Universal Career School General Physical Examination of a Patient Worksheet

Client Initials

N.M

Culture/Ethnicity

Mexican / White Hispanic

Support system:

Lives with husband, mother and 3 children

UnitRoom/Bed

ED 101

Religion:

Catholic

AgeSex

36 F

Language:

Spanish and English

WeightHeight

68 Kg, 150 lb 5 Feet 1 Inches

Marital status:

Married

Current medical diagnosis:

Diarrhea

Occupation:

Medical office manager

Children:

3 son

Health insurance

Aetna

Name of significant other/primary caregiver

Primary Care Giver: C.S

Mother: MC

Current work status

Employed

Highest grade completed:

MBA

Genogram: Use back of page

Diagnostic procedures:

• Chest XR.
• Standard EKG.
• Ct Scan of Abdomen
• Endoscopy

Labs to be taken and analyzed:

• Fecal leukocytes and occult blood, Stool cultures with Ova and Parasites, CBC and DIFF, sodium, potassium, chloride, glucose, BUN, creatinine, PT-INR, PTT, hepatic function panel, amylase, lipase, and urinalysis.

Patient Care Orders:

• Vital signs every 8 hours.
• Input/output every shift.
• Notify doctor if diarrhea volume and frequency >2 times/Hour or if bleeding present.

Surgical procedures:

N/A

Past Surgical History:

• Appendectomy 20 years ago.
• Bilateral tubal ligation , 2013

Past Medical History:

Not significant other than three normal vaginal deliveries .

Pathophysiology: (List reference)

Diarrhea can be define as loose or watery stools on three or more occasions per day. Almost everyone will encounter at least one episode in their lifetime. The primary prevalence of frequent and chronic diarrheal conditions are found more often in developing countries but it is also commonly seen on returning travelers from geographic areas where the indices of such medical condition is elevated. There are multiple causes of acute or chronic diarrhea and the highest incidence is due to infectious processes. In addition, diarrhea can have other causes like the side effects of medications, overutilization of antibiotics, food allergies, inflammatory bowel disease, chronic parasites infestation, lactose intolerance and on some instances the original cause or precipitating factors are never discovered. Patient with mild diarrhea does not need direct medical attention with usual resolution between 48 hours. However, if the diarrheal process has a longer presentation with patient developing dry mouth, muscle cramps, infrequent urination, lightheadedness and on more severe cases with abdominal pain, blood in the stools or hemodynamic instability then immediate medical attention is required with possible hospitalization for hydration, electrolyte correction and prevention of further medical decline that could even reach the culmination of life itself.

Psychopathology:

Patient that develop chronic diarrhea are more prone to have a direct socioeconomic impact to their respective communities with lack of work related productivity, frequent hospitalizations and possible spreading of the infectious process to immediate member of his family or friends. Depending on the causative agent of the diarrheal process, in underdeveloped countries it is more common caused by the lack of minimal sanitation standards, poor hygiene practices, and limited food safety with lack of inspection services by their respective Countries health system management agencies. A simple diagnosis of diarrhea with the progression to a chronic state, might have a significant rolling down spiral effect on the person household economics, increase incidence of infecting other close relatives and subsequently limiting the development of the infrastructure of any community when it becomes a pandemic situation in that geographic location.

BRIEF HEALTH HISTORY

SUMMARY:

Patient with no significant health history presents to ED on 9/5/2015 complaining of abdominal pain, fever and diarrhea for the last four days after returning from vacation to Mexico where she consumed street prepared food/ fruit beverages. Patient denies nausea and vomiting. Vital signs : BP 100/75 mm Hg, Temp: 100̊ F , HR 68 beats/min, RR 16 beats/min, oxygen saturation 99%. Abdomen distended, tympanic and hyperactive. Patient was asked to collect a fecal sample for oval/parasite testing.

