MEDICAL/SURGICAL
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
PATIENT DEMOGRAPHICS:
Student Name: Tiara Loving
Patient Initials: K.T
Age: 68
Admission Date:
11/07/2022
Gender: female
Clinical Date: 11/10/22
Clinical Faculty Name: Dr.
Henshaw
Allergies/Reactions to: latex squash pcn fish green beans
squash
LMP: NA
(Mark NA if not applicable)
Pain: scale used- number scale
Gravida: 2
Height: 5ft4in
Location: ankle and lower back
Characteristics: sharp pain
Para: 2
Weight: 155 lbs
Rating: 7
Duration:
AB:na
BMI: 26.6
Non-verbal:
Religion: How does it affect their care?
Christian
Cultural Considerations:
none
Psychosocial Considerations (family, financial, social, etc that may impact care and discharge planning)
He lives by his sister she should be present when he is being discharged to make sure she is aware of the
wound care he needs
CHIEF COMPLAINT: (in pt’s own words)
“I been here for two weeks what you mean, I had a lot falls at home”
HISTORY OF PRESENT ILLNESS: (How, when, where, what and why of the chief complaint)
Syncope episodes multiple falls at home orthostatic hypotension. Pressure injury
PAST MEDICAL HISTORY:
Alcohol abuse, pressure injury right ankle stage 3, severe protein calorie malnutrition, hyponatremia,
diabetic type 2, bipolar, sleep apnea, a fib
CURRENT ORDERS:
Diet: reg
IV access/fluids: saline lock no running fluids
Activity: as tolerated assist x1 with walker
Treatments: wound care
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MSW 4/21
Vital Signs: q4h
O2: room air
Isolation/Type: none
Other:
Risks:
FALL
SKIN
Safety
PATIENT ASSESSMENT:
VITAL SIGNS:
TIME
BP
TEMP
HR
RESP
O2 SAT
0730
183/90
97.6
57
16
96
1200
127/77
97.4
70
17
96
BLOOD GLUCOSE MONITORING:
TIME
COVERAGE
BLOOD GLUCOSE
(Insulin type and amount)
0503
50
Glucagon
0528
90
nothing
INTAKE AND OUTPUT:
INTAKE
Breakfast: 100
OUTPUT: Urine
voided incontinent
Foley
Lunch: 100
Amount: not assessed
BOWEL MOVEMENTS
Last BM:
continent
incontinent
0712/2022
yes
Date: 07/12/22
Dinner: 100
Color: not assessed
Amount: medium
Fluids: 100
Clarity: not assessed
Color: brown
Enteral: (NG/PEG) na
Symptoms: none
Consistency: soft
IV fluids-Type/Volume:
na
Emesis: none
Ostomy: na
NG: na
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MSW 4/21
IV Push meds: na
Drains: na
PHYSICAL ASSESSMENT:
(Complete head to toe assessment. WNL is not accepted. Normal is not acceptable. Please be specific.)
Neurological:
Orientation, Level of
Consciousness LOC,
Speech, Affect/Behavior,
Appearance, Pupils,
Ability to Swallow,
GCS (Glasgow Coma
Scale)
HEENT:
Head, ears, eyes, nose,
throat, neck, thyroid,
lymph nodes
Respiratory:
Lungs Sounds, Oxygen,
Cough, Sputum,
Symmetry, , Chest Tubes,
trach, Dressing
integrity?Mechanical
Support –Ventilator
SettingsNote: Anterior,
Posterior and Lateral;
accessory muscle use,
expansion, tactile
fremitus
Cardiovascular:
S1 S2; Rhythm & *Analysis
(PR Interval., QRS;
artificial devices,
peripheral pulses-grade,
edema, murmur, JVD,
capillary refill, IV Types:
Peripheral/central
Arterial Venous shunts &
Devices : AV Fistulas
Pt was alert and orientated times 4 resting in bed awake with no distress wellgroomed eye contact and spoke when approached pt able to swallow puff cheeks
put frown and smile pupils dilated he was able to follow the cardinal signals with no
problem GCS- eye opening to speech verbal response oriented to time person and
place motor response obeys commands there were no nodules or masses when the
skull was palpated. Cooperative and pleasant
Head was free of lesion, bugs no lump or bumps noted three scratch like abrasions
on head from fall, pt hair clean and hydrated ears are symmetrical no drainage in
ear canal or pain eye sclera is, white PEERLA eyes equal in size no redness irritation
or drainage from eyes nose had moist mucus membranes no drainage throat was
clear no abnormal patches redness or inflammation no pain neck was normal size
thyroid did not enlarge no abnormalities assessed lymph nodes not swollen
Lung sounds clear no wheezing or abnormal breath sounds no fluids on room air
normal breath sounds not in distress not using accessary muscles no cough or
