Download MEd Surg I Patient assessment tool

UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
Student: Lauren Wright
PATIENT ASSESSMENT TOOL .
Assignment Date: 2/3/2013
Agency: STJ, UD
Patient Initials: JC
Age: 36
Admission Date: 3/14/2013
Gender: Male
Marital Status: Married
Primary Medical Diagnosis with ICD-10 code:
G61.0 Guillain-Barre syndrome
Primary Language: Spanish
Level of Education: High School
Other Medical Diagnoses: Influenza B
Occupation (if retired, what from?): Cook at Mexican Restaurant
Reflux esophagitis
Number/ages children/siblings: 2 siblings: 32/male, 35/ female
Code Status: full code
Living Arrangements: lives in ground level apartment with wife
Advanced Directives: none
Surgery Date: 3/16, 3/17, 3/17, 3/18, 3/19/2013
Procedure: Plasmapheresis
Culture/ Ethnicity /Nationality: Hispanic
Religion: catholic
Type of Insurance: Humana
 2 CC: “I have been feeling weak and coughing up yellow. Today I began to lose control over my left leg.”
 3 HPI: (OLD CART)
Patient is a 36 year old male who arrived to the emergency department via ambulance with wife on 3/14 experiencing
parasthesia and weakness in lower left extremity (which progressively spread to right) that began 4 days ago. Also
complained of generalized fatigue, muscle aches, peri-orbital headache, nasal congestion with yellow sputum, and
productive cough with yellow sputum with the onset of these symptoms beginning approximately two weeks ago.
Assessment in emergency department revealed areflexia in patellar and Achilles tendons, and nasal swab confirms
Influenza B. Admitted to CCT5 on 3/14, a nerve conduction study confirms Guillain- Barre syndrome. Catheter lab on
3/15 for placement of right internal jugular hemodialysis catheter. Antibiotic therapy as well as IgG treatments started
3/15 relieved the patient’s symptoms (which had been aggravated prior to light and movement).
University of South Florida College of Nursing – Revision April 2012
1
 2 PMH/PSH Hospitalizations for any medical illness or operation
Father
60
Mother
58
Brother
32
Sister
35
Tumor
Stroke
Stomach Ulcers
Seizures
Heart Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Environmental
Allergies
Cause
of
Death
(if applicable)
Alcoholism
Age (in years)
 2 FMH
Kidney
Problems
Mental Health
Problems
Management/Treatment
Appendectomy
Patient treats with over the counter anti-ulcer
agents as needed
Hypertension
Operation or Illness
appendicitis
Reflux esophagitis
(angina, MI, DVT etc.)
Date
08/2004
2011
relationship
relationship
relationship
Comments: Patient doesn’t know the date of onset for family history, “been going on for as long as I can remember…”.
 1 IMMUNIZATION HISTORY
YES
NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Dec 2011)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
University of South Florida College of Nursing – Revision April 2012
2
 1 Allergies or
Adverse Reactions
NAME of
Causative Agent
Type of Reaction (describe explicitly)
NKA
Medications
NKA
Other (food, tape,
dye, etc.)
 5 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis,
prognosis or treatment)
Introduction
According to Medical Surgical Nursing (Osborn, Wraa, and Watson, 2010):
Guillain- Barre syndrome is a disorder in which the body’s immune system attacks part of the peripheral nervous
system. The first symptoms of this disorder include varying degrees of weakness or tingling sensations in the legs.
In many instances the weakness and abnormal sensations spread to the arms and the upper body. These
symptoms can increase in intensity until certain muscles cannot be used at all and, when severe, the patient is
almost totally paralyzed. In these cases the disorder is life threatening- potentially interfering with breathing and,
at times, with blood pressure or heart rate- and is considered a medical emergency. (p.706).
Exact molecular action is unknown, but it is believed that the immune response occurring after infection triggers antigenic
targets on both infectious organisms and peripheral nervous tissue.
