7.30.2023
7.30.2023
GOLDEN WEST COLLEGE SCHOOL OF NURSING
Medical/Surgical Nursing Assessment
STUDENT: Chadeau Daugherty
DATE OF CARE: 5-09-2024
Indicate abnormal signs & symptoms in RED
Client Initials: N.L
Age:82
Gender: M
Length of Stay: 2
Code Status: FULL Allergies: NKA
HX of Present Illness: Pneumonia 2020
Medical Diagnosis: Pneumonia
Surgical Procedure(s): Click or tap here to enter text.
Past medical history: CHF
Past surgical History: None
Isolation: Type Standard
Reason
Restraint: No
Yes X
Type 2-point
Physical Exam Data and Review of Systems
h)
i)
j)
k)
General Survey: Click or tap here to enter text.
1)
2)
3)
Vital Signs
a) Temp: 98.5 Route Oral
b) Pulse - Apical: 78
Radial: 70
c) Blood Pressure: 111\70
d) Respiratory Rate: 18
Comfort: Pain
a) Location
b) Intensity 0\10
c) Characteristic
d) Onset & Duration
e) Aggravation & Alleviation
f) PCA Pump Not present
5)
Perfusion: Cardiovascular
a) Apical Rhythm: Regular
b) Peripheral pulses: Strong bilaterally +2
c) Capillary Refill immediate <3 sec:
d) Edema: None
e) Homan’s Sign:
f) AV Shunt: ______________
6)
Tissue Integrity: Integumentary
a) Skin Temperature: Cool
b) Skin Turgor: ______Tenting _________________________________
c) Skin Condition
i) Rashes
ii) Petechiae
iii) Lesions
iv) Bruising
v) Incisions
vi) Wound drainage
vii) Pressure Injuries
viii) IV sites: 20gage, R-AC
ix) Other:
7)
Cognition: Neurological
a) Level of Consciousness: Alert & O X1
b) Glasgow Coma Scale Number (total number:
)
i) Eye opening: 3
ii) Verbal response: 2
iii) Motor response:2
c) Pupils: ____PERRLA____________________________________________
d) Numbness/Tingling:________________________________
e) Orientation_____X1_________________________
f) Memory
i) Distant: Knows B-day
HEENT
a) Head: symmetrical, nontender, hair thinned over crown
b) Eyes: clear bilaterally, no discharge
c) Ears: clear, no drainage, hearing intact, no hearing aids
d) Nose: left & right nostril adequate airflow, pink, no
drainage
e) Throat & Mouth: pink, pale, moist, dry, no lesions,, all
teeth missing, has dentures
4)
Oxygenation
a) Skin /Mucus Membrane/Nail Beds Color: tight and Pink &
moist
b)
c)
d)
e)
f)
g)
Lung Sounds: Clear bilaterally in all 4 lobes
Respiratory Depth & Effort: unlabored breath sounds
Oxygen: 3L NASAL CANAULA
Pulse Ox: 98% 3L of O2 NC
Cough: non-productive
Sputum/color: none
Dyspnea: Not present
Trach:
Chest Tubes:
Other:
7.30.2023
ii)
Recent: Ate dinner last night but can’t remember
what it was
g)
h)
i)
j)
8)
Speech: Clear
Language Vietnamese
Seizure activity: None
Other:
Mobility: Musculoskeletal
a) Mobility/describe: walk independently
b) Gait/Balance: UNSTEADY
c) Fall risk indication: > 82 years, weakness, unsteady
gait/balance,
