CLIENT INFORMATION SHEET (CIS)
Student Name: Jasmine Hsieh
Date: 1/28/19
Patient Initial: M.K.
M XF
Allergies: NKA
Age: 55
DNR AD XNone
Admission Date: 1/26/19
Religion: N/A
Primary Language: English
Height: 152.9 cm Weight: 87.7kg
Admission Diagnosis: Left lower quadrant abdominal pain
Current Diagnosis [reason for admit/chief complaint]: Perforation diverticulitis of the small intestine.
Surgical/Invasive Diagnostic Procedures [this admit]: Waiting for surgery.
Concurrent Medical History [past]: HTN, DM
Past Surgeries:
Course of Hospitalization [what happened during stay]: M.Ｋ. is a 55-year-old female admitted 3 days thus far for perforation diverticulitis of the small
intestine with complaints of left lower quadrant abdominal pain. CT of the abdomen showed diverticulitis with perforation on 1/26/2019. Will perform serial
abdominal exam and recommend diet advancement when appropriate. Patient is NPO, receiving IVPB antibiotics and is currently waiting to be scheduled for
surgery.
Precautions/Special Needs [isolation, fall, restraints]: Fall risk
Activity Order: Bed rest
External Devices [orthopedic, SCD/IPC]: SCD, cardiac tele monitoring
Treatments [wound care, 02]: N/A
Vital Signs: frequency: Q4 hours BP: 128/54 T:37.1 P: 81 R: 18 PaO2: 98%
Baseline: BP: 120/62 T: 36.6 P: 74 R: 18
BS Glucose: AM:
Diet: NPO
Intake: 880 mL
PM:
Tube Feeding: type, rate/frequency, site: N/A
Output: 600 mL
Oral:
Urine/Foley/Incontinent/Voids: Voids
Parenteral:
Drainage tubes: N/A
Tube Feed: N/A
Other:
Q 8 H or Q 12 H or Q24H
Total Input: 880 mL
Total Output: 600 mL
Venous Access Devices: [type, solution, rate/saline lock, site]
PIV: Left antecubital with 20 gauge, 1/26/2019
CVC:
Other:
Pathophysiology of Medical Problem [describe etiology, progression, treatment-specific to client]:
Patient with cellulitis is cause by bacterial skin infection and symptoms includes inflammation, redness, fever and swelling. Cellulitis usually affects the surface
of the skin but can affect the underlying tissue and spread to the lymph nodes or bloodstream. The common treatment to cellulitis is usually oral antibiotics but
surgery to remove the cellulitis may be needed if determined by doctor. Patient is also experiencing dementia which is a group of symptoms that affects memory,
thinking and social abilities which may interferes with daily functioning. S/S of dementia that the patient is experiencing includes difficulty communicating,
memory loss, confusion and disorientation. Currently receiving IV antibiotics, dressing change care and monitoring for sign and symptoms of infection (Huether
& McCance, 2016).
Consultations [type, date, results]: Social worker/case management ordered on 1/22/2019
Current Lab Results:
Normal
Note Additional Diagnostic Studies Below (Radiographs, Scans, etc.)
Pt. Results
Significance of Abnormals: [indicates kidney failure, anemia, etc.]
Na+
135-145
141
K+
3.5-5
4.0
Cl`
95-105
107
CO2
22-26
24
Glu
65-139
85
Ca2+
8.5-10.5
8.9
BUN
8-21
9
Cr
0.6-1.2
0.61
Mg2+ 1.6-2.6
1.8
WBC
4.5-11
11.8 (high)
HgB
11.7-17.3
11.7
HcT
33-39
37
Plt
150-450x109/L
PTT/PT/ INR
Elevated WBC due to cellulitis, surgery and open wound healing.
Currently receiving treatment of antibiotics.
445
28/14.1/1.1 secs
Other:
Other:
Medications: List only [complete on medication form]:
Sodium chloride, piperacillin/tazobactam, acetaminophen, and enoxaparin.
Nursing Diagnosis: [list 3 & prioritize]
1.
2.
3.
Impaired skin integrity related to abscess of the left thigh as evidenced by surgery to remove the cellulitis and wound dressing on left thigh.
Alternation in nutrition less than body requirement related to memory loss, confusion and disorientation as evidenced by inability to care and feed for
self.
Self-care deficit related to cognitive and neuromuscular impairment as evidenced by inability to perform wound dressing change and maintain proper
and appropriate hygiene.
Pain related to
Deficit self-care
All Nursing interventions/actions:
-
Discharge planning contact with social worker.
