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COLLEGE OF NURSING
1 CHIEF COMPLAINT:
“There is a cold inside of me. It’s like lightning and thunder inside of me. I have difficulty breathing, like I’m heaving.”
2
Kidney Problems
Environmental
Trouble
Health
Stomach Ulcers
Bleeds Easily
Hypertension
Cause
etc.)
FAMILY
Alcoholism
Glaucoma
Diabetes
Arthritis
Seizures
Anemia
Asthma
of
Cancer
Tumor
Problems
Stroke
Allergies
MI, DVT
MEDICAL
Gout
Death
Mental
Heart
HISTORY (if
(angina,
applicable
)
Father
Mother 74
Brother
Sister
Comments:
Patient denies detailed knowledge of family medical history. Patient reports that she has no relationship with her father due to domestic
violence between him and her mother. She reports that her grandmother had type 2 diabetes, and as a result her grandmother had her
leg amputated. Patient denies knowledge of any medical history of her three brothers and three sisters.
1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U
Adult Tetanus (Date) U
Influenza (flu) (Date) 01/20/2017
Pneumococcal (pneumonia) (Date) 01/20/2017
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Patient denies any allergies or adverse reactions to medications or
Medications environmental allergens.
5 MEDICATIONS:
Name albuterol-ipratropium bromide Concentration Dosage Amount 3 mL
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Con Carb (60-75 g) Heart Healthy Analysis of home diet
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
“My boyfriend does.”
How do you generally cope with stress? or What do you do when you are upset?
“I just watch TV. It is a good way to distract myself you know? I particularly love the crime shows.”
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“None that I can think of.”
Have you ever felt unsafe in a close relationship? “No. Well a long time ago, my dad would talk loud. But it was okay as
long as them bills were paid. He never hit me or nothing.”
Have you ever been talked down to? “Yes.” Have you ever been hit punched or slapped? “Yes.”
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
“No.” If yes, have you sought help for this? “He left so I didn’t need to worry. God was with me.”
4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion 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 Erickson’s developmental stage for your
patient’s age group:
Generativity vs. self-absorption occurs at the approximate stage of “middle adulthood (35-65 yr)”. Developmental task is
“fulfilling life goals that involve family, career, and society; developing concerns that embrace future generations”.
Successful competition of this stage is “ability to give and to care for others”. Unsuccessful resolution of crisis leads to
“self-absorption; inability to grow as a person”. (Varcarolis & Halter, 2014, p. 23)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
This patient is currently in the stage of generativity versus stagnation. This stage tends to be present in the middle adult
years. During this stage, it is important to create and nurture things that will outlast them. She currently resides in the
generativity stage. This finding is presented in the way in which she regards her well being in: it is “coming soon…you
know death. I’m trying to get things done.” This statement displays her need to leave things behind and in order for her
family.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
Her current condition is exacerbating an area of the stage that she had not experienced for a short while. Since she was
hospitalized last year due to an exacerbation of shingles, she revisited the stage of standing still. She is unable to do
everything she has wanted to do, since she is in the hospital with a condition that is progressively getting worse. This
hospitalization due to her Sarcoidosis is greatly impacting her psychosocial stage and the development to successfully
progress through the stage.
+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“Well we have a family history of it, on my mama’s side. My grandmother had it, the diabetes.”
Are you currently sexually active? “Every now and then.” If yes, are you in a monogamous relationship? “Yes.”
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? “A condom. But I don’t need to worry about that anymore.”
How long have you been with your current partner? “7-8 years. But we knew each other 20 years before that.”
Have any medical or surgical conditions changed your ability to have sexual activity? “I have no pleasure in it anymore.”
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
“No.”
Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? If yes, what did they use to try to quit?
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years?
Volume: 1 cup (age thru )
Gin
Frequency: on the weekend “It was only when I was young. I
don’t drink anymore now.”
If applicable, when did the patient quit? Patient denies specific ages for
starting and stopping drinking.
“It was hurting me. It got dead to me, I found no pleasure in it.”
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 thru )
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
“No, not that I know of.”
5. For Veterans: Have you had any kind of service related exposure?
Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin: due to
GERD Cholecystitis Fever
shingles outbreak last year
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Hemorrhoids: patient reports, “those
Dandruff started after I had my children” Lupus
Blood in the stool
Psoriasis Yellow jaundice Hepatitis C Rheumatoid Arthritis
Sarcoidosis: patient reports “I have that
Hives or rashes Pancreatitis
in my lungs and liver.”
Skin infections Colitis Tumor
Use of sunscreen SPF: Diverticulitis Life threatening allergic reaction
Bathing routine: shower every other day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy
HEENT Other: cholecystostomy Hematologic/Oncologic
Difficulty seeing: corrective glasses Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known:
Post-nasal drip Normal frequency of urination: 4/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems: dentures Metabolic/Endocrine
Routine brushing of teeth: once a day Diabetes Type: 2
Routine dentist visits: 1 or every 2
Hypothyroid /Hyperthyroid
years
Vision screening Intolerance to hot or cold
Other: brushes and soaks dentures over
Osteoporosis
night
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Infection of the female genitalia:
Asthma Dizziness
syphillis
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia: patient reports, “I have had
Date of last gyn exam? 03/2016 Seizures
that in the past”
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche 13 age Encephalitis
menopause: patient did not report
last CXR? Meningitis
knowledge of exact onset of menopause
Date of last Mammogram & Result: 35
Other: Other:
years old, no abnormal findings
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
University of South Florida College of Nursing – Revision September 2014 9
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Injuries or Fractures: left ankle
Murmur
fractured in four locations
Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? Arthritis Chicken Pox
Other: Other: Other:
General Constitution
Recent weight loss or gain
“I lost 100 pounds when I was in the hospital with shingles. This wasn’t intentional, but it did help me lose weight that I have wanted
to lose for a while. My health was very poor at this time!”