d) Hip precautions: _____None _________________________
e) CPM@_________________________________________________
f) Assistive equipment: WHEEL CHAIR
g) Activity order: Bed written
h) Muscle strength
i) LUE: 2
ii) LLE:
2
iii) RUE:
3
iv) RLE:
3
i) Range of Motion
i) LU: 2
ii) LL: 2
iii) RU: 3
iv) RL: 3
j) Other:
h)
i)
j)
k)
l)
m)
n)
o)
12) Fluid & Electrolytes
a) IV solution_____D5NS________________Rate____50______mL/hr
b) 24-Hour Intake & Output
c) Fluid shift intake
d) Tissue turgor quick recoil
e) Mucous membranes moist
f) Other
g) ________________________________________________________________________
h)
13) Metabolism: Endocrine & Reproductive
a) Blood Glucose
b) Thyroid/Pituitary
c) Stressors___Hospitalization
____________________________________________
d)
9)
Elimination: Gastrointestinal
a) Abdomen
i) Inspection: Flat
ii) Auscultation: Hypoactive in 2 quads
iii) Palpation: non-distended
iv) Percussion: not G140 assessment
b) Bowel
i) Flatus: Yes
ii) Last BM/description: 4-24-24 Dark brown & hard
iii) Laxative use: none
c) NG/GT/JT: Suction__________ Gravity______ Amount_________
d) Ostomy – stool characteristics
e) Other:
10) Elimination: Urinary
a) Urinary
i) Appearance: yellow, clear, no odor
ii) Output: - 24 hr output: Shift output: 400mL
iii) Catheter: NEPHROSTOMY
iv) Incontinence:
v) Other: Voluntary
11) Nutrition
a) Weight (actual): 187lbs
b) Height 5,7
c) Diet Regular
d) NPO -rationale
e) Appetite
i) Breakfast
NPO
%
ii) Lunch 20%
iii) Dinner
%
f) Supplement Ensure
g) NG/JPEG______________________Rate_____________________
TPN/PPN______________________Rate_____________________
Nausea No
Vomiting No
Gag reflex NO
Food preferences American
Difficulty Swallowing No
Assistance required Yes
Other
Other
14) Rest & Sleep
Describe frequent naps during the day
15) Support Systems/Coping
Family Support Daughter visits
Acceptance of Support Becomes Happy when daughter arrives
Coping Mechanisms Visits with his daughter
Interaction with daughter
REFERENCES:
1. Assessment Technologies Institute (2019). Fundamentals
for Nursing (Version 10)
2. Jarvis, C. (2008). Physical Examination & Health
Assessment (5th edition). St. Louis: Saunders
3. Lippincott CoursePoint for Nursing Concepts. Wolter
Kluwer, 2nd ed.-on-line resource.
7.30.2023
7.30.2023
Hematology
Test
Date
Date
H/L
Ref. Range
4.20 – 5.40
mil/ul
12.0 – 16.0
g/dl
37.0 – 47.0%
150 - 400
k/cmm
4.8 – 10.8
K/uL
RBC
Hgb
Hct
Platelet
WBC
Chemistry
Test
Date
Date
H/
L
Na
K
Cl
CO2
Calcium
Glucose
Ref. Range
Nursing Assessments/
Interventions Required
Urea nitrogen levels tend to
increase with age. Generally, a
high BUN level means your kidneys
aren't working well. But
elevated BUN can also be due to.
Dehydration, resulting from not
drinking enough fluids.
