac dysrhythmias, blood dyscrasias. Decrease absorption with antacids; decrease absorption of ketoconazole; toxicity with metoprolol.
Nursing considerations/ Patient Teaching: administer drug just before meals or at bedtime to decrease food-induced acid secretion; be alert that older adults have less
gastric acid and need reduced doses of drug; metabolic acidosis must be prevented; administer IV drug in 20 to 100 mL of solution; teach patient to report pain, coughing,
or vomiting of blood; advise patient to avoid smoking, because it can hamper effectiveness of drug; remind patient that the drug must be taken exactly as prescribed; direct
patient to separate ranitidine and antacid dosage by at least 1 hour; warn patient not to drive a motor vehicle.

Name: omeprazole (Prilosec)

Concentration

Dosage Amount: 40 mg = 1 capsule

Route: PO delayed release capsule

Frequency: 1x daily

Pharmaceutical class: Proton Pump Inhibitor

Home

Hospital

or

Both

Indication: Used for GERD

Adverse/ Side effects: dizziness, drowsiness, fatigue, headache, weakness, chest pain, Pseudomembranous colitis, abdominal pain, acid regurgitation, constipation,
diarrhea, flatulence, nausea, vomiting, hypomagnesemia, itching, rash, bone fracture, allergic reactions. Decrease metabolism and increase effects of antifungal agents;
may decrease absorption of drugs requiring acid pH; decrease effects of atazanavir and nelfinavir; may increase risk of bleeding with warfarin; voriconazole may increase
levels; rifampin may decrease levels and may decrease response; may increase levels of tacrolimus and methotrexate; St. Johns wort may decrease levels and may
decrease response.
Nursing considerations/ Patient Teaching: Assess patient routinely for epigastric or abdominal pain and frank or occult blood in stool, emesis, or gastric aspirate;
monitor bowl function; Diarrhea, abdominal cramping, fever, and bloody stools should be reported to provider as a sign of pseudomembranous colitis; monitor CBC with
differential periodically during therapy. Instruct patient to take medication as directed for full course of therapy, even if feeling better; Take missed doeses as soon as
remembered but not if almost time for next dose; may cause occasional drowsiness or dizziness, caution patient to avoid driving; instruct patient to notify provider of all
prescribed and over the counter medications, vitamins, or herbals; advise patient to avoid alcohol, products containing aspirin or NSAIDS, and foods that may cause an
increase in GI irritation; advise female patient to notify health care provider if pregnancy is planned or suspected or if breast feeding.
Name: losartan (Cozaar)

Concentration: 12.5 mg = 0.5 tab

Route: PO

Dosage Amount: 25 mg oral tablet

Frequency: 1xdaily

Pharmaceutical class: angiotensin 2 receptor antagonist

Home

Hospital

or

Both

Indication: Used to decrease blood pressure due to patients hypertension

Adverse/ Side effects: dizziness, fatigue, headache, insomnia, weakness, chest pain, edema, hypotension, nasal congestion, hypoglycemia, weight gain, diarrhea,
abdominal pain, dyspepsia, nausea, impaired renal function, hyperkalemia, back pain, myalgia, angioedema, fever. Additive hypotension with other antihypertensives;
excessive hypotension may occur with concurrent use of diuretics; increase risk of hyperkalemia with concurrent use, of potassium supplements; increase risk of
hyperkalemia renal dysfunction, hypotension, and syncope with concurrent use of ACE inhibitors; rifampin may decrease antihypertensive effects; NSAIDS and selective
COX-2 inhibitors may blunt the antihypertensive effect and increase the risk of renal dysfunction

University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching: assess blood pressure (lying, sitting, standing) and pulse frequently during initial dose adjustment and periodically during
therapy. Notify health care provider of significant changes; monitor frequency of prescription refills to determine compliance; assess patient for signs of angioedema
(dyspnea, facial swelling); monitor renal function may cause increase BUN and serum creatinine. Teach patient to take the medication even if feeling well; teach patient to
take medication the same time each day; caution patient to avoid salt substitutes containing potassium or foods containing high levels of potassium or sodium unless
directed by health care provider; caution patient to avoid sudden changes in position to decrease orthostatic hypotension; may cause dizziness and instruct patient to avoid
driving; instruct patient to notify health care provider of medication regimen before surgery; advise patient of childbearing age to use contraceptives and notify health
provider if pregnancy is planned or suspected, Losartan should be discontinued as soon as pregnancy is detected; instruct patient to notify health care provider if swelling
of face, eyes, lips, or tongue or if difficulty swallowing or breathing occur.
Name: fluticasone (Flovent HFA)

Concentration:

