Adult Med Surgical Assessment Tool

General Information

Indentification: Patient was a 53 year old, Caucasian female who appeared to be at the

stated age. She is a 5’4” and 90 lbs female with brown shoulder length hair and brown

eyes. Her upper and lower extremities were bilaterally symmetrical with no obvious

deformities, body fat was evenly distributed, posture was slouched, limbs and trunk were

proportionate to body height, and had a slight non offensive body odor.

Her admission date was November 5, 2010 for a pneumothorax, with chief complaints of

severe shortness of breath with activities.

Vitals Signs: 36.7°C, 52, 16, 132/70

Psychological Presence: Her dress was weather appropriate and her overall groom was

moderate. Her mood and manner was very anxious but also very compliant. She

demonstrated a lot of hesitation with topics of family history and abuse. Her speech

pattern was clear and understandable; her rate, pitch and volume all varied normally. Her

facial expressions were normal to the environment and changed naturally.

Distress: Her breathing was effortless without any notable wheezing but did demonstrate

a productive cough. During the assessment I was able to notice that while she was

speaking she was beginning to become breathless with short sentences. She did

demonstrate signs of emotional distress and anxiety with her current medical condition

and the inability to care for herself.

Chief Complaint: This is a 53 year old Caucasian woman who presented to the

emergency room (ER) with complaints of shortness of breath (SOB) and left-sided chest
pain

History of Present Illness: Patients states that she has been symptomatic with the SOB

and lightheadedness for the last 2 years due to her history of COPD. The symptoms are

provoked by many activities including walking and climbing stairs. She state that her

condition has severely disabled her and she fully relies on her oldest son for day to day

activities. At about 2pm on 11/12/2010 she’s walking up stairs from doing laundry and

she became very short of breath, with a sharp “deep” pain in the left side of her chest. She

could not catch her breath and became very anxious and agitated. She denies falling for

and fainting episodes, but her son noticed her condition and called the paramedics. Upon

assessment and evaluation in the ER her heart rate was rapid at 110 Beats per minute and

a respiration was 30, and was very cyanotic. Upon further evaluation it was determined

that the patient had a Pneumothorax and a chest tube was warranted. After placement of

the chest tube by the ER physician in the left flank an X-ray was done to ensure

placement, the patient had immediate relief and was admitted to the floor for further

evaluation and observation.

Past Medical History: COPD, CHF, HTN, depression, infective endocarditis, C-diff.

Current medications: Heparin, Ativan, Ventolin, Spiriva, Deltasone, Percocet

Allergies: NKDA

Past Surgical History: Total Hysterectomy, Evacuation of Subdural Hematoma, skin

graft over coccyx area

Family History: Father- Heart Disease and High Blood Pressure. Mother- High Blood

Pressure and Mental illness (could not specify). Grand mother- “Died from Stroke”.

Social History: Was married for 32 years, relations then became “very abusive” and
decided to get divorced. She has two sons 25 and 20. They 20 year old is in the navy and

she claims that at one point they were in a altercation and her struck her in the ribs which

resulted in multiple rib fractures. She claims that she no longer is in contact with this son.

She describes her other as being her “life line”, claims that he is very helpful and really

takes good care of her. She does reside with her oldest son in the area in a 3 story home.

Other than her two sons she claims to have no contact with any other family and states

that “they want nothing to do with me.

Past Medical History

Assessment

Cardiovascular: Heart rate was irregular 52 BPM, able to auscultate s1-s2 sounds

and all sights, no murmurs or friction rubs noted. Pulses, +3 carotid, +1 radial, absent

posterior tibial, +1 dorsalis pedis, and PMI absent. Normal capillary refill, negative

Homans sign, no varicosities. 2+ edema bilateral lower extremities.

Respiratory: Normal respiration rate was 16 BPM, depth was shallow, chest

raised and fell symmetrically with respirations. There was no use of accessory muscles

or nasal flaring. Her lung sounds were clear in all fields, however I was able to palpate a

significant amount of crepitus in the left flank around her pneumothroacentesis site. She

did produce yellow viscous sputum with her cough. She was on three liters of O2 nasal

cannula with an O2 saturation of 100%.

 Neurological:

Patient was awake, alert, and oriented times 3 with a GCS of 15. PERLA. Able

to demonstrate hand grasps bilaterally. She had no deep tendon reflex in her patellar

tendon and had a +1 reflex in her biceps tendon bilaterally. Was also able to demonstrate

dorsal and plantar flexion bilaterally. Denies any numbeness or parasthesias.

Musculoskeletal:

She had no contractions with slouched posture and normal gait. Was able

to demonstare flexion, and extension in shoulders, elbows, wrists, fingers, hips, knees,

ankles and toes. While also being able to abduct and adduct her shoulders and hips. She

was able to do all ROM with out any pain or hesitation.

Integumentary:

Her skin was grayish pale complection, warm and dry bilaterally. She had

normal skin turgor with no lesions or moles. Large areas of ecchymosis on all extremites

was appreciated probaley related to the heparin therapy. She had a large are a heald skin

graft in the coccyx area that she described as beig from purposely being placed on a hot

stove as a child. Her dressing from her chest tube on her left flank was clean dry and

intact, with crepitus in the skin around the dressing site.

Gastrointestinal:

Her stomach had normal contour and was symterical with a scar in the

suprapubic area measuring about 6-8 inches. I was able to hear hyperactive bowel sounds

in all four quadrants, no masses or nodules were noted upon plapation and also denies
any pain or tenderness with palpation. She denies any diarrhea or constipation with her

last bowel movement being within the last 24 hours.

Genitourinary:

Patient was cotinent with both bowel and bladder and claimed to have

normal elimination patterns. Denies buring or frequency of urination.

Nursing diagnosis

With the patients chief complaint being “severe SOB with all activites” , and her

significant history of COPD, I was able to formulate a nursing diagnosis that would

enable the patient and myself to establish a focal goal that would involve treating and

preventing the SOB during activites, while also teaching the patient different techniques

to avoid becoming SOB, early signs and symptoms, and what causes her to become

symptomatic. One of the nursing diagnoses tat I feel best fit for my patient would be

Activity intolerance, related to insufficient oxygen for activites of daily living.

Alog with respiratory problems that my patient was expericnng, I believe that she

was experiencing a significant amount of stress, depression, and anxiety. She was going

in to detail about the serious history of physical abuse she had experienced from her

parents, ex-husband, and youngest son. She was very hesitant to discuss in detail at first

but slowly began to open up and share specific events in her past. She seemed very

disturbed while discussing her past and had very negative connotation on life and what

she expects.