Teaching on wound care and S/S of infection.
-
Assess support, self-concept, mental status, emotional response to hospitalization. Promote quite atmosphere and bed rest.
Assess self-concept, mental status, emotional response to the injury and hospitalization.
Acquire and monitor lab values. Monitor intake and output.
Assessment for cardiovascular – S1/S2. Assessment for respiratory – clear. Assessment for pulses – 2+.
Assess IV line – Left antecubital with 20 gauge - 1/26/2019
Anticipated Discharge Needs: [equipment; include teaching]
- Educate on self-care abilities in ambulation, eating, and pain management.
- Educate on adequate intake of nutrition. Well-balanced diet as well as adequate fluid intake.
- Educate on comfort and pain management.
- Teach healthy lifestyle and diet practices. Teach information regarding health promoting plan or activities.
- Provide patient and care taker with information regarding modifiable risk factors, prevention and treatment methods. To enhance compliance and
information decisions about lifestyle changes
- Educate on pain control, and non-pharmacological pain treatment.
References:
Deglin, J.H, Vallerand, A.H., Sanoski, C.A. (2014) Davis’s Drug Guide for Nurses 14 th edition. Philadelphia: F.A. Davis Company.
Doenges, M.E. (2010) Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales 12th edition. Philadelphia: F.A. Davis Company.
Huether, S. E., & Mccance, K. L. (2016). Understanding pathophysiology. St. Louis, Mo: Mosby.
Ralph, S. S., & Taylor, C. M. (2014). Sparks & Taylors nursing diagnosis reference manual. Philadelphia, Pa: Wolters Kluwer Health in Lippincott William &
Wilkins.
MEDICATION FORM
Drug (Class, Generic/Trade name,
order date), Dose, Safe range,
Route, Time
Pharmacological Action and desired
in client (why is this client on this
med?)
Side Effects &
Nursing Implication/Actions
Contraindications
Expected Outcome
Specify how to administer the Med
1.
Sodium Chloride (IV), 1,000
mL at rate of 100 mL/hr.
Rate should not exceed 100
mL/hr or 1 mEq/ kg/hr.
2.
Piperacillin/tazobactam
(Zosyn) 50 mL IV piggyback
every 8 hours at 12.5 mL/hr.
Range: 3.375 g q 6 hr.
3.
Acetaminophen (Tylenol),
650 mg oral tablet every 6
hours. Range 325– 650 mg q
6 hr or 1 g 3– 4 times daily
or 1300 mg q 8 hr
1.
My patient is taking this to
prevent dehydration.
Pharmacological action:
Hydration and provision of
NaCl in deficiency states.
Maintenance of fluid and
electrolyte status.
2.
My patient is taking this
medication because of
diverticulitis and infection.
Pharmacological action:
Piperacillin: Binds to bacterial
cell wall membrane, causing
cell death. Spectrum is
extended compared with other
penicillins. Tazobactam:
Inhibits beta-lactamase, an
enzyme that can destroy
penicillins.
3.
My patient is taking this
medication because of mild
pain.
1.
Contraindicated in
Hypertonic (3%, 5%)
solutions should not be
used in patients with
elevated, slightly
decreased, or normal serum
sodium; Fluid retention or
hypernatremia.
Side effects: heart failure,
pulmonary edema, general
edema, hypernatremia,
hypervolemia,
hypokalemia. IV—
extravasation, irritation at
IV site.
2.
Contraindicated in
Hypersensitivity to
penicillins, beta-lactams,
cephalosporins, or
tazobactam.
Side effects: seizure, C.
Diff, diarrhea, N/V, rash,
confusion, phlebitis at IV
site and headache.
3.
Contraindicated in
Previous hypersensitivity;
Products containing
alcohol, aspartame,
saccharin, sugar, or
Was outcome achieved-provide evidence
1. Assess fluid balance (intake and output,
daily weight, edema, lung sounds). Assess
patient for symptoms of hyponatremia
(headache, tachycardia, lassitude, dry
mucous membranes, nausea, vomiting,
muscle cramps) or hypernatremia (edema,
weight gain, hypertension, tachycardia,
fever, flushed skin, mental irritability). How
to administer: Administer 3% or 5% NaCl
via a large vein and prevent infiltration. Rate
of hypertonic NaCl solutions should not
exceed 100 mL/hr or 1 mEq/ kg/hr.
Expected outcome: Prevention or
correction of dehydration. Normalization of
serum sodium and chloride levels.
2.