Route: Nasal spray

Dosage Amount: .05 mg/inh

Frequency: 2xdaily

Pharmaceutical class: Corticosteroids

Home

Hospital

or

Both

Indication: Used for patients asthma

Adverse/ Side effects: Headache, dizziness, dysphonia, hoarseness, oropharyngeal fungal infections, nasal stuffiness, rhinorrhea, sinusitis, bronchospasm, cough, upper
respiratory tract infection, wheezing diarrhea, adrenal suppression, decrease bone mineral density, decrease growth in children, Cushings syndrome, muscle pain,
hypersensitivity reactions including: anaphalaxis, laryngeal edema, urticarial, bronchospasm, Churg-Strauss Syndrome, fever.
Nursing considerations/ Patient Teaching: monitor respiratory status and lung sounds; assess pulmonary function test periodically during and for several months after a
transfer from systemic to inhalation corticosteroids; assess patients changing from systemic corticosteroids to inhalation ones for signs of adrenal insufficiency (anorexia,
nausea, weakness, fatigue, hypotension, hypoglycemia) during initial therapy and periods of stress. If these signs appear, notify health provider immediately; monitor for
withdrawal symptoms; monitor growth rate in children receive chronic therapy, use lowest does possible; may cause decreased bone mineral density during prolonged
therapy; monitor for signs of hypersensitivity reaction. Advise patients to take dose as directed; advise patients using inhalation corticosteroids and bronchodilator to use
bronchodilator first and to allow 5 min to elapse before administering the corticosteroid; advise patient to stop using medication and notify provider immediately if signs
and symptoms of hypersensitivity reactions occur; caution patient to avoid smoking, known allergies, and other respiratory irritants; advise patient to notify provider if
sore throat or mouth occurs; teach female patients to notify provider if pregnancy is planned or suspected or if breastfeeding.
Name: alprazolam (Xanax)

Concentration: 0.125mg = 0.5 tab

Route: PO

Dosage Amount: .25 mg tab

Frequency: 1xdaily hs

Pharmaceutical class: Benzodiaepines

Home

Hospital

or

Both

Indication: Used to treat patients anxiety

Adverse/ Side effects: dizziness, drowsiness, lethargy, confusion, hangover, headache, mental depression, paradoxical excitation, blurred vision, constipation, diarrhea,
nausea, vomiting, weight gain, rash, physical dependence, psychological dependence, tolerance. Alcohol, antidepressants, other benzodiazepines, antihistamines, and
opioid analgesics concurrent use results in increased CNS depression, may decrease efficacy of levodopa, sedative effects may be decreased by theophylline, cigarette
smoking decrease levels and effects. Kava-kava, valerian, or chamomile can increase CNS depression, concurrent ingestion of grapefruit juice can increase levels and
effects.
Nursing considerations/ Patient Teaching: assess degree and manifestations of anxiety and mental status prior to and periodically during therapy; assess patients for
drowsiness and dizziness; assess CNS effects and risk for falls; monitor CBC and liver and renal function periodically during long term therapy, may cause decrease
hematocrit and neutropenia. Instruct patient to take medication as directed, do not skip or double dose if you miss a dose, teach patient to avoid driving due to drowsiness
and dizziness; advise patient to avoid drinking grapefruit juice during therapy; teach patient to avoid alcohol or other CNS depressants; teach patients other ways to
decrease anxiety nonpharmaceutical.
Name: fluticasone (Flovent HFA)

Concentration: 220 mcg = 1 puff

Route: inhalation

Dosage Amount: 220 mcg or 1 puff

Frequency: rt2xdaily

Pharmaceutical class: Corticosteroids

Home

Hospital

or

Both

Indication: Used for patients asthma

Adverse/ Side effects: Headache, dizziness, dysphonia, hoarseness, oropharyngeal fungal infections, nasal stuffiness, rhinorrhea, sinusitis, bronchospasm, cough, upper
respiratory tract infection, wheezing diarrhea, adrenal suppression, decrease bone mineral density, decrease growth in children, Cushings syndrome, muscle pain,
hypersensitivity reactions including: anaphalaxis, laryngeal edema, urticarial, bronchospasm, Churg-Strauss Syndrome, fever.
Nursing considerations/ Patient Teaching: monitor respiratory status and lung sounds; assess pulmonary function test periodically during and for several months after a
transfer from systemic to inhalation corticosteroids; assess patients changing from systemic corticosteroids to inhalation ones for signs of adrenal insufficiency (anorexia,
nausea, weakness, fatigue, hypotension, hypoglycemia) during initial therapy and periods of stress. If these signs appear, notify health provider immediately; monitor for
withdrawal symptoms; monitor growth rate in children receive chronic therapy, use lowest does possible; may cause decreased bone mineral density during prolonged
therapy; monitor for signs of hypersensitivity reaction. Advise patients to take dose as directed; advise patients using inhalation corticosteroids and bronchodilator to use
bronchodilator first and to allow 5 min to elapse before administering the corticosteroid; advise patient to stop using medication and notify provider immediately if signs
and symptoms of hypersensitivity reactions occur; caution patient to avoid smoking, known allergies, and other respiratory irritants; advise patient to notify provider if
sore throat or mouth occurs; teach female patients to notify provider if pregnancy is planned or suspected or if breastfeeding.
Name: morphine (Roxanol)

Concentration: 2 mg = 2 mL

Route: IV

Dosage Amount: 2 mg

Frequency: q4hr

Pharmaceutical class: opioid agonist

Home

Hospital

or

Both

Indication: used for patients pain. PRN for pain

Adverse/ Side effects: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred vision, diplopia, miosis,
respiratory depression, hypotension, bradycardia, constipation, nausea, vomiting, urinary retention, flushing, itching, sweating, tolerance, physical and psychological

