Head to Toe Assessment and NCP PDF

Preview

Summary

Sim Lab assignment...

Description

Centennial College Practical Nursing Focused Assessment Client Admitting Diagnosis: RIGHT HIP SURGERY Client Past Medical History: HYPERTENSION, TYPE 2 DIABETES, CVA WITH NO RESIDUAL EFFECTS Allergies & Reaction: PENICILLIN Code Status: Data Gap Current Diet: Data gap Current Medical Issues and Treatments: PAIN Isolation Status: ☐Contact ☐Airborne ☐Droplet Interdisciplinary Team Involved in Client Care: ☐Wound Care ☐SLP ☐Social Worker ☐OT☐ PT ☐Recreation Therapist ☐Pharmacist ☐Other (please specify): Main Issues from Change of Shift Report/Transfer of Accountability:

System

Neuro Baseline Status:

Assessment

   

Level of Consciousness Orientation GCS Score: Motor Strength (upper and lower extremity) FOCUSED: Neuro related condition  PERRLA

Assessment Findings (must use proper terminologies)

Findings: Pt is alert, awake, and oriented times three (person, place and time). While doing the neuro assessment also confirm pt’s identity. Ask the pt to repeat their name, his current location and the date and time. Pt got all three getting three out of three.

☒Normal

☐Abnormal

Analysis TMT(P)/TMT(N): Analyze the data findings using evidences from PNUR126, PATH122 and PNUR124. Norms: By asking the pt these questions, you are assessing the pt’s mental status. Evaluation of their cerebral function; which is responsible for memory, language, concentration and thought process (Kozier, et, al, 2018). TMT (P): Pt is oriented enough to accurately provide information needed for the assessment.

1

Please identify the Need Affected based on the Analysis

☐Activity & Exercise ☐Sleep & Rest ☐Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☐Oxygen ☒Self-concept ☐Sexuality

System

Assessment (Must use proper termislogies)

Assessment Finding

Analysis

Needs Affected

TMT (N): The nurse will be able to accurately assess the pt and use this to probably plan a care plan based on the pt’s need. Pain Baseline Status:

 Location  PQRST

Findings: Pt was rest due to pain. Pt was complaining with grimacing face and grading his right side. The pain was assess using PQRSTU. * P (Precipitating/palliative factor) – subjective: @ rest 7/10 @ movement 10/10 *Q (quality) – subjective pt “I am in so much pain”. *R (Region) – Pain is ay right hip and head. *S (sign) – changes in the vital sign BP 170/80, RR 30, HR 107 *T (Timing) – Started around 1330 H after the prior pain medication subjective data “pt complains about too much pain and need medication”. *U (understanding) – post surgery pain ☐Normal

Norms: Pain is a stressor that affect pt’s ability to heal or recover. The only valid measurement of pain is whatever the pt is experiencing (Kozier, et, al, 2018). TMT (P): The effectiveness of pain management is based on the subjective data collected form the pt (Kozier, et, al, 2018).

☒Abnormal TMT (N): When assess the pt’s pain level, nurse need to 2

☒Activity & Exercise ☒Sleep & Rest ☒Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☐Oxygen ☐Self-concept ☐Sexuality

System

Assessment (Must use proper termislogies)

Assessment Finding

Analysis

Needs Affected

listen and rely on the pt’s perceptions because it’s a subjective experience (Kozier, et, al, 2018).

Cardiovascular: Baseline Status:

 Temperature (Route):  Radial Pulse (Rate, strength, regularity):  BP:

Findings: BP is 170 / 80 and HR 107

☐Normal

Norms: BP normal is 120 / 80 and HR is 60 to 100 (Kozier, et, al, 2018).

☒Abnormal TMT (P): the pt’s noxious causing elevated blood pressure and increase heart rate (Kozier, et, al, 2018).

☐Activity & Exercise ☒Sleep & Rest ☐Sensory ☐Skin & Hygiene ☒Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☐Oxygen ☐Self-concept ☐Sexuality

TMT (N): Will need to reduce the noxious, to reduce both the BP and HR (Kozier, et, al, 2018). Peripheral Vascular

 Lower Extremity Pulses (present or absent)  Peripheral Edema (check

Findings: No edema present, normal skin color, warm to touch 3

Norms: ☐Activity & Exercise The finding is within ☐Sleep & Rest the normal rang. ☒Sensory

System

Baseline Status:

Assessment (Must use proper termislogies)

bilaterally):  Lower Extremity skin color: (pink/pale/jaundice/cyanotic )  Lower Extremity Temperature (warm or cold)

Assessment Finding

☒Normal

☐Abnormal

 Lower Extremity Cap refill

Respiratory Baseline Status:

 Inspect Anterior & Posterior Chest Symmetry and Shape  Use of accessory muscles (yes or no)  Resp Rate and Depth:  O2 sat: % (on room air, nasal prongs or face mask)

Findings: Uses accessory muscles RR: 30 O2 sat: 95% Chest was auscultated for air entry ☐Normal

☒Abnormal

 Auscultate Chest Anterior and Posterior for Air Entry:

4

Analysis

TMT (P): pt does not have any inflammation or obstruction in the lower extremity (Kozier, et, al, 2018).