Consult with doctor about getting order
for IV fluids and keep patient hydrated
by offering water and monitor I& O’s
Pathophysiologic Reason for
Abnormal Results
Nursing Assessments/
Interventions Required
Pathophysiologic Reason for
Abnormal Results
Nursing Assessments/
Interventions Required
100 - 110 mmol/L
24 - 32 mmol/L
8.4 – 10.2 mg/dL
65 - 99 mg/dL
H
42
7 - 22 mg/dL
Creatinine
4-2424
H
2.0
0.4- 1.5 mg/dL
M 10 - 40 U/L
F 9 – 25 U/
M 10 – 55 U/L
F 7 – 30 U/L
3.5 – 5.0 gm/dL
16-40 mg/dL
AST (SGOT)
ALT (SGPT)
Albumin
Prealbumin
Cholesterol
< 200 mg/dL
Triglycerides
40 – 150 mg/dL
HDL
LDL
Hgb A1C
> 60 mg/dL
< 100 mg/dL
Arterial Blood Gases
Date
Date
H/
L
pH
PaCO2
HCO3PaO2
Ref. Range
7.35-7.45
35-45 mm Hg
22-26 mm Hg
80-100 mm Hg
Urinalysis
Color
Spec
Gravity
RBC
Pathophysiologic Reason for
Abnormal Results
3.5 – 5 mmol/L
4-2424
Test
Nursing Assessments/
Interventions Required
135-145 mmol/L
BUN
Test
Pathophysiologic Reason for
Abnormal Results
Date
Date
H/
L
Ref. Range
1.000 – 1.030
< 4 RBC/HPF
WBC
< WBC/HPF
Bacteria
Negative
Nitrate
Negative
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Coagulation Panel
Test
Date
Date
H/
L
Ref. Range
Pathophysiologic Reason for
Abnormal Results
Nursing Assessments/
Interventions Required
Pathophysiologic Reason for
Abnormal Results
Nursing Assessments/
Interventions Required
12 – 14 sec
(control)
(1.5 - 2.5 X control
Therapeutic range)
< 2.0 (control) (2.0 –
3.5 Therapeutic
range)
22 – 34 sec
(control)
(1.5 to 2.5 X control
Therapeutic range)
PT
INR
APTT
Other Lab Diagnostics
Test
Date
Date
H/
L
Ref. Range
Troponin
Other Results
Cultures, EKG, Echocardiogram, Imaging
(ie., X-Ray, CT, MRI, PET Scan, Ultrasound)
Test
Date
WNL / ABN
Pathophysiologic Reason
for Abnormal Results
Nursing Assessments/
Interventions Required
2.19.2024
CLINICAL JUDGMENT MEDICATION LIST
Medication
name
GENERIC:
Azithromycin
TRADE: Zithromax
CLASSIFICATION:
Macrolides
Mechanism of action –
in your own words
Purpose of the
medication
for THIS client –
(Assessment, VS, labs,
etc)
To treat and fight
against bacteria such
as respiratory
infections and skin
infections.
To treat Pneumonia
Works by relaxing
the muscles in the
prostate and bladder
so that urine can
flow easily.
Treats Urine
retention & Enlarged
prostate.
Monitor Resp. and
Heart Rate
Monitor: I’O’s
How will the nurse
know there is a
problem, or the client
is not tolerating the
medication?
In your own words.
No copying or pasting.
Be brief.
How will the nurse
know the medication
is effective?
Patient/ Family
Education
SOB, Rash, Diarrhea
fast pounding heart
rate, dizziness
Decrease in fluid
and electrolyte
Take with food,
Notify doctor for
adverse effect
Dizziness, weakness,
nausea, chest pains
Normal urine flow
30mLhr
Take 30mins after
meal,
Take same time
Change positions
clow
Is the dose safe?
200mL\hr
GENERIC: Flomax
TRADE: Tamsulosin
CLASSIFICATION:
Alpha blockers
Is the dose safe?
200mL\hr
Monitor Heart Rate,
Blood pressure
Monitor I&O’s,
2.19.2024
CLINICAL JUDGMENT MEDICATION LIST
Medication
name
GENERIC: Albumin
25% 200ml\hr
TRADE: Albuminex,
Mechanism of action –
in your own words
Purpose of the
medication
for THIS client –
(Assessment, VS, labs,
etc)
Increasing plasma
Increasing plasma
volume or levels of volume or levels of
albumin in the
albumin in the blood.
blood.
Monitor RBC’S
CLASSIFICATION:
Plasma expanders
Monitor: Vital Signs
Is the dose safe?
yes
Monitor: Liver
Enzymes & kidneys
How will the nurse
know there is a
problem, or the client
is not tolerating the
medication?
In your own words.
No copying or pasting.
Be brief.