University of South Florida College of Nursing Revision September 2014

dependence. Use extreme caution in patients receiving MAO inhibitors within 14 days prior; increase CNS depression with alcohol and sedative hypnotics; may increase
anticoagulant effect of warfarin, cimetidine decreases metabolism and may increase effects. Kava-kava, valerian, or chamomile can increase CNS depression.
Nursing considerations/ Patient Teaching: assess type, location, and intensity of pain prior to and 1 hour following PO, subcutaneous, IM, and 20 min following IV
administration; patients on continuous infusion should have addition bolus doses provided every 14-30 min as needed for breath through pain; assess level of
consciousness, BP, pulse, and respirations before and periodically during administrations; prolonged use may lead to physical and psychological dependence; assess bowl
function routinely. Teach patient how and when to ask for pain meds; may cause drowsiness and dizziness, caution patient to call for assistance when ambulating; advise
patient to change positions slowly to minimize orthostatic hypotension; caution patient to avoid concurrent use of alcohol or other CNS depressants.
Name: hydrochlorothiazide (Microzide)

Concentration:

Route: PO

Dosage Amount: 12.5 mg

Frequency: 1 capsule 1xdaily

Pharmaceutical class: thiazide diuretics

Home

Hospital

or

Both

Indication: Used to treat patients hypertension and leg edema

Adverse/ Side effects: dizziness, drowsiness, lethargy, weakness, hypotension, anorexia, cramping, hepatitis, nausea, vomiting, Stevens Johnson Syndrome,
photosensitivity, rash, acute angle-closure glaucoma, acute myopia, hyperglycemia, hypokalemia, dehydration, hypocalcemia, hypochloremic alkalosis,
hypomagnesaemia, hyponatremia, hypovolemia, blood dyscrasiasis, byperuricemia, hypercholesterolemia, muscle cramps, pancreatitis. NSAIDS may decrease
effectiveness, hypokalemia increase risk of digoxin, decrease the excretion of lithium.
Nursing considerations/ Patient Teaching: Monitor BP, intake, output, and daily weights and assess feet, legs, and sacral area for edema daily; if hypokalemia occurs
consideration may be given to potassium supplementation or decrease dose of diuretic; assess patient for allergy to sulfonamides. Instruct patient to take this med at the
same time each day; instruct patient to monitor weight biweekly and notify the health care provider of significant changes; caution patient to change position slowly to
minimize orthostatic hypotension; advise patient to wear sunscreen and protective clothing when going outdoors.
Name: Ondansetron (Zofran)

Concentration:

Route: PO

Dosage Amount: 100 mg 1 capsule

Frequency: 2xdaily

Pharmaceutical class: Five ht3 antagonist

Home

Hospital

or

Both

Indication: Used for patients postoperative nausea and vomiting

Adverse/ Side effects: headache, dizziness, drowsiness, fatigue, weakness, Torsade De Pointes, QT interval prolongation, constipation, diarrhea, abdominal pain, dry
mouth, increased liver enzymes, extrapyramidal reactions. Use with amorphine increased risk of severe hypotension and loss of consciousness; concurrent use
contraindicated; carbamazepine, phenytoin, and rifampin may decrease levels.
Nursing considerations/ Patient Teaching: assess patient for nausea, vomiting, abdominal distention, and bowel sounds prior to and following administration, assess
patient for extrapyramidal effects periodically during therapy; instruct patient to take Zofran as directed; advise patient to notify provider immediately if symptoms of
irregular heart beat or involuntary movement of eyes, face, or limbs occur.

Name: hydromorphone (Dilaudid)

Concentration: 1 mg = 1 mL

Route: IV

Dosage Amount: 1 mg

Frequency: q4hr PRN

Pharmaceutical class: opioid agonist

Home

Hospital

or

Both

Indication: Used to treat patients pain. PRN for pain

Adverse/ Side effects: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred vision, diplopia, miosis,
respiratory depression, hypotension, bradycardia, constipation, dry mouth, nausea, vomiting, urinary retention, flushing, sweating, physical and psychological dependence,
tolerance. Use extreme caution in patients receiving MAO inhibitors within 14 days prior; increase CNS depression with alcohol and sedative hypnotics; may increase
anticoagulant effect of warfarin, cimetidine decreases metabolism and may increase effects. Kava-kava, valerian, or chamomile can increase CNS depression.
Nursing considerations/ Patient Teaching: assess BP, pulse and respirations before and during administration; assess bowl function routinely, institute prevention of
constipation with increased intake of fluids and bulk, and laxatives to minimize constipating effects; assess type, location, and intensity of pain, prior to and 1 hr following
IM or PO and 5 min following administration; assess cough and lung sounds during antitussive sue; instruct patient on how and when to ask for pain medication; advise
patient that hydromorphone is a drug with known abuse potential; may cause drowsiness and dizziness, caution patient to call for assistance when ambulating; advise
patient to change positions slowly to minimize orthostatic hypotension; caution patient to avoid concurrent use of alcohol or other CNS depressants.
Name: docusate calcium (Colace)

Concentration:

Route: PO

Dosage Amount: 100 mg

Frequency: 2x daily

Pharmaceutical class: stool softener

Home

Hospital

or

Both

Indication: Used due to patient being on opioids to prevent constipating

Adverse/ Side effects: throat irritation, mild cramps, diarrhea, rashes.
Nursing considerations/ Patient Teaching: Assess patient for abdominal distention, presence of bowl sounds, and usual pattern of bowl function, assess color,
consistency, and amount of stool produced. Advise patients that laxatives should only be used for short term therapy; encourage patients to use other forms of bowl
regulation, such as increasing bulk in the diet and increasing fluid intake; instruct patients with cardiac disease o avoid straining during bowel movements; advise patients
not to use laxatives when abdominal pain, nausea, vomiting, or fever is present; advise patients not to take docusate within 2 hr of other laxatives.
Name: ibuprofen (Motrin)