PAST MEDICAL HISTORY:

No significant other than P3013, normal vaginal deliveries

PAST SURGICAL HISTORY:

Appendectomy 20 years ago, bilateral tubal ligation in 2013

ALLERGIES:

No allergies to any medication.

MEDICATIONS:

Multivamins .

PHYSICAL EXAMINATION:

General: Patient is overweight, alert and oriented X 3

Vital Signs: She is afebrile. BP 110/75 mm Hg

Neck: Supple.

Chest: Clear of adventitious sounds.

Abdomen: Distended, tympanic and hyperactive

IMPRESSION AND PLAN:

The patient presents with a medical diagnosis of diarrhea. Patient is being monitored post hydration and fecal analysis sent for ova/parasites is still pending.

Discharge teaching will involve discussion of pharmacological regimen, non-medical therapeutic lifestyle changes such as avoid eating or drinking local food/beverages prepared on street when traveling.

Vital signs/Frequency

09/05/2015 2000

BP: 100/75 mmHg

Temp: 100.0 Fahrenheit

HR: 68 Beats per min.

Resp: 16 Breaths per min.

SpO2: 99%

Assess if any change in health status occurs.

____________________________________

Allergies/Side effects

NKDA

____________________________________

Diet with rationale:

Start a soft diet for two days and start integrating normal diet after. Drink 6-8 glasses of water daily after hospitalization.

___________________________________

Activity order:

Ambulate out of bed with no restrictions.

____________________________________

Limitations/prosthetic devices

No physical limitations.

PERTINENT LABORATORY DATA Lab Test #1

White Blood Cells

(WBC)

__________________________

Results:

11.7 K/uL [above normal]

Reference Range:

3-10 K/uL

__________________________

Rationale of abnormal results

The WBC is really a nonparameter, since it simply represents the sum of the counts of granulocytes, lymphocytes, and monocytes per unit volume of whole blood. Automated counters do not distinguish bands from segs; however, it has been shown that if all other hematologic parameters are within normal limits, such a distinction is rarely important. Also, even in the best hands, trying to reliably distinguish bands from segs under the microscope is fraught with reproducibility problems. Discussion concerning a patient’s band count probably carries no more scientific weight than a medieval theological argument. (Smeltzer, 2009).

PERTINENT LABORATORY DATA Lab Test #5

Fecal Culture

__________________________

Results:

Moderate grow of Escherichia

coli

__________________________

Rationale of abnormal results

The most common cause of traveler’s diarrhea is enterotoxigenic Escherichia coli (ETEC) bacteria. These bacteria attach themselves to the lining of your intestine and release a toxin that causes diarrhea and abdominal cramps.( Mayo Clinic,, 2013)

PERTINENT LABORATORY DATA Lab Test #2

Neutrophils

___________________________ Results:

81.6 % [above normal]

Reference Range:

40-75 %

__________________________

Rationale of abnormal results

Neutrophils are the main defender of the body against infection and antigens. High levels may indicate an active infection (Porth, 2007).

PERTINENT LABORATORY DATA Lab Test #3

Fecal WBCs

__________________________

Results:

0-2/HPF

Reference Range:

None WBC Seen

__________________________

Rationale of abnormal results

The presence of fecal leukocytes indicates bowel mucosal inflammation, which occurs in invasive bacterial enteritis and ulcerative colitis. The sensitivity of the fecal leukocyte test is approximately 70% for diarrheal disease caused by Shigella, but lower for other bacterial pathogens. (Siletti,1996)

PERTINENT LABORATORY DATA Lab Test #4

Shiga toxin 1

__________________________ Results:

Positive for serovar 0103

Reference Range:

Negative

__________________________

Rationale of abnormal results

Among the E.coli human pathogens, Shiga toxin-producing strains of E.coli gained in importance in recent years. The main sources of infection are contaminated, raw or insufficiently heated foods of animal origin, egg, meat and dairy products.. These microorganisms can enter the food during the processing of meat and dairy products if hygienic conditions are inadequate.(Maniar, 1990)

INTRAVENOUS SOLUTION #1

Type: IV infusion

[21ga IV access to RAC]

D5W NaCl 0.9%: 1000 mL Q24H PRN daily.