Risk factors
According to Patel and Garcia (2013):
2/3 of cases associated with antecedent bacterial or viral infection, usually of the respiratory or GI tract:
Campylobacter jejuni: The most common precipitant of GBS, seen in 21–32% of cases:
Associated with axonal degeneration, slower recovery, more severe residual disability
Cytomegalovirus: Primary CMV infection precedes 10–22% of cases
Also associated w/Mycoplasma pneumoniae (5%), influenza, Epstein-Barr virus, varicella zoster virus, and HIV
infections. (p.5).
Diagnosis
University of South Florida College of Nursing – Revision April 2012
3
The patient presents with the subtybe of Guillain- Barre syndrome characterized by progressive limb weakness and
arreflexia called Acute inflammatory demyelinating polyradiculoneuropathy (AIDP). It is diagnosed by assessing patient
history, physical exam and diagnostic studies mentioned below.
AIDP presents as an acute neuropathy that is at its climax within four weeks, characterized by progressive onset of limb
weakness. 75% of patients have had an infection in the past 6 weeks, and the patient is confirmed to have
Influenza B. Symptoms for which manifested 2 weeks ago. According to Patel and Garcia (2013), “Earliest
symptoms are pain, numbness, paresthesias, or limb weakness. Numbness and paresthesias affect the extremities
and spread proximally. Pain present in the majority, most commonly in the back and lower extremities; may be
severe. A purely sensory syndrome, without weakness, excludes GBS.” (p.1).
A nerve conduction study is a helpful confirmatory test because the conduction velocities measured are deficient in eighty
five percent of patients with Guillaine- Barre. A cerebrospinal fluid (CSF) assay should be done since elevated protein
occurs in nearly eighty percent of those affected after forty eight hours of onset. A Stool culture and serology test is useful
to determine causation from Campylobacter jejuni (responsible for 21-32% of cases). Acute and convalescent serology
can be used to determine Cytomegalovirus (which causes 10-22% of cases), Epstein Barr Virus, and Micoplasma
pneumonia (causes 5%).
Genetic factors:
While the exact mechanism of action is unknown, making it difficult to determine genetic factors related to diagnosis, it is
interesting to note that in 1976 there were more cases diagnosed during the US national immunization program against
swine associated Influenza A virus.
Prognosis
Without treatment, Guillaine- Barre syndrome consists of three phases. The initial progression can last up to four weeks
and mortality risk is highest in this phase. Risk of death is significantly increased in patients requiring mechanical
ventilation. Gratefully, the patient caught the illness in the first week of progression- sparing him from any visceral
paralysis. Had he been left untreated, it would have progressed to a variable plateau phase and then recovery, which may
have taken six to twelve months for full function to return. However, twenty percent of patients do not get full function
back after demyelination and paralysis. Some of these contributing factors include: over sixty years of age, rapid
progression of disease, prior C. jejuni infection and diarrhea.
University of South Florida College of Nursing – Revision April 2012
4
Genetic factors: According to Sommers (2011), “Family history appears to be a significant risk factor for GERD. Twin
concordance has been shown to be 42% among identical twins and only 26% between nonidentical twins.” (p. 3). C.
Jejuni is the most frequent bacterial cause of gastroenteritis. So deductive reasoning and the patient’s history of reflux
esophagitis makes it plausible that he is at increased risk of infection, and while not documented in the chart that a
serology test was ordered to screen for this micro-organism, it stands to reason that it may have been a contributing factor
in his disease process.
Treatment
The first line treatment for Guillain-Barre syndrome is plasmapheresis and is most beneficial if started within seven days
of symptomatic onset. IV administration of immunoglobulin (IVIg) is just as effective and may be started within two
weeks of onset. The CSF should be re-evaluated before administering IVIg therapy. Corticosteroids may be given as
second line treatment to decrease inflammation and hasten recovery.
Genetic factors: Plasmapheresis removes the unwanted antigens produced by the patient’s immune response from the
plasma and then filters the plasma back into the body. IgG is the primary antibody for viruses, bacteria, and produces
immunity before birth. If patient were immune-deficient from birth they would receive this treatment.
__________________________________________________________________________________________________
References:
Osborn, K., Wraa, C., Watson, A. (2010). Medical- Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ:
Pearson.