Concentration:

Dosage Amount: 400 mg 1 tab

University of South Florida College of Nursing Revision September 2014

Route: PO

Frequency: q6hr

Pharmaceutical class: nonopioid analgesic

Home

Hospital

or

Both

Indication: Used to treat patients post operative pain. PRN for pain
Adverse/ Side effects: headache, dizziness, drowsiness, intraventricular hemorrhage, psychic disturbances, amblyopia, blurred vision, tinnitus, arrhythmias, edema,
hypertension, GI bleeding, hepatitis, constipation, dyspepsia, nausea, vomiting, abdominal discomfort, cystitis, hematuria, renal failure, Steven Johnson Syndrome, rashes,
anemia, blood dyscrasias, prolonged bleeding time allergic reaction anaphalaxis. Concurrent use of aspirin may decrease the effects of ibuprofen. Chronic use with
acetaminophen may increase risk of adverse renal reactions, may decrease the effectiveness of diuretics, ACE inhibitors and other antihyprtensives. Increase bleeding risk
with arnica, chamomile, feverfew, garlic, ginger, ginkgo, panax, and ginseng.
Nursing considerations/ Patient Teaching: Assess patient for signs and symptoms of GI bleeding, assess pain prior to and 1-2 hr following administration, monitor
temperature, note signs associated with fever. Advise patients to take with a full glass of water, instruct patient to take medication as directed, may cause drowsiness and
dizziness so tell patient to avoid driving, advise patient to inform provider prior to having surgery.

References
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (n.d.). Unbound Medicine, Inc. [Software]. Daviss Drug Guide.
Nursing Central. Retrieved from http://www.unboundmedicine.com/products/nursing_central.

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Analysis of home diet
Diet ordered in hospital? The patient was ordered and full
After analyzing the patients diet and comparing it to my
liquid and food diet with no diet restrictions.
Diet patient follows at home? Regular diet however patient plate I would suggest that the patient make some
modifications to her diet. Due to the patients age a well
states nothing spicy due to stomach problems.
balanced diet is essential in order to maintain the best
24 HR average home diet:
Breakfast: Patient states that she typically eats an 8 oz cup health possible and to recover quickly from her surgery. To
begin the patient is not consuming any vegetables in her
of vanilla low fat yogurt, 1 cup of mixed fruit (grapes,
diet in addition to not enough fruit in her diet. Vegetables
watermelon, oranges, blueberries), 1 cup of cereal
and fruit are an important source of all vitamins and
(cheerios) with 1 cup of whole milk, and one 8 oz mug of
minerals. Potassium is also found in vegetables and due to
black instant coffee.
the patients hypertension she should consider adding more
vegetables in her diet because it has been shown that
Lunch: Patient states that she typically eats one turkey
potassium acts to lower blood pressure. The patient did not
sandwich (2 slices of multi grain bread, 1 slice of Swiss
state that she was taking a multivitamin therefore it is
cheese, 1 tablespoon mustard, 2 slices of turkey) and one 8
essential for her to include vegetables and fruits in her diet.
oz mug of coconut water, tea, or cranberry juice.
Although the patient is consuming a large portion of grains
(whole and refined) I would not recommend decreasing her
Dinner: Patient states she likes to have 1 medium sized
grain intake because grains are high in fiber. Due to the use
portion of grilled chicken breast on top of 2 cups of pasta
and possibly being sent home with opioids for pain, the
and sometimes substitutes the grilled chicken with salmon.
patient should maintain a high fiber intake in order to
She also has a glass (5 oz) of red wine with dinner.
prevent constipation and encourage a bowl movement at
least once every three days. The patient is not receiving the
Snacks: Patient states she does not eat any snacks and
recommended daily amount of protein in her diet. The
sticks with her 3 meals per day.
patient should increase her protein intake. The body uses
protein in order to build and repair tissue. Due to the
Liquids (include alcohol): cranberry juice, water, red
patients recent surgery and her age, her body is less well
wine, coconut water, tea.
adapted and it may take longer for her body to heal. By
increasing her protein intake, she is giving her body the
resources necessary to jump start the healing process.

References
United States Department of Agriculture. (2015). SuperTracker. United States Department of Agriculture.
Retrieved from https://www.supertracker.usda.gov/

University of South Florida College of Nursing Revision September 2014

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? I live alone so I am pretty independent and I take care of myself. My husband has
Passed away for quite sometime now so I have leaned to take care of myself. When I am really sick my daughter or my
two sons come and take care of me.
How do you generally cope with stress? or What do you do when you are upset? When I get stressed I like to talk to
people wether it be on the phone with my daughter or with my family back in cuba. If I am really anxious I like to take my
dog for a walk by the bay.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) I stress over a
lot of things that I cant control, and when I get stressed out I like to vent to my family. I dont really get depressed, lately I
have been very anxious about my surgery.
+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? Yes with my husband, he was physically abusive.
Have you ever been talked down to? Yes. Have you ever been hit punched or slapped? Yes all three and he chocked
me.
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
I have also been threatened with a knife. If yes, have you sought help for this? No when I was young abuse wasnt
frowned upon as it it is now.
Are you currently in a safe relationship? Yes this happened years ago when my children were really young he has passed
now and my children take really good care of me.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your

patients age group: Integrity vs Despair is the final stage of Ericksons stages of psychosocial development.
This stage occurs when an individual reaches the later parts of their lives and is characterized as being over the
age of 65 until death. In this stage the individual begins to reminisce on their life and come away with either a
sense of Integrity or a sense of despair. Those who have truly believed they have lived a beautiful life full with
excitement and no regrets will come away with a sense of integrity, gain wisdom and welcome with open arms
the next chapter in life which is death. Those individuals who look back onto their lives and are filled with
regret because they feel as if they did not do everything they wanted to do and are not satisfied will leave with a
sense of despair.