Rationale for solution: often used to restore fluid and electrolyte imbalance. Pertinent to the maintenance of homeostasis.

MEDICATION NAME

TRADE/GENERIC

DOSAGE ORDERED

TIMES ADMINISTERED

DOSE ROUTE

RATIONALE FOR ADMINISTERING

THERAPEUTIC RANGE FOR AGE/WEIGHT

NURSING IMPLICATIONS

Zestril (lisinopril)

40 mg tab

Q24H daily

PO

Alone or with other agents in the management of Hypertension; management of heart failure; reduction of risk of death or development of HF after MI. (Davis’ Drug Guide, 2010)

Adults: 10mg once daily, can be increased up to 20-40 mg/day. Initiate therapy at 5 mg/day in patients recieving diuretics. (Davis’ Drug Guide, 2010)

• Monitor BP and pulse frequently during initial dosage adjustment and periodically during therapy.
• For heart failure, monitor weight and assess for fluid overload.
• Correct volume depletion, if possible, before initiation of therapy.
• May cause fatigue, dizziness, or headache.

(Davis’ Drug Guide, 2010)

Coreg (carvedilol)

6.25 mg tab

Twice daily

PO

Decreased heart rate and blood pressure. Improved CO, slowing of the progression of CHF and decreased risk of death. (Davis’ Drug Guide, 2010)

For hypertension, 6.25 mg twice daily, may be increased every 7-14 days up to 25 mg twice daily. (Davis’ Drug Guide, 2010)

• Monitor BP and pulse frequently during dose adjustment period and periodically during therapy.
• Monitor I/O ratios and daily weight. Routinely assess for evidence of fluid overload.
• May cause bradycardia, exacerbation of CHF symptoms, and pulmonary edema.

(Davis’ Drug Guide, 2010)

Atropine

0.5- 1mg

PRN daily

IV push

Antidote for bradycardia- increases heart rate. Reversal of muscarinic effects, decreased GI and respiratory secretions. (Davis’ Drug Guide, 2010)

IV (adults0: 0.5-1mg; may repeat as needed q 5 min, not to exceed a total of 2 mg. (Davis’ Drug Guide, 2010)

• Intense flushing of the face and trunk may occur 15-20min following IM administration and is not harmful.
• Y-site incompatible with thiopental.
• If overdose occurs, physostigmine is the antidote.

(Davis’ Drug Guide, 2010)

Lasix (furosemide)

20 mg tab

Twice daily

PO

Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions) (Davis’ Drug Guide, 2010).

For edema: PO (adults): 20-80 mg/day as a single dose initially, may repeat in 6-8 hr; may increase dose by 20-40 mg every 6-8 hr until desired response. (Davis’ Drug Guide, 2010)

• Assess fluid status. Monitor daily weight, I/O ratios, amount and location of edema, lund sounds, skin turgor and mucous membranes.
• Monitor BP and pulse before and after administration.
• Patients taking digoxin are at risk for digoxin toxicity because of potassium- sparing effect (Davis’ Drug Guide, 2010).

Ecotrin (Aspirin)

81 mg tab

Q24H daily

PO

Analgesia, reduction of inflammation and fever, decreased incidents of transient ischemic attacks and MI (Davis’ Drug Guide, 2010).

Prevention of ischemic attacks: 50-325 mg daily. Prevention of MI: 80-325 mg daily (Davis’ Drug Guide, 2010).