Respiratory distress
SOB, sweeting, pale
skin, confusion, rash
N\V
How will the nurse
know the medication
is effective?
Blood volume
increases
Patient/ Family
Education
Notify Dr if you have
any adverse effects
Notify Dr. before
taking over the
counter drugs and
vitamins
Monitor WBC’S
GENERIC: Heparin
5000 units\mL
TRADE: Hep-Pak
(obsolete)
CLASSIFICATION:
Heparins
Is the dose safe?
to treat and
prevent blood clots
Prevent blood clots
Montior Pt, INR,
Platelets
Monitor vial signs
Bruising, headache,
stomach pain
Not blood cloth or
abnormal bleeding
Notify doctor for
unusual bruising and
bleeding
Don’t take Motrin or
Aspirin
2.19.2024
(Adapted from NurseTim)
Provide a written SBAR summary report (examples on Canvas).
82-year-old Male patient initials N.L admitted on 5-8-24 for Pneumonia. Pt was at nursing home in
bedroom and nurse noticed that he was having a difficulty breathing & wasn’t eating well, Lungs
were assessed & crackles were present. A facility called ambulance; patient was taken to
Huntington Beach hospital. Once arrived X-Ray was performed and displayed fluid around the
lungs. He has a history of Pneumonia, CHF and A-Fib, patient is a Full Code & NKA. Upon
assessment, the patient is A&O X1, skin dry and wrinkled, lungs crackle, Heart normal sinus
rhythm, she has a 20gage on his R-AC, Labs results: BUN was 42 and CR was 2.0. The plan of care
is to Monitor Lung sounds, Respirations, BUN & CR, administer meds as prescribed, and perform
safety precautions.
2.19.2024
GOLDEN WEST COLLEGE SCHOOL OF NURSING
Form B: CLINICAL JUDGEMENT CONCEPT MAP
Student name: Chadeau Daugherty
Patient Admit Date: 5-8-2024
Pt. initials: N.L
Age: 82
Gender: M Date of Care: 5-9-24
Hospital Days 2 days
Primary Medical Diagnosis/Chief Complaint:
Click or tap here to enter text.
Pneumonia\ SOB & Fall
Pathophysiology (in your own words) of the primary medical diagnosis
Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus, causing cough with pus, fever,
chills, and difficulty breathing. There are a variety of organisms, such as bacteria, viruses and fungi. Pneumonia can range in seriousness from
mild to life-threatening. There are four main types of Pneumonia: Community-Acquired Pneumonia: This occurs within the community setting,
meaning areas outside a hospital or care home. It also includes patients that have developed pneumonia within the first 48 hours of being
admitted in a hospital or care home. Health Care-Associated Pneumonia: The infection would occur in patients who are not admitted to
hospitals but would still be in contact with health care professionals. This includes patients in nursing homes, patients receiving home-based
care, out-patient clinics, family members with a multidrug-resistant bacterial infection and patients who would have been in an acute hospital
for more than 2 days within the past 3 months. Hospital-Acquired Pneumonia: This occurs in patients who have been hospitalized for more
than 48 hours. Ventilator-Associated Pneumonia: This infection develops at least 48 hours after endotracheal intubation. AspirationPneumonia: This type of infection occurs because food, saliva, liquid or vomited is inhaled into the airways instead of passing through the
esophagus and into the digestive system. Signs and symptoms Rapid onset of chills, Fever spike (starting from 38.5 to 40.5°C) Pleuritic chest
pain that becomes worse with deep breathing and coughing, tachypnoea, respiratory distress. It also has many Risk factors such as COPD
Asthma, AIDS. Treatment depends on the type of pneumonia and the severity, however they range from Antobtiocs, cough medicine, and
fever\pain reduces such as Tylenol , NSAIDS .
Significant Past Medical History (that relate to this hospitalization)
CHF, A-FIB
Scheduled and PRN Medications (include dosage, frequency & rationale)
2.19.2024
Patient Priority Problem #1 Infection
Recognize cues: What information/data did you notice (see, hear, assess, read) that you identify as important?