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

University of South Florida College of Nursing Revision September 2014

10

The stage that my patient is in is the despair stage. My patient was unsatisfied with her life and expressed a large amount
of regret. She stated Being in an abusive relationship for most of my life I wasnt able to do much of anything. My life
consisted of staying home, taking care of the kids, and tending to my husbands every need; I didnt know better. After
explaining to her that I was Greek my patient also expressed regrets of not being able to travel, as it was always a passion
of hers when she was a little girl. My patient stated I always wanted to go to Greece and other places in Europe because I
would always see pictures of how beautiful it is, but I was never able to leave home. I believe that abuse was not looked
down upon as it is now and women during her time period did not know any better. This is very sad because I believe her
life was taken away from her and she has many regrets in her life that cannot be changed.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

My patient expressed the same regret and despair about her most recent hospitalization. My patient stated
Being in the hospital, not being able to go where I want to go or do what I want to do makes me feel like I was
married to my husband again. I am finally able to enjoy my life and yet its like I have someone telling me what
to do again. I believe this most recent hospitalization has had a negative impact on my patients developmental
stage of life because it is like reliving her abusive relationship all over again. If she was not diagnosed with a
PTX she possibly could do the things that she always wanted to do such as travel. But now that she has had
surgery, in addition to being the age that she is, she may have to take it slow for some months in order to
recover.
References
Cherry, K. (n.d.). Generativity Versus Stagnation. About Psychology. Retrieved from

http://psychology.about.com/od/psychosocialtheories/a/integrity-versus-despair.htm
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? I believe it is a message from God. He is trying to get a check on my
life. I also believe that what you speak and all the negativity that you bring into your home is what will then happen to
you. I havent been saying nice things to people lately and I havent been going to church much, so I believe it is a
message from God.

What does your illness mean to you? My illness shows me that I have to have a repetent heart. I hold a lot of grudge and
hate in my heart for my husband and I think God gave me this illness in order to teach me that I need to forgive and forget
or else I will never make it to heaven.

+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

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11

Have you ever been sexually active? Yes I have three children.
Do you prefer women, men or both genders? Just men.
Are you aware of ever having a sexually transmitted infection? No.
Have you or a partner ever had an abnormal pap smear? No only normal.
Have you or your partner received the Gardasil (HPV) vaccination? No.
Are you currently sexually active? No. If yes, are you in a monogamous relationship? ____________________ When
sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? __________________________________
How long have you been with your current partner? I am widowed.
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.

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life? It means the most to me. I got to church every Sunday and I pray to
the saints and God every night.
Do your religious beliefs influence your current condition? Yes everything I go through, especially with cancer for example, I have
been more in touch with God.

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
How much?(specify daily amount)
If so, what? Yes I used to smoke cigarettes
when I drank coffee. Only occasionally.
1 cigarette per day

Yes
No
For how many years? 36 years
(age

17

thru

53

If applicable, when did the

patient quit? 20 years ago

Pack Years: 2
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No lives alone

Has the patient ever tried to quit?

If yes, what did they use to try to quit? Yes stopped easily
did not use anything.

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
How much? 1 glass per day
What? Only a glass of red wine with
Volume: 5 ounces
dinner somtimes.
Frequency: daily (most days).
If applicable, when did the patient quit?

No
For how many years? 53 years
(age

20

thru 73

3. 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?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No, I only worked inside when I moved to the U.S. after my husband passed.
5. For Veterans: Have you had any kind of service related exposure? N/A

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health?