• Patients who have asthma, allergies, and nasal polyps, or who are allergic to tartrazine are at an increased risk for developing hypersensitivity reactions.
• Assess pain before and after administration.
• Monitor labs for symptoms of hepatotoxicity. (Davis’ Drug Guide, 2010)

Aldactone (spironolactone)

25 mg tab

Q24H daily

PO

Increased survival in patients with severe HF. Weak diuretic and antihypertensive response when compared with other diuretics. (Davis’ Drug Guide, 201

PO (Adults): 25-400 mg/day as a single dose or 2 divided doses. For CHF: 25-50 mg/day (Davis’ Drug Guide, 2010).

• Monitor intake and output ratios and daily weight during therapy.
• Monitor response of signs and symptoms of hypokalemia or for development of hyperkalemia.
• Caution patient to avoid salt substitutes and foods that contain high levels of potassium.
• Avoid if breastfeeding. (Davis’ Drug Guide, 2010)

Norvasc (amlodipine

5 mg tab

Q24H daily

PO

Systemic vasodilation resulting in decreased BP; coronary vasodilation resulting in decreased frequency and severity of attacks of angina (Davis’ Drug Guide, 2010).

PO (Adults): 5- 10 mg daily. If hepatic impairment, initiate therapy at 2.5 mg/day and increase as tolerated up to 10 mg day (Davis’ Drug Guide, 2010).

• Monitor BP and pulse before therapy, and after. Monitor ECG periodically during prolonged therapy.
• Assess for signs of CHF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distension)
• Dose reduction recommended in geriatric patients due to risk of hypotension.
• Contraindicated in a systolic BP < 90 mm Hg (Davis’ Drug Guide, 2010).

NURSING DIAGNOSES

LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN PRIORITY)

NURSING INTERVENTIONS

UTILIZE A THEORY (NEEDS THEORY/NURSING THEORY) FOR RATIONALE

1. Diarrhea related to bacterial infection as evidence by frequent elimination of liquid stools and abdominal pain.

1. Risk of deficient fluids volume related to loss of gastrointestinal fluids as evidence by diarrhea.

1. Deficient knowledge of diarrhea prevention when travelling.

Theory:

The large intestine is the primary organ of bowel elimination. The large intestine absorbs water, sodium and chloride from digested food. If peristalsis is abnormally fast, there is less time for water to be absorbed and the stool is watery (Potter & Perry, 2009 p 1088). It is important to assess in this patient the frequency of defecation, consistency, amount, fluids intake, alterations in perineal sensations and perineal skin integrity. Gradually progress from fluids to small meals, instruct her to avoid gaseous, spicy, high fiber and high lactose foods, include low fiber diet to reduce the bulk of fecal material. Replace fluids and electrolyte loses to prevent dehydration, monitor bowel movements every shift and record, assist with perineal care after each episode and keep rectal area clean and dry.

Theory:

According to Potter & Perry: Fundamentals of nursing (page 887) “Diseases, medications, or other factors disrupt fluid intake or output and imbalances sometimes occur”. Diarrhea is an example of that statement, because fluid output increases and fluid intake does not correspond appropriately and imbalances occur. To restore previous balance and prevent severe dehydration is important to monitor gastrointestinal loses, diuresis, and oral intake. Also monitor fever and watch for early signs of hypovolemia.

Theory:

“Nurses have an ethical responsibility to teach their patients.” (Heiskell, 2010). The patient needs to understand how to prevent diarrheas. Instruct patient to maintain a proper hand hygiene when preparing food or before eating. Explain patient the importance to drink bottled water every time she is travelling to prevent traveler’s diarrhea. It is crucial to teach the patient Standard Precautions to prevent spread of infectious diarrhea.

ASSESSMENT DATA

SUBJECTIVE/

OBJECTIVE

NURSING DIAGNOSIS

PLAN

OUTCOME CRITERIA (CLIENT CENTERED)

INTERVENTIONS

(NURSE CENTERED)

RATIONALE FOR INTERVENTIONS

EVALUATION

Subjective:

“Whenever I try to do anything, I get so out of breath.”