• Fluid around lungs
• SOB
• NPO
• Fatigue & weakness
• A&OX1
Analyze cues: What is the meaning/interpretation of the information and why did you identify it as important?
Infections such as pneumonia left untreated, bacteria can enter the circulatory system, causing sepsis, a serious systemic infection that
affects the whole body. Sepsis is a serious, life-threatening condition with potentially fatal outcomes.
Infection
Prioritize hypothesis: Based on the data above, what are your main concerns? Priorities?
Impaired health impairment r\t inflammatory process AEB increase fluid around lungs & decreased urine output
Generate solutions: What are your SMART goals/outcomes?
Patient will not have inflammatory process AEB decrease fluid around lungs and urinary output 30mLhr.
Take actions: Identify at least 4 nursing interventions and rationales. Include interventions that may prevent the complications from
occurring.
“A”- Assess & recognize changes in LOC, monitor the vital signs of the patient, especially alterations in respirations, blood pressure, &
pulse rate which may indicate sepsis Q4.
“M” – Collaborate with Dietitian to ensure patient is ordered a high protein nutrient rich diet by 8:00am
“T” -Educate patient and family the importance of infection control, such as handwashing.
“C”- Administer prescribed medication Azithromycin 200mL\HR Q12
Sepsis
A- Assess & Montior Vital signs Q4
M- Collaborate with Physician for the best treatment plan by 11am
T- Educate patient the importance on how to identify s\s of Sepsis and to adhere to all doctor orders BEOF
C- Administer fluids and antibiotic as ordered 9am, 12pm, 1500, 1800
2.19.2024
Patient Priority Problem #2
Oxygenation
Recognize cues: What information/data did you notice (see, hear, assess, read) that you identify as important?
• RESP rate 22
• Fatigue
• Nausea
• Weakness
• Dry skin
Analyze cues: What is the meaning/interpretation of the information and why did you identify it as important?
There is fluid around the lungs that is making it difficult to breath and talk, if the fluid isn’t treated it can cause severe complications such as
lung failure and\or collapsed lungs
Prioritize hypothesis: Based on the data main concerns? Priorities?
Ineffective breathing pattern r\t excess fluid AEB SOB, and fatigue
Oxygenation
Generate solutions: What are your SMART goals/ above, are your outcomes?
Patient will maintain an effective breathing pattern, AEB Respirations WNL 12-20 bpm, increase energy BEOS
Take actions: Identify at least 4 nursing interventions and rationales. Include interventions that may prevent the complications from
occurring.
A”- Assess lung sounds, & apply 3L of O2 via nasal cannula Q4
“M” – Collaborate with Respiratory therapist to administer oxygen therapy and breathing treatments Q4
“T” -Teach patient deep breathing exercises and pursed lip breathing Q4
“C”- Encourage patient to use incentive spirometer 10 breaths Q hour, ensure patient HOB remains at 45-degree Q2
Respiratory Acidosis
A- Montior patient’s level of consciousness, mental status, and sleep and wake cycle, monitor vital signs including oxygen saturation and
cardiac rhythm Q2
M- Collaborate with Respiratory therapist to administer O2 and monitor respirations Q2
T- Educate the patient about energy-conserving techniques such as time management, scheduling activities, and delegating tasks to
significant others Q4
C- Assist the patient in a semi or high-Fowler’s position or elevate the head of the bed at beginning of shift and Q2
2.19.2024
Patient Priority Problem #3
Elimination
Recognize cues: What information/data did you notice (see, hear, assess, read) that you identify as important?
• Urinating 10mL
• NPO Status.
• Immobile
• Nephrostomy
Analyze cues: What is the meaning/interpretation of the information and why did you identify it as important?