Integumentary: Patient denies any changes in skin appearance. Patient denies any problems with nails or
dandruff. Patient denies any hives or rashes. Patient denies any skin infections. Patient does use sunscreen when
going outdoors to garden (SPF 15). Patient states she bathes twice per day in the morning and at night.
HEENT: The patient denies difficulty seeing. Patient denies cataracts and glaucoma. Patient states she does have
hearing loss and has a hearing aid but will not wear it. Patient stated her hearing loss begin 3 years ago. Patient
describes the location of her hearing loss in the right ear. Patient characterizes her hearing loss as very faint
noise and difficult hear even when speaking to someone up close. Patient says not wearing her hearing aid
makes it worse and only wearing her hearing aid makes it better. Patient states when not using her hearing aid
she can hear about a 3 out of 10. Patient denies any ear infections. Patient denies sinus pain or infections. Patient
denies nose bleeds. Patient denies post nasal drip. Patient denies oral/pharyngeal infection. Patient denies dental
problems. Patient brushes her teeth 2x per day. Patient tries to make an effort of seeing a dentist once per year.
Patients last vison screening was 3 years ago.
Pulmonary: Patient states she does have shortness of breath. Patient states her shortness of breath started on
10/2/15 and she has pain in her upper right lung, back and chest area and lasted for two weeks. Patient states that
the pain felt like pressure pain. Patient states that moving made the pain worse and nothing seem to make the
pain better. Patient states her pain is now a 7 out of 10. Patient states she does have a history of asthma,
emphysema, and bronchitis. Patients denies pneumonia, tuberculosis and environmental allergies. Patients last
chest X-ray was 10/23/15.
Cardiovascular: patient states she has a problem with hypertension for about 10 years now. Patient denies having
hyperlipidemia and chest pain. Patient denies having myocardial infarction, CAD/PVD, CHF, murmur,
thrombus, rheumatic fever and myocarditis and arrhythmias. The patients last EKG was done on 10/16/2015.
GI: Patient denies having nausea, vomiting, diarrhea, and constipation. Patients does have GERD. Patient denies
indigestion, hemorrhoids, yellow jaundice. Pancrititis, colitis, diverticulitis, appendicitis and abdominal abscess.
Patients last colonoscopy was two years ago. Patient denies irritable bowel, cholecystitis. Patient does suffer
from gastric ulcers. Patient states that she has had a problem with ulcers for a couple years now and has to watch
her diet and stay away from spicy foods. Patient denies hepatitis and blood in the stool.
GU: Patient denies nocturia, dysuria, hematuria, polyuria, and kidney stones. Patient normally urinates six times
per day. Patient denies having bladder or kidney infections.
Women/Men Only: Patient denies having infection of the female genitalia. Patient states after having breast
cancer she constantly does self breast exams and she see her doctor once per year for her annual checkup.
Patient does not go for pap/pelvic exam and cannot recall last gyn exam. Patient states she does not have
menstrual cycles anymore. Patient states her menarche began at the age of 13 and menopause began at the age
of 53. Patients states her last mammogram was about a year ago and that the results came back clear with no
signs of cancer. Patient denies having a DEXA exam.
Musculoskeletal: Patient denies any injuries or fractures. Patient denies any weakness, pain, gout, and
osteomyelitis. Patients states she does suffer from arthritis. Patient does not recall when she was diagnosed with
arthritis. Patients complains of stiffness and tenderness in joints and take her medication to help relieve the pain.

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14

Immunologic: Patient denies chills with severe shaking, night sweats, and fever. Patient denies HIV or AIDS.
Patient denies having Lupus. Patient states she does suffer from rheumatoid arthritis. Patient states her arthritis
is in the joints of her arms and legs. Patient states she has tenderness, stiffness, and sharp pain associated with
her rheumatoid arthritis. Patient states walking her dog aggravates her arthritis and her medication helps to make
it feel better. Patients states her pain when her arthritis really acts up us about a 7 out of 10. Patient denies
sarcoidosis. Patient denies any tumors. Patient denies life threatening allergic reactions and enlarge lymph
nodes.
Hematologic/Oncologic: Patient denies anemia, bleeding easily and bruising easily. Patient states she did have
breast cancer 7 years ago. Patient denies blood transfusions.
Metabolic/Endocrine: Patient denies diabetes, hypo/hyperthyroid, intolerance to hot or cold and osteoporosis.
Central Nervous System: Patient denies CVA, dizziness, severe headaches, migraines, seizures, ticks or tremors,
encephalitis, and meningitis.
Mental Illness: Patient denies depression and schizophrenia. Patient states she does have anxiety. Patient states
that her anxiety has gotten worse sense she has had to have this surgery and being in the hospital. Patient denies
Bipolar.
Childhood Diseases: Patient denies having measles, mumps, polio, and scarlet fever. Patient states she did have
chicken pox when she was young.
General Constitution: Patients states she did not have any recent weight loss. Patient views her overall health
as very good despite coming in for surgery.

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.

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10 PHYSICAL EXAMINATION:

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General survey: Patient is a 73-year-old Hispanic female who is obese and shows no obvious or visible signs of distress.
Height : 51 (stated) Weight: 152.3 lbs BMI: 26 kg/m Pain (include rating and location): 7 out of 10 upper right
back/lung (pain intensity scale)
Pulse: 65 Blood Pressure (include location): 111/72 brachial pulse Temperature (route taken): 97.8 F Oral
Respirations: 16 SpO2: 98% Room Air or O2: O2 2L NC
Overall Appearance: Patient is clean with her hair combed and dressed appropriately for setting and temperature. Patient
maintains eye contact and there are no obvious handicaps. Patient is sitting in the chair on the side of the bed.
Overall Behavior: Patient is awake and seems to be very pleasant and is conversing with family members in the room.
Patient seems calm and relaxed and displays happiness to have visitors. Patients judgment is in tact.
Speech: Patients speech is clear and concise. Patient articulates how she feels appropriately.
Mood and Affect: Patient is pleasant and very willing to participate in the examination. Patient is very cheerful and
talkative. Patient seems very happy that her surgery went well.
Integumentary: skin is warm and dry however it is not intact due to surgical wound. The dressing is clean, dry, and intact
with no drainage visible. Skin turgor is normal. There are no rashes, lesions, or deformities. No clubbing of the nails. Her
hair is evenly distributed and clean. Patients capillary refill is brisk less than 3 seconds bilaterally in upper extremities.
IV Access: Patient has a 22-gauge 1-inch IV on the right forearm. The IV was inserted on 10/16/2015. The patient is on
normal saline. There is no redness, edema, or discharge at the IV site.
HEENT: Patients facial features are symmetrical and there is no pain in the sinus region. Patient has no pain or clicking of
TMJ. Trachea is midline and her thyroid is not enlarged. There are no palpable lymph nodes. The patients sclera is white
and the conjunctiva is clear with no visible discharge. Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands
symmetric without edema or tenderness. Pupil size is 4mm in both eyes and the pupils are equal, round, reactive to light and
accommodation (PERRLA). Patients peripheral vision is intact. EOM intact through all 6 cardinal fields without
nystagmus. Ears are symmetric without lesions or discharge. Whisper test was heard well in the left ear with no problems at
8 inches. Patient was unable to hear the whisper test at 8 inches on the right ear. Patients nose is without lesions or
discharge. Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Pulmonary/Thorax: Patients respirations are regular and unlabored. Transverse to AP ratio is 2:1. Patients chest expansion
is symmetric. Percussion is resonant throughout all lung fields, and dull towards the posterior bases. Patient does not have
any sputum production. Diminished lung sounds in R lung fields with no crackles. Left lung fields clear are clear to
auscultation.
Cardiovascular: No lifts, thrills, or heaves palpated or auscultated. S1 and S2 are present. Heart rate is regular with with
regular rhythm. The PMI is best palpated at the fifth intercostal space of the left midclavicular line. No murmur, clicks, or
adventitious heart sounds auscultated. No JVD. Calf pain is negative bilaterally. Pulses are equal bilateral 3+ normal upper
extremities. Pulses are equal bilateral 3+ normal lower extremities. Carotid, brachial, radial, DP, PT pulses are 3+ equal
bilaterally. Could not palpate popliteal pulses. No temporal or carotid bruits. 1+ LE edema which is non pitting.
Extremities warm with capillary refill less than 3 seconds in both upper and lower extremities.
GI: Bowl sounds are present in all 4 quadrants. No bruits auscultated and no organomegaly. Percussion is dull over liver
and spleen and tympanic over stomach and intestine. Abdomen is non-tender to palpation. Patients last bowel movement
was on 10/22/15 and it was soft with medium brown color. Patient does not have nausea or emesis. Patients genitalia were
not assessed however patient, patient is alert, oriented, and denies problems.
GU: Patient states her urine is clear with a yellow color. Patients 24-hour output N/A. Patient does not have a foley catheter
and is allowed to use the restroom with assistance during ambulation. No CVA tenderness.
Musculoskeletal: Full ROM intact in all extremities without crepitus. Strength bilaterally equal at __4__ RUE __4__
LUE __4__ RLE & __4____ in LLE (4 = against some resistance). Vertebral column is without kyphosis or scoliosis.
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Neurological: Patient is awake, alert, oriented to person, place, time, and date (AOx3). Patient is not confused. CN 2-12 is
grossly intact. Sensation intact to touch, pain, and vibration. The Romberg test is negative. Stereognosis, graphesthesia, and
proprioception are intact. Gait was not assessed did not want patient to move due to pain post surgery. DTR was not
assessed due to lack of reflex hammer.

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
University of South Florida College of Nursing Revision September 2014
17

abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
WBC

Dates
13.9 H

(10/16/2015)

9.2

(10/23/2015)

Normal (4.5-11)

RBC
4.79
3.53 L
Normal (3.60-5.40)

10/16/2015
10/21/2015

HGB
14.0
10.4 L
Normal (12.0-16.0)

10/16/2015
10/21/2015

HCT
41.0
30.4 L
Normal (37.0-47.0)

10/16/2015
10/21/2015

Trend
Upon admit, and before
surgery the patients WBC
were in the high range
However after the
patients surgery, WBC
are trending downwards.

Analysis

Upon admit, and before

surgery the patients RBC
was in the normal range.
After surgery the patients
RBC trended downwards
in the low range.

Postoperatively the
patient may have lost
some blood during the
procedure which is
perfectly normal. Even
thought the patients RBC
is below the normal range
it is only slightly and it
does not seem to raise a
huge concern.
The patient may have
experienced a low HGB
due to the loss of blood
during the procedure. In
addition, the patient also
state that she has had an
ulcer. The patients low
HGB may also be a result
of bleeding in the GI.
The patient may have
experienced a low HCT
postoperatively due to
blood loss after surgery.
In addition, the patient
does not eat a healthy diet
high in vitamins (B12).
This may be indicative of
her low levels of HCT.

Upon admit, and before

surgery the patients HGB
was in the normal range.
After surgery the patients
HGB is in the low range
and trended down.

Upon admit, and before

surgery the patients HCT
was in the normal range.
After surgery the patients
HCT is in the low range
and trended down.

Number of infection fighting

cells. Although a High WBC
does normally indicate the
presence of an infection, a high
WBC may also indicate stress,
inflammation or trauma. Upon
admission the patient was
diagnosed with a PTX. This is
considered a trauma and may
have also caused stress and
inflammation for the patients.
After surgery the patients
WBC was within the normal
range indicating the patient has
decreased inflammation, stress,
and trauma.

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18

PLT
308
171
Normal (140-500)

10/16/2015
10/21/2015

Upon admit, and before

surgery the patients PLT
was in the normal range.
After surgery the patients
PLT trended down into
the low range.

The patient may be

experiencing a low PLT
due to blood loss
experienced post surgery.