sputum chest posterior and anterior symmetrical no nodules when palpated no
chest tubes has a healing area from a previous trach clean dry and intact no
mechanical support normal chest expansion with respirations tactile fremitus not
assessed
Chest is normal in appearance heart rate and rhythm are sinus rhythm no murmurs
or rubs auscultated S1 and S2 were heard and are at normal pace no jugular venous
distention peripheral pules all present and at normal intensity capillary refill within
1-2 seconds has 20g left ac no fluids iv was clean dry and intact not redness
swelling or leaking at the iv site
Breast and Axilla
Pain, tenderness, lesions,
lumps, swelling, rashes,
Not assessed
Gastrointestinal:
Bowel sounds active in all four quadrants he eats by mouth and pills whole when
palpated no tenderness sort to touch no distention no nausea or vomiting reported
by pt she did have a GI bleed
Bowel sounds, Abdomen
Soft, Non-tender,Nondistended Nausea,
vomiting, or visible signs
of GI bleeding
(oral/rectal) Ostomy
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MSW 4/21
Type: Iliostomy,
Colostomy All GI
associated lines and
tubes go here! Nasal
Gastric(NG),PEG,
Genitourinary:
No catheter or ostomy, continent no swollen lymph nodes
Indwelling
Catheter/Ostomy;
continent/incontinent;
Foley; lymph nodes;
Musculoskeletal:
Joint Swelling or
Tenderness; Range of
Motion(ROM) and/or
Limitations in all 4
Extremities; Muscle
Weakness (NOT related
to Central Nervous
System Impairment)
Continuous Passive
Motion (CPM) Machine
FALL RISK Assessment
Scale: Safety assessment
and Transfer Method; use
of assistive devices
Pain Assessment:
Pain scale used, rating,
location, characteristics,
duration, non-verbal,
exacerbating, relieving
factors.
Integumentary:
Warm, Dry and Intact:
without rash/lesions or
discoloration.
Braden Scale Rating;
Pressure Ulcer Staging:
Stage I, Stage II, Stage III,
StageIV; hair, nails,
texture, lesions, nevi,
scars
Psychosocial:
Erikson and Piaget
developmental stages
Nutritional:
ROM of arms and legs was preferred with no difficulties she is a fall risk due pt is
fall risk score 12 which is moderate fall risk pt is assist time 1 pt able to sit on side
of the bed and walk with walker with assistance
Numerical scale
Pain score 7
Sharp pains in ankle and lower back
Skin warm dry and intact no rashes or lesions or discoloration absent has a stage 3
pressure ulcer on left ankle 2.6x2.5x0.3 cm wound bed 90 yellow adherent slough
10% small pink amount no odor wound intact hair full and distributed evenly for
age and gender no flaking and hydrated nails pink oval no clubbing capillary refill 2
seconds. Ted hoses in use.
Ego integrity vs despair
Formal operational stage
Regular diet, ate 100% of meals and overweight
Diet type, amount eaten,
overweight, underweight,
4
MSW 4/21
MEDICATIONS:
**Don’t copy & paste**
(Include ALL medications patient is currently taking unless otherwise advised by instructor)
Trade Name:
Neurontin
Mechanism of
Action
Generic Name:
Gabapentin
Mechanism of
action is
Class:
unknown. An
Central
nervous system effect of
agent
gabapentin on
Dose:
central serotonin
60 mg
metabolism has
been postulated
Is dose safe?
Condition That
Patient is
Receiving
Medication
Chronic
NerveFor
Pain
Potential Adverse
Effects
Drowsiness,
fatigue, tremor,
headache, weight
gain, n\v, rash.
yes
Nursing
Implications &
Patient Education
Monitor for
therapeutic
effectiveness; may
not occur until
several weeks
following initiation
of therapy. Assess
frequency of
seizures. Assess
safety.
Route:
oral
Form:
cap
Frequency:
4 times a daily
Trade Name:
Buspirone
hydrochloride
Generic Name:
Buspar
Mechanism of
Action
Condition That
Patient is
Receiving
Anxiety
Medication For
An anxiolytic that
focuses mainly on
Class:
the brain
Central nervous
dopamine
system agent
receptors
Dose:
10 mg
5
Potential Adverse
Effects
Dizziness
headache mood
changes n/v sob
weakness
Nursing
Implications &
Patient Education
Monitor for
therapeutic
effectiveness.
Desired response
may begin within
7–10 d; however,
optimal results
take 3–4 wk.