Assess patient for infection (vital signs;
appearance of wound, sputum, urine, and
stool; WBC). Observe patient for signs and
symptoms of anaphylaxis. Monitor bowel
function. How to administer: Reconstitute
each 1 g of piperacillin with at least 5 mL of
0.9% NaCl, sterile water for injection, or
D5W. Infuse over 30 min. Expected
outcome: Resolution of the signs and
symptoms of infection. Length of time for
complete resolution depends on the
organism and site of infection.
3.
Assess overall health status and alcohol
usage before administering acetaminophen.
Assess for rash periodically during therapy.
May cause Stevens-Johnson syndrome. How
tartrazine should be
avoided.
Side effects:
hepatotoxicity, rash,
Stevens-Johnson
syndrome, N/V and renal
failure.
Pharmacological action:
Inhibits synthesis of
prostaglandins that may serve
as mediators of pain and fever,
primarily in the CNS.
4.
Enoxaparin (Lovenox), 30
mg/0.3 mL subcutaneous
BID. Range: 1 mg/kg every
12 hr or 1.5 mg/kg every 24
hr.
4.
4.
My patient is taking this
medication because risk of
developing DVT. Prevention
of venous thromboembolism
(VTE) (deep vein thrombosis
(DVT) and/or pulmonary
embolism (PE)) in surgical or
medical patients.
Pharmacological action:
Potentiates the inhibitory
effect of antithrombin on
factor Xa and thrombin.
Contraindicated in
Previous hypersensitivity;
and patient with severe
hepatic impairment/active
liver disease.
Side effects: dizziness,
headache, insomnia,
edema, bleeding, anemia,
urinary retention, erythema
at injection site, hematoma,
irritation, pain.
to administer: Administer with a full glass
of water. May be taken with food or on an
empty stomach. Expected outcome: Relief
of mild to moderate pain.
4.
Assess for signs of bleeding and hemorrhage
(bleeding gums; nosebleed; unusual
bruising; black, tarry stools; hematuria; fall
in hematocrit). Monitor patient for
hypersensitivity reactions (chills, fever,
urticaria). Report signs to health care
professional. How to administer:
Administer deep into subcut tissue. Inject
entire length of needle at a 40-90 angle into
a skin fold. Do not aspirate or massage.
Rotate sites frequently. Expected outcome:
Prevention of deep vein thrombosis and
pulmonary embolism.
Reference:
Deglin, J.H, Vallerand, A.H., Sanoski, C.A. (2014) Davis’s Drug Guide for Nurses 14th edition. Philadelphia: F.A. Davis Company.
EHR EPIC Med Surg
Review of Systems
Constitutional: Positive for fatigue. Negative for activity change, appetite change,
chills, diaphoresis, fever and unexpected weight change.
HENT: Negative. Negative for congestion, dental problem, drooling, ear discharge, ear
pain, facial swelling, hearing loss, mouth sores, nosebleeds, postnasal drip,
rhinorrhea, sinus pain, sinus pressure, sneezing, sore throat, tinnitus, trouble
swallowing and voice change.
Eyes: Negative. Negative for photophobia, pain, discharge, redness, itching and
visual disturbance.
Respiratory: Negative. Negative for apnea, cough, choking, chest tightness, shortness
of breath, wheezing and stridor.
Cardiovascular: Negative. Negative for chest pain, palpitations and leg swelling.
Gastrointestinal: Negative. Negative for abdominal distention, abdominal pain, anal
bleeding, blood in stool, constipation, diarrhea, nausea, rectal pain and vomiting.
Soft, left lower quadrant tender with voluntary guarding. Right abdomen nontender.
Endocrine: Negative. Negative for cold intolerance, heat intolerance, polydipsia,
polyphagia and polyuria.
Genitourinary: Negative. Negative for decreased urine volume, difficulty urinating,
discharge, dysuria, enuresis, flank pain, frequency, genital sores, hematuria, penile
pain, penile swelling, scrotal swelling, testicular pain and urgency.
Musculoskeletal: Negative for gait problem. Negative for arthralgias, back pain, joint
swelling, myalgias, neck pain and neck stiffness.
Skin: Positive for wound. Negative for color change, pallor and rash.
Allergic/Immunologic: Negative. Negative for environmental allergies and food
allergies.
Neurological: Negative for dizziness, tremors, seizures, facial asymmetry, speech
difficulty, weakness, light-headedness, numbness and headaches.
Hematological: Negative for adenopathy. Does not bruise/bleed easily.