Ultrasound:10/19/2015: US venous upper extremity unilateral right: There is no eveidence of deep venous
thrombosis.
Chest X-ray: 10/16/2015: Large R pneumothorax, possibly under tension. Collapse of the right lung. Left lung is
relatively clear.
Chest X-ray: 10/20/2015: post surgical changes are present with a right chest tube. No PTX
Chest X-ray: 10/25/2015: Linear opacity in the right upper lobe is unchanged. This may represent a small PTX
but could also be postop in nature. CT may be performed if indicated.
CT scan showed large bleb in the apex of the right lung.

+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 should have their vitals q4hours. Patient given oxygen via nasal cannula at 2L/minute when resting. Patient I
scheduled for routine chest X-ray in order to see the progression and treatment of the patients PTX. The patient was ordered
a chest tube placement that was placed in the ED. Patient is ordered a pulmonary consult to mange the chest tube and
provide further recommendations. Patient is ordered to be on nebulizers for medication administration for the treatment of
her COPD. Pain control is also ordered in order to best manage the patients pain. The patient is ordered a regular diet with
no restrictions. Patient is ordered to be on sequential compression device (SCDs) in order to prevent to DVT during
recovery.

8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Ineffective breathing pattern related to chronic obstructive pulmonary disease (COPD) as evidence by shortness of breath
and previous PTX surgery.
2. At risk for falls related to older age.

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19

3. At risk for constipation related to opioid medication for pain.

4. Anxiety related to PTX surgery as evidence by patient stating she feels very anxious in addition to taking antianxiety
medication (alprazolam).
5. At risk for readmission to the hospital due to a high percentage (50%) of patients who suffer from a PTX will have a
reoccurring PTX.
6. Activity intolerance related to patients rheumatoid arthritis and fibromyalgia as evidence by patient stating her joint s
become stiff and tender.

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20

 15 CARE PLAN
Nursing Diagnosis: Anxiety related to PTX surgery as evidence by patient stating that she is very anxious in addition
to taking antianxiety medication (alprazolam).
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
The
nurse
patient
relationship
is
very
My patient will identify and
Use empathy to encourage the
I provided the patient with empathy
important and the way a nurse interacts
verbalize symptoms of anxiety and client to interpret the anxiety
and she was able to verbalize her
with the client truly has a major influence
what she fears most about her
symptoms as normal.
anxiety and her fears.
on the patients quality of life. By being
procedure.
empathetic to their concerns and not only
Intervene when possible to remove showing that you truly do care but also
being an active listener and stopping them
sources of anxiety.

My patients vital signs will be

decreased slightly by the end of my
shift

Explain all activities, procedures,

and issues that involve the cient;
use non medical terms and calm
slow speech. Do this in advanced
to procedure when possible.
Assess the clients level of anxiety
and physical reactions to anxiety in
order to get a baseline
(Tachycardia, tachypnea, nonverbal
expressions to anxiety).

and intervening while replacing irrational

fears about their procedure with more
positive rational sense, provides the
patient with physical and psychosocial
support and reduces the symptoms
associated with anxiety. (Ackley &
Ladwig, 2014)
The clients sympathetic nervous system
was very high when the nurse told the
client that she was getting her chest tube
removed. Due to my lengthy interview I
developed a great nurse client relationship
and I offered the client an explanation of
the procedure that broke the procedure
down in very simple terms. She was able
to relax and understand that this procedure
was very minimal and it did not require
her to even leave her room. efficient
nurse client communication is critical to
efficient care provision. Anxiety has also
been shown to be a major risk factor for
CAD (Ackley & Ladwig, 2014, p.138).

University of South Florida College of Nursing Revision September 2014

The clients vitals were taken prior

to and after the procedure. The
clients vitals (RR,BP,HR) were all
lower than the previous
measurement.

21

Patient will demonstrate some

Encourage the client to use positive
ability to reassure self by the end of self talk.
the shift.

Reducing positive self talk and removing

those doubt and unnecessary negative
perceptions and replacing them with
motivational sayings and positive self talk
has been shown to be very productive in
all types of anxiety.
(Ackley & Ladwig, 2014)

Patient was able to demonstrate the

positive aspects of her life in
addition to reducing negative self
talk during my shift.

Patient will display posture, facial

expressions, gestures, and activity
levels that reflect decreased distress
by the end of my shift.

Use therapeutic touch and healing

touch techniques, which includes
giving patient backrubs to decrease
anxiety.

It has been shown that the power of

healing touch is one of the most powerful
intervention a nurse may provide in order
to reduce anxiety. (Ackley & Ladwig,
2014).

Goal was not met because it was

only my first day meeting the
patient and I was not sure if she
was completely comfortable with
me to apply healing touch. Next
time I would try and ask the patient
because of how well it has been
shown to decrease anxiety.

Teach patient ways to control

anxiety besides medication such as
suggest yoga to the client.

Yoga was found to significantly reduce

anxiety in patients who were severely
burned. Multiple studies have been done
that showed guided imagery and music
reduced anxiety in patients after surgery.
(Ackley & Ladwig, 2014).

Goal was not met due to it being

long term and I was only aloud to
see the patient for one day.

Long term goal

Patient will gradually be weaned
off the alprazolam and instead will
use non pharmacological methods
to reduce anxiety within the next
three months.

Provide client with a means to

listen to music of their choice or
audiotapes.

Guided imagery can be used to

decrease anxiety.
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
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F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

References
Ackley, B., Ladwig, G. (Ed. 10). (2014). Nursing Diagnosis Handbook An Evidence-Based Guide to Planning Care. St. Louis, Missouri: Elsevier
Mosby.

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References

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