MSW 4/21
Is dose safe?
yes
Reinforce the
importance of
continuing
treatment to
patient.
Route:
oral
Form:
tab
Frequency:
Daily
Trade Name:
Duloxetine
Mechanism of
Action
Generic Name:
Cymbalta
Exact mechanism
of action on
controlling
Class:
depression or
Central nervous
pain that is
system
unknown
Condition That
Patient is
Receiving
Medication For
pain
Potential Adverse
Effects
Fatigue hot
flashes dizziness
mental status
changes tremor
nausea dry mouth
weight loss
Dose:
60 mg
Is dose safe?
yes
Route:
oral
Nursing
Implications &
Patient Education
Ensure that a
complete list of all
concurrent
medications is
obtained.
Monitor for S&S of
numerous drugdrug interactions
The beneficial
effects of this drug
may not be felt for
approximately 4
wk.
Form:
tab
Frequency:
daily
Trade Name:
Insulin Lispro
Mechanism of
Action
Generic Name:
Humalog
Class:
Hormone and
synthetic
Dose:
100 u
Condition That
Patient is
Receiving
Medication
Diabetes
typeFor
2
Insulin lispro of
recombinant DNA
origin is a human
insulin that is a
rapid-acting,
glucose-lowering
agent
6
Potential Adverse
Effects
Itching rash
swelling in hands
and feet weight
gain injection site
reactions
Nursing
Implications &
Patient Education
Assess for
hypoglycemia
from 1 to 3 h after
injection.
Assess highly
insulin-dependent
patients for need
for increases in
MSW 4/21
Is dose safe?
yes
intermediate/longacting insulins.
Route:
Injection
Class:
Antidiabetic
agent
Frequency:
Q6h
7
MSW 4/21
Trade Name:
Mechanism of
Action
Condition That
Patient is
Receiving
Medication For
Potential Adverse
Effects
Nursing
Implications &
Patient Education
Mechanism of
Action
Condition That
Patient is
Receiving
Medication For
Potential Adverse
Effects
Nursing
Implications &
Patient Education
Generic Name:
Class:
Dose:
Is dose safe?
Route:
Form:
Frequency:
Trade Name:
Generic Name:
Class:
Dose:
Is dose safe?
Route:
Form:
Frequency:
8
MSW 4/21
Trade Name:
Mechanism of
Action
Condition That
Patient is
Receiving
Medication For
Potential Adverse
Effects
Nursing
Implications &
Patient Education
Mechanism of
Action
Condition That
Patient is
Receiving
Medication For
Potential Adverse
Effects
Nursing
Implications &
Patient Education
Generic Name:
Class:
Dose:
Is dose safe?
Route:
Form:
Frequency:
Trade Name:
Generic Name:
Class:
Dose:
Is dose safe?
Route:
Form:
Frequency:
9
MSW 4/21
LAB DATA & DIAGNOSTIC EVALUATION:
If the patient does not have recent labs/diagnostic tests,
Write what would be indicated for a patient with this diagnosis
Include diagnostic test like X-rays, CTs, and MRIs
Lab Data
Date 11/10/2022
Reason for lab:
Normal Values
Check electrolytes
LAB Ordered:
Potassium
Co2
BUN
Creatine
Metabolic
Panel
Date
Client Results
Potassium 4.1
CO2 27
BUN 7
Creatine 0.77
NA- 129
Chloride- 96
Glucose- 196
Calcium- 8.2
Reason for lab:
Normal Values
Client Results
Reason for abnormal
results (or n/a if
normal)
Reason for lab:
Normal Values
Client Results
Reason for abnormal
results (or n/a if
normal)
LAB Ordered:
Date
Reason for abnormal
results (or n/a if
normal)
LAB Ordered:
Diagnostic Tests
Date:
Reason for test:
Nursing Considerations
Client Results
Test Ordered
10
MSW 4/21
Date:
Reason for test:
Nursing Considerations
Client Results
Test Ordered
MEDICAL DIAGNOSIS:
List all current medical diagnoses.