NPO status can cause moderate to severe complications if the body doesn’t receive proper nutrition. If patient doesn’t have proper food and
fluids it can lead to major complications such as Malnutrition that leads to respiratory failure and death
Prioritize hypothesis: Based on the data above, what are your main concerns? Priorities? Elimination
Impaired urinary elimination related to infection secondary to Pneumonia AEB urine output 10mL\hr inadequate fluid intake
Generate solutions: What are your SMART goals/outcomes?
Patient will demonstrate voiding frequency 30mL\he BEOS
Take actions: Identify at least 4 nursing interventions and rationales. Include interventions that may prevent the complications from
occurring.
“A”- Montior urinary elimination, & prostatic hyperplasia (BPH) symptom severity Q4
“M” - Collaborate with physician to ensure patient receives adequate fluid intake and assess diet order Q4
“T” – Educate importance of drinking water and staying hydrates Q4
“C”- Nurse will use bladder scanner to for fluid retention or urinary flow Q4
UTI
A- Assess urine-color, characteristics, frequency, & monitor BUN & CR Q4
M- Collaborate with physician for prescribed orders such as fluids and oral supplements Q4
T- Educate patients on the importance of adequate fluid intake (2 to 4 L per day), avoiding caffeine and use of aspartame, and limiting intake
during late evening and at bedtime. Recommend the use of cranberry juice/vitamin C. Q4
C-Assist patient with clothing change, ensure he keeps loose clothing on during hospitalization Q4
2.19.2024
Reflect on your interventions. Have they been effective? If not, why and how would you modify them?
1) Goal partially met: Patient did have inflammatory process but show signs of improvement AEB, improved breathing and urinary output
2) Goal Met: Patient had effective breathing AEB respirations 18 and increased energy BEOS
3) Goal Met: Patient urinated 30mL\hr BEOS
Identify at least one unique need based on beliefs, values, cultural, or generational diversity & one way that you would adapt your
nursing care based on this need.
Patient didn’t speak English. I will adapt my nursing care by collaborating with interpreter during all communication with patient
and assess if there is a family member that speaks English to help with translation.
Reference: National Council of State Boards of Nursing (2020). NCSBN Clinical Judgment Measurement Model. https://www.ncsbn.org/14798.htm
2.19.2024
GOLDEN WEST COLLEGE SCHOOL OF NURSING
G 170C Health and Illness II Weekly Clinical Performance Evaluation Tool
Student Name: Click or tap here to enter text.
Date: Click or tap here to enter text.
S=Satisfactory (meets or exceeds minimum standard for class level)
NI= Needs improvement (does not meet minimal standards for class level)
Clinical Unit: Click or tap here to enter text.
D: Developing as expected based on clinical learning objectives
U=Unsatisfactory (does not meet minimal standard for class level)
Core Competencies Weekly Evaluation N 170C the student nurse caring for patients in the clinical section of Health and Illness II can:
Patient-Centered Care: Utilize the Nursing Process, differentiating and applying the steps of this process as a framework for patient-centered nursing care (CLO).
Interdisciplinary Collaboration: Uses effective communication skills to collaborate as a member of the health care team as a patient advocate to promote
continuity of patient care.
Evidence Based Practice: Uses current evidence from scientific and other reliable sources as a basis for nursing practice and clinical judgment.
Quality Improvement: Identify at least one clinical agency-promoted quality improvement project related to improvement of health care services.
Safety: Utilize patient safety standards in the clinical setting to maintain a safe environment for the patient and health care team.
Informatics: Use information technology in collaboration with nursing and healthcare teams to facilitate communication and coordinate patient care (pSLO)
Patient Education: Promotes health and wellness through provision of patient education that is culturally appropriate and based on evidence.
Professionalism: Demonstrate professional behavior and adhere to legal, ethical, and professional standards (pSLO)
Additional comments for NI and U evaluation; refer to detailed learning objectives from comprehensive G170C clinical evaluation tool:
Student_________________________________Date________________Faculty ______________________________ Date________