Psychiatric/Behavioral: Negative for agitation, behavioral problems, confusion,
decreased concentration, dysphoric mood, hallucinations, self-injury, sleep
disturbance and suicidal ideas. The patient is not nervous/anxious and is not
hyperactive.
Objective:
Physical Exam
Constitutional: He is oriented to person, place, and time. Vital signs are normal. He
appears well-developed and well-nourished. Non-toxic appearance. He does not have a
sickly appearance. He does not appear ill. No distress.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate.
Eyes: Conjunctivae, EOM and lids are normal. Pupils are equal, round, and reactive to
light. Lids are everted and swept, no foreign bodies found. Right eye exhibits no
discharge and no exudate. No foreign body present in the right eye. Left eye exhibits
no discharge and no exudate. No foreign body present in the left eye. No scleral
icterus.
Neck: Trachea normal, normal range of motion and full passive range of motion without
pain. Neck supple. Normal carotid pulses, no hepatojugular reflux and no JVD present.
No tracheal tenderness present. Carotid bruit is not present. No tracheal deviation
present. No thyroid mass and no thyromegaly present.
Cardiovascular: Normal rate, regular rhythm, S1 normal, S2 normal, normal heart
sounds, intact distal pulses and normal pulses. Exam reveals no gallop, no distant
heart sounds and no friction rub.
No murmur heard.
Pulmonary/Chest: Effort normal and breath sounds normal. No accessory muscle usage or
stridor. No respiratory distress. He has no decreased breath sounds. He has no
wheezes. He has no rhonchi. He has no rales. He exhibits no tenderness.
Abdominal: Soft. Normal appearance and bowel sounds are normal. He exhibits no
distension and no mass. There is no tenderness.
Genitourinary: Rectum normal, prostate normal, testes normal and penis normal.
Musculoskeletal: He exhibits no edema or deformity.
Right arm: He exhibits decreased range of motion and decreased strength. He
exhibits no tenderness, no bony tenderness, no swelling, no crepitus, no deformity and
no laceration.
Left thigh: He exhibits decreased range of motion. He exhibits no tenderness, no
bony tenderness, no swelling, no crepitus, and no deformity.
Lymphadenopathy: He has no cervical adenopathy.
Neurological: He is alert and oriented to person, place, and time. He is not
disoriented. He displays no tremor. No cranial nerve deficit. Coordination normal. GCS
eye subscore is 4. GCS verbal subscore is 5. GCS motor subscore is 6.
Skin: Skin is warm and dry.
Burn noted. 6% TBSA, 2nd degree burn to right arm from wrist to shoulder are
hyperemic and hypopigmented. Excision and grafting from left thigh donor. No abrasion,
no bruising, no ecchymosis, no laceration, no lesion, no petechiae and no rash noted.
He is not diaphoretic. No cyanosis or erythema. No pallor. Nails show no clubbing.
Psychiatric: He has a normal mood and affect. His speech is normal and behavior is
normal. Judgment and thought content normal. Cognition and memory are normal.
Vitals reviewed.
Assessment:
1. Impaired skin integrity related to abscess of the left thigh as evidenced by
surgery to remove the cellulitis and wound dressing on left thigh.
2. Alternation in nutrition less than body requirement related to memory loss,
confusion and disorientation as evidenced by inability to care and feed for
self.
3. Self-care deficit related to cognitive and neuromuscular impairment as
evidenced by inability to perform wound dressing change and maintain proper and
appropriate hygiene.
Plan:
Title: Cognitive: BH Health Maintenance Alteration (Done)
Teach: Teach healthy lifestyle practices (Done)
Teach: Teach information regarding health promoting plan or activities (Done)
Title:
Teach:
Teach:
Teach:
Teach:
Pain Management (Done)
Pain Medication Actions & Side Effects (Done)
Pain Control (Done)
Pain Rating Scale (Done)
Non-Pharmacological Comfort Measures (Done)
Title: Nutrition: (Done)
Teach: Teach information regarding nutritional needs (Done)
Teach: Discuss dietary adjustments (Done)
Title: Cognitive: GEN Walking Impairment (Done)
Teach: Discuss assistive devices (Done)
Teach: Discuss behavior to reduce risk (Done)
Title:
Teach:
Teach:
Teach:
(Done)
Teach:
Pharmacy Medication Education (Active)
Teach wound care (Done)
Teach hand washing before and after patient contact as needed (Done)
Teach patient & family and caregiver about signs and symptoms of infection
Teach precautions to protect skin integrity (Done)
Teach: Discuss treatment plan for related conditions (Done)