Patel, N., Garcia, E. (April 3, 2013) “Guillain-Barré Syndrome”, 5 minute Clinic, Nursing Central. Retrieved from:
http://nursing.unboundmedicine.com/nursingcentral/ub/view/5-Minute-ClinicalConsult/116252/all/Guillain_Barré_Syndrome?q=guillain_barré_syndrome
Sommers, M. (April 28, 2011) “Gastroesophogeal Reflux Disease”, Diseases and Disorders, Nursing Central. Retrieved
from: http://nursing.unboundmedicine.com/nursingcentral/ub/view/Diseases-andDisorders/73594/all/gastroesophageal_reflux_disease__gerd_
 5 MEDICATIONS: (Include both prescription and OTC)
Name fondaparinux (Arixtra)
Concentration 2.5
mg/0.5 ml
Route subcutaneous
Dosage Amount 2.5
mg
Frequency1 x daily
Pharmaceutical class anticoagulant
Home
Hospital
or
Both
University of South Florida College of Nursing – Revision April 2012
5
Indication prevention of emboli formation per internal jugular IV site
SE: confusion, dizziness, headache, insomnia, edema, hypotension, constipation, diarrhea, dyspepsia, increased liver enzymes, nausea, vomiting,
urinary retention, bullous eruption, hematoma, purpura, rash, bleeding, thrombocytopenia, and hypokalemia.
Name pantaprozole (Protonix)
Concentration
Dosage Amount 40mg
Route PO
Frequency 1 X daily
Pharmaceutical class proton pump inhibitor
Home
Hospital
or
Both
Indication increases gastric pH in the presence of medications and esophagitis to prevent gastroesophogeal reflux
SE: headache, abdominal pain, diarrhea, eructation, flatulence, hyperglycemia, hypomagnesemia (especially if treatment duration ≥3 mo), and bone
fracture.
Name sodium citrate
Concentration 1000ml
Route IV
Dosage Amount 1000ml/hr
Frequency continuous during plasmapheresis
Pharmaceutical class alkalinizing agent
Home
Hospital
or
Both
Indication to oxidize bicarbonate and increase pH during plasmapheresis
SE: tetany, diarrhea, fluid overload, hypernatremia, hypocalcemia, metabolic acidosis
Name albumin (human)
Concentration 150g/ 3L
Route IV
Dosage Amount 150g
Frequency PRN
Pharmaceutical class blood product, colloid
Home
Hospital
or
Both
Indication albumin replacement during plasmapheresis
SE: headache, PULMONARY EDEMA, fluid overload, hypertension/hypotension, tachycardia, increased salivation, nausea, vomiting, rash, urticarial,
back pain, chills, fever, flushing.
Name oseltamivir (Tamiflu)
Concentration
Dosage Amount 75mg capsule
Route PO
Frequency q12 hrs, over 5 days
Pharmaceutical class neuramidase inhibitor
Home
Hospital
or
Both
Indication treatment of influenza B in patients symptomatic >2 days with severity of illness
SE: SEIZURES, abnormal behavior, agitation, confusion, delirium, hallucinations, insomnia, nightmares, vertigo, bronchitis, nausea, and vomiting.
Name diphenhydramine (Benadryl)
Concentration 50mg/1ml
Route IV
Dosage Amount 50mg
Frequency PRN
Pharmaceutical class antihistamine
Home
Hospital
or
Both
Indication in the event of anaphylaxis,/ adverse reaction during plasmapheresis
SE: drowsiness, dizziness, headache, paradoxical excitation (increased in children), blurred vision, tinnitus, hypotension, palpitations, anorexia, dry
mouth, constipation, nausea, dysuria, frequency, urinary retention, photosensitivity, chest tightness, thickened bronchial secretions, and wheezing
Name calcium gluconate and sodium chloride 0.9%
Concentration 3g/30ml
Route IV
Dosage Amount 3g
Frequency 90ml/2hrs (during plasmapheresis procedure)
Pharmaceutical class mineral/ electrolyte replacement
Home
Hospital
or
Both
Indication: Calcium replacement necessary for introduction of new albumin during plasmapheresis
SE: headche, tingling, syncope, CARDIAC ARREST, arrhythmias, bradycardia, constipation, nausea, vomiting, calculi, hypercalciuria, and
phlebitis.