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
“Nothing, other then my shingles last year.”
Any other questions or comments that your patient would like you to know?
“Nothing, right now.”
General Survey: 59 year Height 169 cm Weight 81.64 kg BMI 28.58 Pain: Patient is in no acute
old female, resting in Pulse 84 Blood Pressure: 147/70 Right arm pain at the time of the
chair, patient does not Respirations 18 assessment
appear to be in any
distress at the time of
assessment
Temperature: 98, oral SpO2 90% Is the patient on Room Air or O2?
Patient is on nasal cannula oxygen, 5 L
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
Central access device Type: Location: Date inserted:
Fluids infusing? no yes - what?
Peripheral IV site Type: 20 gauge Location: Right AC Date inserted: 01/23/2017
no redness, edema, or discharge
Fluids infusing? no yes
HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Teeth are uniform, clean, and without abnormalities
Comments: Whisper test was not conducted due to patient’s appropriate response to questions in previous assessment
Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent
RUL CR LUL CR
RML CR LLL CR
RLL CR
Notes: patient is currently on oxygen therapy; patient was admitted with sputum production; sputum production currently
absent
University of South Florida College of Nursing – Revision September 2014 11
Cardiovascular: No lifts, heaves, or thrills
Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD
Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: Radial: 2 Femoral: Popliteal: DP: 2 PT: 2
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
Extremities warm with capillary refill less than 3 seconds
GU Urine output: Clear Cloudy Color: Previous 24 hour output: mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: [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: Babinski:
RBC Red blood cell counts This low RBC count may
4.05 L 01/23/2017 trending down. Lower be related to the patient’s
3.46 L 01/24/2017 than normal range. diagnosis of Sarcoidosis,
Normal which may present with
4.3-5.5 anemia. This should be
monitored for potential
need for blood transfusion.
HGB Hemoglobin trending This low HGB count may
12.0 01/23/2017 down. Latest value be related to the patient’s
10.3 L 01/24/2017 lower than normal diagnosis of Sarcoidosis,
Normal range. which may present with
12-16 anemia. This should be
monitored for potential
need for blood transfusion.
HCT Hematocrit trending This low HCT count may be
38.4 01/23/2017 down. Latest value related to the patient’s
32.8 L 01/24/2017 lower than normal diagnosis of Sarcoidosis,
Normal range. which may present with
38-54 anemia. This should be
monitored for potential
need for blood transfusion.
Platelet Platelet count trending This low platelet count may
162 01/23/2017 down. Latest value be related to the patient’s
120 L 01/24/2017 lower than normal diagnosis of Sarcoidosis,
Normal range. which may present with
150-450 anemia. This should be
monitored for potential
need for blood transfusion.
University of South Florida College of Nursing – Revision September 2014 13
Na Sodium consistent Na well within normal
141 01/23/2017 trend. Within normal range. This value was
141 01/24/2017 range. obtained through typical lab
Normal work up.
135-145
8 NURSING DIAGNOSES
1. Ineffective airway clearance related to Sarcoidosis present in lung tissues as evidenced by crackles in all lung
fields, and increased respiratory rates.
2. Activity intolerance related to Sarcoidosis present in lung fields as evidenced by exertional dyspnea, exertional
discomfort, verbal response of fatigue, and decreased oxygen saturation.
3. Ineffective peripheral tissue perfusion related to Sarcoidosis present in lung tissues as evidenced by decreased
oxygen saturation with out oxygen therapy and ineffective airway clearance.
4. Risk for impaired liver function related to Sarcoidosis present in liver.
5. Risk for infection related to secretions present in lungs and immunosuppression through corticosteroid
administration.
±2 DISCHARGE PLANNING:
Consider the following needs:
SS Consult
Dietary Consult – Patient would benefit from education regarding well balanced meals to help manage her type 2 diabetes and overall health
PT/ OT- Patient would benefit from PT and OT due to difficulty ambulating related to exertional dyspnea
Pastoral Care
Durable Medical Needs
F/U appointments – Patient should follow up with primary care to ensure
Med Instruction/Prescription – Patient requires medication instructions for proper administration as per hospital protocol
Are any of the patient’s medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
Epocrates. (2014). Epocrates Reference Tools for Healthcare Professionals (16.8) [Mobile application software].
Osborn, K. S., Wraa, C .E., Watson, A. B., & Holleran, R. (2014). Medical-surgical nursing: Preparation for
https://www.supertracker.usda.gov/foodtracker.aspx#graph
Varcarolis, E. M., & Halter, M. J. (2014). Foundations of psychiatric mental health nursing: A clinical