MEDICAL DIAGNOSIS
TEXTBOOK CLINICAL PICTURE
CLIENT’S ACTUAL CLINICAL PICTURE
(Current)
Include definition, signs, and
symptoms that should be seen
What Signs and Symptoms your patient actually
exhibited
Full thickness skin loss
involving damage or
necrosis of subcutaneous
tissue
A form of low blood
pressure that happens
when standing after sitting
or lying down
2.6x2.5x0.3 cm wound bed 90 yellow
adherent slough 10% small pink amount no
odor wound intact
Suicidal thoughts of
harming self
Pt has active ideations having killed himself
Stage 3 pressure ulcer
Orthostatic hypotension
Upon rising patient is faint blood pressure
drops
Suicidal Ideation
PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS:
List all nursing diagnosis relevant to patient condition & based on assessment
1.Risk for Suicide related to psychiatric illness
2. ineffective tissue perfusion related to pressure injury as evidence by stage three pressure ulcer
3. Fall risk related to syncope episodes as evidence by orthostatic hypotension
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MSW 4/21
NURSING CARE PLAN
Student Name: _____________________________________________ Date: ____________________Class: ________________ Patient Initials: _______________
A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include “related
to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write at least one short term and one long term (“expected outcome”) measurable goal per
nursing diagnosis stated in terms of client achievement (“the client will…”). List at least 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific
rationale for selecting the action you will use to work toward that goal, along with the cited reference of that rationale. Evaluate if goal was met and list specific assessment data to
support it (How did you know goal was met?)
NURSING DIAGNOSIS
(NANDA APPROVED)
EXPECTED OUTCOME
(Measurable Goal with dates)
ST: within time frame of
clinical
LT: can be outside of time
frame of clinical
1. Risk for Suicide
related to psychiatric
illness
ST: Patient will refrain
from attempting suicide
NURSING
INTERVENTIONS
(What do you plan to do for
the client to accomplish the
goal? Be specific and include
time frames)
RATIONALE
(Why are you doing this?)
(Citation for each rationale)
1. Encourage the client to
avoid decisions during the
time of crisis until
alternatives can be
considered
1.During crisis situations
people are unable to
think clearly or evaluate
their options readily
2.Encourage the client to
talk freely about feelings
and help plan alternative
ways handling
disappointments, anger,
and frustration.
2.Gives clients other ways
of dealing with strong
emotions and gaining a
sense of control over their
lives
12
EVALUATION
(If goal not met, need to evaluate why?
And what to do to meet goal?)
ST: Patient reframed from
attempting suicide
2. ineffective tissue
perfusion related to
pressure injury as
evidence by stage three
pressure ulcer
LT: Patient will identify at
least one goal for the
future
3.Weapons and pills are
removed by friends,
relatives, and or the
nurse.
3.To provide a safe
environment, free from
things that may harm the
client
LT: Prior to discharge pt will
verbalize one goal for the future
ST: Patient will
demonstrate appropriate
lifestyle modifications to
support adequate tissue
perfusion
1.Provide a through skin
assessment
1.Take note of edema,
wounds, or ulcerations,
skin color, temperature,
hair loss and thickened
nails
ST: patient was willing to make the
lifestyle modification for healthy
wound healing
2.Assess peripheral Pulses
2.monitor for absent
weak pulses which can
indicates poor tissue
perfusion
3.Assess for pain and
numbness
3.They may experience
pain or dulled sensations
from poor blood flow
LT: Patient will maintain
adequate peripheral
perfusion as evidenced by
strong pedal pulses warm
skin temperature and
intact skin
13
LT: Patient will have a follow up to
assess the prefusion and wound
healing
3. Fall risk related to
syncope episodes as
evidence by orthostatic
hypotension
ST: Patient will remain
free of falls
LT: Patient will
demonstrate the correct
way to rise from lying to
standing
1. Incorporate
appropriate safety
measures
1. Support of assistive
devices such as walker
and a cane. Bed alarms if
needed
2.Provide footwear and
encourage use
2. non-slip footwear can
prevent falls
3. Encourage assistance
when getting out of bed
3. Provide the call bell
within reach. Encourage
the patient to use to
request assistance when
going to bathroom or
getting out of bed
14
ST: Patient did not have any falls
LT: Patient demonstrate how to get
up when changing positions from
lying to standing
REFERENCES:
(APA format)
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses,
Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
Orthostatic hypotension information page. National Institute of Neurological Disorders and
Stroke. https://www.ninds.nih.gov/Disorders/All-Disorders/Orthostatic-HypotensionInformation-Page. Accessed March 5, 2022.
Rob Holland Drug Cards (2022)
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/O026.html
15
Care Plan Grading Matrix:
Section
Score
Demographic Data
Possible Points
10
Physical Assessment
25
Medications
10
Lab & Diagnostic Evaluation
5
Medical Diagnosis
5
List of Prioritized Nursing
Diagnosis One-part statements
Nursing Care Plan
 (3) 3 part nursing diagnoses
 (1) Short Term goal with
Evaluation
 (1) Long Term goal with
Evaluation
 (5) Nursing interventions for
each nursing diagnosis
Citations, References & APA
format
5
30
10
16
100%
Total
Comments:
17