Name albuterol-ipratroprium (Duoneb)
Concentration:
Route nebulizer inhalant
Dosage Amount 3ml
Frequency PRN, q4hrs
Pharmaceutical class adrenergic -anticholinergic
Home
Hospital
or
Both
Indication bronchodilator if patient experiences shortness of breath or wheezing related to influenza or further Guillain-Barre paralysis
SE: dizziness, headache, nervousness, blurred vision, sore throat, epistaxis, nasal dryness/irritation, bronchospasm, cough, palpitations, GI irritation,
nausea, and rash
Name epinephrine
Concentration 1mg/1ml
Dosage Amount 1mg
University of South Florida College of Nursing – Revision April 2012
6
Route subcutaneous/IM injection
Frequency PRN
Pharmaceutical class adrenergic
Home
Hospital
or
Both
Indication in event of anaphylaxis/ adverse reaction during plasmapheresis
SE: nervousness, restlessness, tremor, headache, insomnia, paradoxical bronchospasm (excessive use of inhalers), angina, arrhythmias, hypertension,
tachycardia, nausea, vomiting, and hyperglycemia.
Name heparin
Concentration 5000 units/1ml
Route IV
Dosage Amount 5000 units
Frequency PRN
Pharmaceutical class anticoagulant
Home
Hospital
or
Both
Indication to instill in each lumen of dialysis catheter port post plasmapheresis
SE: drug-induced hepatitis, alopecia (long-term use), rashes, urticarial, BLEEDING, HEPARIN-INDUCED THROMBOCYTOPENIA, anemia, pain at
injection site, osteoporosis (long-term use), fever, and hypersensitivity.
Name morphine
Concentration 2mg/ 1 ml
Route IV
Dosage Amount 2mg
Frequency PRN, q4hrs
Pharmaceutical class opioid agonist
Home
Hospital
or
Both
Indication in case of pain breakthrough
SE: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred vision, diplopia,
RESPIRATORY DEPRESSION, hypotension, bradycardia, constipation, nausea, vomiting, urinary retention, flushing, itching, sweating, physical
dependence, psychological dependence, and tolerance.
Name nitroglycerin (Nitrostat)
Concentration
Dosage Amount 0.4mg
Route sublingual
Frequency: PRN, q5min x 3 doses
Pharmaceutical class vasodilator
Home
Hospital
or
Both
Indication: if chest pain occurs during plasmapheresis
SE: dizziness, headache, apprehension, restlessness, weakness, blurred vision, hypotension, tachycardia, syncope, abdominal pain, nausea, vomiting,
contact dermatitis, alcohol intoxication (large IV doses only), cross-tolerance, flushing, and tolerance.
Name acetaminophen (Tylenol)
Concentration
Dosage Amount 650mg
Route PO
Frequency PRN, q8hr
Pharmaceutical class NSAID
Home
Hospital
or
Both
Indication if fever occurs per influenza B
SE: HEPATOTOXICITY, increased liver enzymes, renal failure (high doses/chronic use), neutropenia, pancytopenia, rash, and urticaria.
Name sodium chloride
Concentration 1000ml
Route IV
Dosage Amount 1000ml/hr
Frequency continuous infusion
Pharmaceutical class mineral/electrolyte replacement
Home
Hospital
or
Both
Indication maintain adequate hydration while fighting off infection
SE: PULMONARY EDEMA, edema, hypernatremia, hypervolemia, hypokalemia, extravasation, and irritation at IV site.
Name hydrocortisone (Solucortef)
Concentration 100mg/5ml
Route IV push
Dosage Amount 100mg
Frequency PRN, q4hr
Pharmaceutical class: corticosteroid
Home
Hospital
or
Both
Indication: suppress inflammation in event of anaphylaxis/ adverse reaction during plasmapheresis
SE: depression, euphoria, headache, personality changes, psychoses, restlessness, cataracts, increased intraocular pressure, hypertension, PEPTIC
ULCERATION, anorexia, nausea, vomiting, acne, delayed wound healing, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression,
hyperglycemia, fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis, THROMBOEMBOLISM, thrombophlebitis, weight gain,
weight loss, muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain, cushingoid appearance (moon face, buffalo hump), and increased
susceptibility to infection.