Objective:

Dsypnea, respirations > 20 min upon mobility.

Self-care deficit related to activity intolerance due to decreased cardiac output and subsequent dyspnea and fatigue upon exertion.

Patient will identify controllable factors that cause fatigue. Patient will have his self-care needs met.

1. Teach patient how to conserve energy while performing ADL’s, such as sitting in a chair while dressing, wearing lightweight clothing that fastens with Velcro, etc.

2. Teach patient exercises for increasing strength and endurance.

(Sparks & Taylor, 2009)

1. These energy conserving methods will reduce the metabolic and oxygen needs of the heart, allowing the client the vitality to care for himself more.

2. These exercises will improve breathing and promote general physical reconditioning.

(Sparks & Taylor, 2009)

Patient is proficient in conserving energy and performs self-care and ADL’s with little to no symptoms of fatigue; patient’s BP, HR, and RRs remain within normal parameters during periods of activity.

Subjective:

“I eat whenever I feel stressed”.

Objective:

Weight 139.822 kg

Total cholesterol > 240

BP: 156/113

Imbalanced nutrition: More than body requirements, related to excessive caloric intake, as evidenced by client’s central obesity and elevated cholesterol and blood pressure.

Patient will adhere to a low cholesterol/ low fat diet, will participate in a selected exercise program 4x week, and will experience a therapeutic reduction in weight, in BP, and in cholesterol levels.

1. Have dietician calculate target caloric intake and discuss meal planning.

2. Help patient to select an ideal exercise program.

3. Weigh patient weekly, or as prescribed.

(Sparks & Taylor, 2009)

1. These interventions and planning serve to help the patient reach a desirable weight.

2. This aids in weight loss and also offers an alternative to eating to alleviate stress.

3. Weighing the patient serves to monitor the effectiveness of the diet and exercise plan.

(Sparks & Taylor, 2009)

Patient and health care professional establishes a weekly weight loss goal; patient adheres to the prescribed diet and exercise regimen and demonstrates a therapeutic reduction in BP and cholesterol levels.

Subjective:

“I already felt ugly but now I have to wear this stupid heart device for everyone to see!”

Objective:

Weight 139.822 kg

Presence of central obesity

Holter monitor in place

Altered self-concept related to obesity and presence of Holter Monitor.

Patient will voice positive feelings about self, report a sense of control over life events, and will voice acceptance of the Holter Monitor.

1. Explore patient’s usual coping mechanisms in times of stress.

2. Encourage patient to express feelings about self (past and present).

3. Demonstrate methods of concealing the Holter Monitor from the public, and explain its presence is not permanent.

(Sparks & Taylor, 2009)

1. Evaluates patient and gives the opportunity to discuss additional positive methods of coping.

2. Self-exploration encourages the patient to consider future change.

3. Allows patient to feel more self-confident wearing it, and knowing that this treatment is short-term will increase compliance.

(Sparks & Taylor, 2009)

Patient describes how feelings about self have changed since current health problem began and voices understanding of Holter Monitor’s use, importance, and the ease with which it can be concealed.

Subjective:

“I live with my mom and I know she is old, but she ends up taking more care of me than herself..”

Objective:

Client lives with mother, is currently unemployed, and is financially/ physically dependant on his mother.

Risk for caregiver role strain related to patient’s increasing care needs and dependency.

Caregiver will identify formal and informal sources of support and will report increased ability to cope with stress related to her son’s health care/ self-care needs.

1. Encourage caregiver to discuss coping skills used to overcome similar stressful situations in the past.

2. Refer patient caregiver to a psychiatric liason nurse, support group, or home health agency.

(Sparks & Taylor, 2009)

1. This reflection will build confidence for managing the current situation.

2. This will help the caregiver to foster mutual support emotionally and in caring for the patient.

(Sparks & Taylor, 2009)

Caregiver uses appropriate coping skills for each stressful situation and utilizes available support systems.