Name bismuth subsalicylate (Pepto-Bismol)
Concentration
Dosage Amount 30ml
Route PO
Frequency PRN, q6hrs
Pharmaceutical class adsorbents
Home
Hospital
or
Both
Indication: treatment of indigestion when reflux esophagitis bothers patient
SE: constipation,
gray-black stools, impaction (infants, debilitated patients).
University of South Florida College of Nursing – Revision April 2012
7
Deglin, J., Vallerand, A. (2012, December 14) Davis’s Drug Guide, Nursing Central. Retrieved from:
http://nursing.unboundmedicine.com/nursingcentral/ub/index/Davis-Drug-Guide/All_Entries/A
 4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis)
Diet ordered in hospital? Regular
Analysis of home diet (Compare to food pyramid and
Consider co-morbidities and cultural considerations):
Diet pt follows at home? Regular
Out of the 1662 calories eaten, 453 were empty and 258 are
the limit according to USDA’s super tracker (USDA, n.d.).
Breakfast: 2 medium pancakes from Bisquick with 2 syrup
The patient is 1oz short of meeting the 6oz whole grain
packets, 118ml orange juice, and 237ml water.
recommendation. Substituting spelt flour (nutrient dense
whole grain) for Bisquick and having one more pancake is
an easy way to meet this goal without compromising taste.
Lunch: taco salad from work (approximately 2 cups, with
To increase vegetable intake (patient is 1.25 cups short for
ground chuck) with 3T of ranch dressing, 354ml iced tea
the day) asking for an extra handful of greens in salads will
(not sweetened).
boost nutrient dense calories. Asking for a dressing made
with olive oil will lower saturated fat intake, as patient was
2g over recommended daily allowance.
Dinner: 2 chicken chimichangas (tortilla filled with a
Adding 1/4 c of cheese and 2.5oz more chicken to the
chicken, rice, beans and olive mixture - rolled, fried and
chimichangas will nearly satisfy the food group deficits for
topped with avocado, and sour cream ), 500ml water.
the day. The patient’s Hispanic culture may eventually put
him at risk for excessive sodium intake and GERD
symptoms, but according to the 24 hour analysis and no
family history of hypertension, his eating habits are
excellent with these few minor adjustments.
Snacks: 2 bananas
Consider drinking 2 cups of milk.
University of South Florida College of Nursing – Revision April 2012
8
USDA (n.d.). Supertracker: Food tracker. Retrieved from:
https://www.supertracker.usda.gov/foodtracker.aspx#
2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? “My wife.”
How do you generally cope with stress? or What do you do when you are upset?
“ I like to run or go to the boxing gym.”
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“Really just this illness, it really scared my wife and I.”
+2 DOMESTIC VIOLENCE ASSESSMENT
Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.”
Have you ever felt unsafe in a close relationship? _________no______________________________________________
Have you ever been talked down to? No Have you ever been hit punched or slapped? _no____________
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? __not needed____________
Are you currently in a safe relationship? yes
 5 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Trust vs. Mistrust
Intimacy vs. Isolation
Autonomy vs.
Generativity vs.
Doubt & Shame
Initiative vs. Guilt
Industry vs.
Self absorption/Stagnation
Ego Integrity vs. Despair
Give the textbook definition of both parts of Erickson’s developmental stage for your patient’s age group:
Positive development is demonstrated by healthy, close relationships with others. Erickson describes intimacy as finding
one’s self yet losing one’s self in another person so if these relationships fall through they can lead to isolation.
Osborn, K., Wraa, C., Watson, A. (2010). Medical- Surgical Nursing: Preparation for Practice (pp.253). Upper Saddle
River, NJ: Pearson.
University of South Florida College of Nursing – Revision April 2012
9
Describe the characteristics that the patient exhibits that led you to your determination:
The patient spoke fondly of his life outside of this illness and his wife.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
At this point in the illness, as he is nearly fully recovered, it seems he is all the more grateful for his close relationships
and may have increased feelings of intimacy.
+3 Cultural Assessment:
“What do you think is the causes of your illness?”
“I didn’t know what was happening until after I came here. The doctor said it was probably because of the flu.”
What does your illness mean to you?
“ I am just all the more grateful for my returning health.”
+3 Sexuality Assessment: (the following prompts may help to guide your discussion)
Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record”
Not assessed, patient did not seem comfortable enough to talk with a young looking girl about this.
Have you ever been sexually active?____________________________________________________________________
Do you prefer women, men or both genders? _____________________________________________________________
Are you aware of ever having a sexually transmitted infection? _______________________________________________
Have you or a partner ever had an abnormal pap smear?_____________________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___________________________________________
Are you currently sexually active? ___________________________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? __________________________________
How long have you been with your current partner?________________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ___________________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
University of South Florida College of Nursing – Revision April 2012
10
+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?
Yes
No
For how many years?
(age
thru
)
If applicable, when did the
patient quit?
Does anyone in the patient’s household smoke tobacco? If
so, what, and how much?
Has the patient ever tried to quit?
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? 355ml Beer
How much? 3 times weekly
No
For how many years? 10
(age 21
thru 31
)
If applicable, when did the patient quit?
At 31, after getting married.
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
Is the patient currently using these drugs?
Yes No
thru
)
If not, when did he/she quit?
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
“I cook with a lot of hot oil, but so far I have not been burned.”
University of South Florida College of Nursing – Revision April 2012
11
 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen (at beach) SPF: 30
Bathing routine: showers daily
Other:
HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
2x/day
Routine dentist visits
x/year
Vision screening
Other: has not had dental visit or vision
screening in past 5 years
Gastrointestinal
Immunologic
Nausea, vomiting, or diarrhea
Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? 2011
Other:
Chills with severe shaking
Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:
Genitourinary
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: A, Rh positive
Other: undergoing plasmapheresis
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 5x/day
Bladder or kidney infections
Hematologic/Oncologic
Metabolic/Endocrine
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Pulmonary
Difficulty Breathing
Cough - dry or productive yellow sputum
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? Doesn’t know
Other:
Central Nervous System
WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Cardiovascular central line placed 3/15
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? During
last plasmapheresis procedure
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam? “Every
few years”
Date of last prostate exam? 2011
BPH
Urinary Retention
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other: generalized fatigue and paresthesia
of lower extremities
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
University of South Florida College of Nursing – Revision April 2012
12
REVIEW OF SYSTEMS NARRATIVE
General Constitution
Pt’s perception of health: Since IVIg, plasmapheresis, and antibiotic therapy began 3/15 patient regained sensation in lower extremities
and reports no more symptoms shortly afterward (other than yellow sputum that is progressively clearing up). Patient is gaining
strength each day and positive about prognosis. No recent weight loss or gain, signs of infection at IV and central line site, and
remained free from symptoms of reflux esophagitis during hospital stay. Patient reports feeling close to baseline.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
no
Any other questions or comments that your patient would like you to know?
no
University of South Florida College of Nursing – Revision April 2012
13
±10 PHYSICAL EXAMINATION:
Orientation and level of Consciousness:
General Survey: rapidly
Height: 1.8 meters
Weight: 81 kg BMI:25.0
Pain: (include rating & location)
0/10
approaching full recovery
Pulse: 65
Blood
Pressure: 93/60 (brachial, left
Temperature: (route taken?) Respirations: 18
arm)
98.4 PO
SpO2 96% on room air
Is the patient on Room Air or O2:
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
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
talkative
withdrawn
quiet
boisterous
aggressive
hostile
flat
loud
Peripheral IV site Type:
Location:
Date inserted
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type: hemodialysis catheter Location: right, internal jugular
Date inserted: 3/15/2013
Fluids infusing?
no
yes - what? Sodium chloride 0.9%
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
left eye with corrective lenses
Functional vision: right eye - 20 left eye 20without corrective lenses right eye Functional vision both eyes together: with corrective lenses or NA
PERRLA pupil size 2/ mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: did not assess, patient did not demonstrate difficulty hearing
Weber test, heard equally both ears Rinne test, air “not able to be performed”
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: symmetrical, 32 teeth white and intact
University of South Florida College of Nursing – Revision April 2012
14
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL – Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH – Wheezes
Tactile fremitus bilaterally equal without overt vibration
CR - Crackles
Sputum production: thick thin
Amount: scant small moderate large
RH – Rhonchi
Color: white pale yellow yellow dark yellow green gray light tan brown red
D – Diminished
S – Stridor
Ab - Absent
Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th Intercostal space, Left Mid Clavicular Line
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
No JVD
Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze)
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:3
Radial:3
Femoral:3
Popliteal: 3
DP: 3
PT:3
No temporal or carotid bruits
Edema: 0
[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
GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Liver span 8 cm
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color: light yellow
Previous 24 hour output: 2100mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 3 / 22 /2013 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
University of South Florida College of Nursing – Revision April 2012
15
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative
Genitalia:
Clean, moist, without discharge, lesions or odor
Other – Describe:
Not assessed, patient alert, oriented, denies problems
Musculoskeletal:  Full ROM intact in all extremities without crepitus
Strength bilaterally equal at __4_____ in UE & ___4____ in LE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias
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 (not assessed)
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: positive negative Babinski: positive negative
“Unable to assess DTR’s”
±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Labs
Date: 3/19
Trend: 3/17
Analysis
WBC (4.5- 11.1)
RBC (normal 3.80–5.80)
4.5
5.05
L 4.0
5.0
HGB (normal 12.1- 14.6)
H 15.0
14.6
HCT (normal 36-52)
46.0
44
MCV (normal 79-103)
91.0
89
MCH (normal 27- 35)
29.8
27
MCHC (normal 32- 36)
32.7
32.1
RDW (normal 11.6 -14.8)
14.1
13.8
PLT (normal 150-450)
L 147
L 146
Decreased in viral infections
Can tell us if the liver and spleen
are functioning in destruction or
kidneys in producing
erythropoietin.
Increased in hemoconcentration
secondary to albumin
administration
Measures percentage of RBC’s in
total blood volume, if sodium was
elevated and caused RBC’s to
swell- this may be elevated also.
Measure of average blood cell
size, should not be elevated on
anticoagulants.
Indicates amount of hgb carried on
average blood cell, would
decrease in respiratory paralysis
secondary to Guillain-Barre.
Average concentration of HGB in
a given volume, would also be
decreased in respiratory paralysis.
Indicates degree of size variation
among blood cells and could
indicate abnormal production
related to kidney damage in
advanced degrees of GuillainBarre.
Decreased as a result of
ineffective thrombopoesis
secondary to viral infection.
Important to watch during
University of South Florida College of Nursing – Revision April 2012
16
plasmapheresis to determine need
for anticoagulant.
Average platelet size, may be
significantly increased by platelet
destruction/production. Important
to watch during plasmapheresis to
determine need for anticoagulant.
Increased in infectious disease
B cells (lymphocytes) turn into
immunoglobulin-synthesizing
plasma cells. Necessary to watch
while giving IgG treatment.
Increased in infection (increase in
response to inflammation)
Function is phagocytosis of
antigen-antibody complexes such
as Guillain-Barre (GB).
MPV (normal 7 -10.2)
9.8
9.4
SEGS (normal 2.3–6.9)
LYMPHS (1.5–3.7)
3.3
3.0
7.0
2.9
MONO (normal 0.2- 0.4)
H 12
H 13
EOS (normal 0.05-0.5)
4.0
4.2
Sodium (normal 135-145)
141
140
Potassium (normal 3.5-5)
4.2
4.1
Chloride (normal 97-107)
H 109
H 108
C02 (normal 22-26)
26
25
Glucose (normal <110 fasting)
97
98
BUN (normal 5-25 mg/dl)
15
16
Creatinine (normal .5-1.5 mg/dl)
0.86
0.75
Calcium (normal 9- 11 mg/dl)
8.7
9.0
Anion gap (normal 8-16)
6
7
CSF analysis (<3.4 mg/dl)
(3/14)
(Patient’s specific test result not
listed, physician interpretation)
MRI
(3/14)
Hyponatremia can occur after
IVIg therapy.
Sodium chloride infusion can
cause hypokalemia, and low levels
are associated with GB.
Related to metabolic exchange of
intracellular chloride replaced by
bicarbonate secondary to action of
sodium citrate infusion
May be increased due to
respiratory paralysis resulting
from GB.
Elevated levels may occur while
on corticosteroid.
May be elevated in if GB
progresses to paralyze kidney
function.
Rhabdomylosis secondary to GB
may decrease levels.
Must replace during
plasmapheresis, monitor to
evaluate binding with new
albumin.
Lower with administration of
sodium citrate.
Indicated no elevated proteins,
safe to start IVIg
Normal findings
Head CT
(3/14)
Normal findings
Nasal swab, rapid test
(3/14)
Positive for Influenza B
General Chemistry
Van Leeuwen, A., Vroomen-Durning, M.,Poelhuis, D. (2011, January 24) “Complete Blood Count”, Davis’s Lab and
Diagnostic Tests, Nursing Central. Retrieved from: http://nursing.unboundmedicine.com/nursingcentral/ub/view/Davis-Laband-Diagnostic-Tests/425052/all/Complete_Blood_Count_
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:
Although the patient’s symptoms are gone, it is important to monitor vital for respiratory paralysis, pulmonary function
tests with incentive spirometry, airway secretions, intake and output and assessment of bowel and bladder function each
University of South Florida College of Nursing – Revision April 2012
17
shift for a patient with Guillain-Barre. Compression stockings have been discontinued now that the patient is frequently
ambulating and has one more treatment of both IVIg and plasmapheresis (telemetry is still monitored).
University of South Florida College of Nursing – Revision April 2012
18
 2 Medical Diagnoses
(as listed on the chart)
(actual
 8 Nursing Diagnoses
and potential - listed in order of priority)
1. Guillain- Barre syndrome
1. At risk for infection related to risk for hemolysis
secondary to plasmapheresis
2. Influenza B
2. At risk for fluid electrolyte imbalance related to
plasmapheresis
3. Reflux esophagitis
3. At risk for impaired gas exchange related to GuillainBarre syndrome secondary to Influenza B
4. Monocytosis
5.
University of South Florida College of Nursing – Revision April 2012
19
± 15 for Care Plan
Nursing Diagnosis: At risk for infection related to risk for hemolysis secondary to plasmapheresis
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions Evaluation of Interventions
Achieve Goal
Provide References
on Day care is Provided
Demonstrate monocyte level within Monitor CBC with differential and
normal limits after last day of
administer hydrocortisone as
treatments
directed
The WBC count is a better diagnostic
test for adults and most children
(Ackley and Ladwig, pp 492).
The monocyte levels were still
elevated on day of care.
Patient will remain afebrile for
anticipated discharge 3/24
Fever is often the first sign of
infection (Ackley and Ladwig, pp
Patient remained afebrile on day of
care
Observe and report signs of
infection such as redness, warmth,
discharge, and increased body
temperature
492).
± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
□Med Instruction/Prescription
 No take home meds noted on chart
Ackley and Ladwig (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (9th ed.). St. Louis Missouri. Mosby Elsevier.
University of South Florida College of Nursing – Revision April 2012
20
± 15 for Care Plan
Nursing Diagnosis: At risk for fluid electrolyte imbalance related to plasmapheresis
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions Evaluation of Interventions
Achieve Goal
Provide References
on Day care is Provided
Patient’s electrolytes will remain
within limits for discharge
Observe for signs of hyperkalemia
such as dysrhythmia, abdominal
distention and weakness post
plasmapheresis
Patient’s extremities and dependant Fluid management assessment of
areas remain free of edema for
intake and output, weight, and
discharge
peripheral pulses
Hyperkalemia can occur intraoperatively due to massive blood
transfusions (Ackley and Ladwig, pp
Patient displayed no signs of
hyperkalemia and electrolytes
remained within normal limits
400).
Low molecular weight fluids can
cause fluid overload so it
mandatory to assess for it post
procedure (Ackley and Ladwig, pp
Patient displayed no signs of fluid
volume overload
399).
± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
□F/U appts : should follow up with provider 2 weeks after discharge
Ackley and Ladwig (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (9th ed.). St. Louis Missouri. Mosby Elsevier.
Great job Lauren! You received a 98%!
University of South Florida College of Nursing – Revision April 2012
21