TMT (N): Nurse does not need to worry about pt having heart failure which is associated with edema or arterial disease because the pt was warm to touch (Kozier, et, al, 2018). Norms: RR: 12 -16

TMT (P): means that although pt is using accessory muscles for breathing but the pt is RR and O2 sat indicate that the pt’s underlying is affecting the pt’s

Needs Affected

☒Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☐Oxygen ☐Self-concept ☐Sexuality

☐Activity & Exercise ☐Sleep & Rest ☐Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☒Oxygen ☐Self-concept ☐Sexuality

System

Assessment (Must use proper termislogies)

Assessment Finding

Analysis

Needs Affected

vital signs (Kozier, et, al, 2018). TMT (N): This mean that the nurse needs monitor pt RR and O2 sat after providing oxygen therapy. The nurse needs to continue monitoring pt’s vital after the pain is under control. Abdominal Baseline Status:

 Inspect Abdomen (symmetry and contour)  Auscultate Bowel sounds: (location; present or absent)  Palpate Abdomen:  Last Bowel Movement:

Findings: Abdominal auscultate for bowel sounds (normal bowel sound).

Norms: The finding was within the normal rang with the bowl sound.

☒Normal

TMT (P): This mean that the pt does not have any objection back up

☐Abnormal

TMT (N): This mean that the nurse does not need to worry about constipation because Percocet side effect is 5

☐Activity & Exercise ☐Sleep & Rest ☐Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☒Fecal Elimination ☐Oxygen ☐Self-concept ☐Sexuality

System

Assessment (Must use proper termislogies)

Assessment Finding

Analysis

Needs Affected

constipation (Kozier, et, al, 2018). Integumentary Baseline Status:

 Assess oral cavity (dryness, sores)  Assess Skin for breakdown, redness (bony areas), rashes, lesions  Braden Score

Findings: Wound assessment: dry clean and no sound of inflammation

☒Normal

☐Abnormal

Norms: normal healing pattern TMT (P): The surgery wound is healing healthy which will later result in less pain (Kozier, et, al, 2018).

☐Activity & Exercise ☐Sleep & Rest ☐Sensory ☒Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☐Oxygen ☐Self-concept ☐Sexuality

TMT (N): Although the wound is healing, the nurse needs to monitor the site of wound. This is primary intention healing (Kozier, et, al, 2018). Urinary Baseline Status:

 Voiding Issues (discomfort, burning, pain)  Urine Color

Findings: ☐Normal

Norms: Data Gap ☐Abnormal TMT (P):

TMT (N): 6

☐Activity & Exercise ☐Sleep & Rest ☐Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination

System

Dietary Intake* Baseline Status:

Assessment (Must use proper termislogies)

 Amount of Diet Intake  Enteral Feeds Source & Amount:

Assessment Finding

Analysis

Findings: ☐Normal

Norms: Data Gap ☐Abnormal TMT (P):

TMT (N):

Fluid Intake* Baseline Status:

 24hour Intake & Output (from all sources)  Identify the source and amount

Intake Source & Amount 1. PO: 2. Enteral: 3. TPN: 4. IV:

Output Source & Amount 1. Urine: 2. Emesis: 3. Stool: 4. Drainage (specify):

Norms: TMT (P):

TMT (N): Total: Balance:

Lab Values*

Lab Results from chart or electronic system  Specify the date and results being normal or abnormal

Total Data Gap

☐Normal ☐Abnormal Lab Result & Date Abnormal or Normal 1. Na: 2. K 3. Hgb (CBC) 4. Platelets (CBC): 7

Norms:

TMT (P):

Needs Affected

☐Oxygen ☐Self-concept ☐Sexuality ☐Activity & Exercise ☐Sleep & Rest ☐Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☐Oxygen ☐Self-concept ☐Sexuality ☐Activity & Exercise ☐Sleep & Rest ☐Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☐Oxygen ☐Self-concept ☐Sexuality ☐Activity & Exercise ☐Sleep & Rest ☐Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination

System

Assessment (Must use proper termislogies)

Assessment Finding

Analysis

5. WBC: 6. Cultures & Sensitivity Results (Wound, Blood, Sputum): ☐Normal Psychosocial (Cultural/Spiritual )* Baseline Status:

During your interaction, did the client or family mention about any preferences or choices specific to any current treatments that they are receiving

Needs Affected

TMT (N):

☐Fecal Elimination ☐Oxygen ☐Self-concept ☐Sexuality

Norms: Not everyone have support at home

☐Activity & Exercise ☐Sleep & Rest ☐Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☐Oxygen ☒Self-concept ☐Sexuality

☐Abnormal

Client Concerns/ Preferences: Daughter was at bedside providing support and assess the pt.

TMT (P): This means client have support to help him out TMT (N): Nurse need to teach the daughter pain management therapy to help manage the pt’s pain.

NCP Priority Need

Nursing Diagnosis

Expected Outcomes

8

Nursing Interventions (With rationale and references)

Evaluation

System

Assessment (Must use proper termislogies)

☒Activity & Exercise ☐Sleep & Rest ☐Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☐Oxygen ☐Self-concept ☐Sexuality Rationale and references: Pain is a stressor that cause underling physiological, psychological, and psychosocial for the pt. Acute pain will affect pt ability to move comfortably causing intolerance in everyday living. If pain goes unmanaged it will cause pt to bcome immobile (Kozier, et, al, 2018).

Assessment Finding

#1 Expected Outcome Pt pain will be reduced to a Activity intolerance 2/10 at movement 1400 H related to pain form right after given the pnr hip surgery s/b Percocet @ 1330 H today. subjective data of pt’s pain scale 10/10 at movement, and #2 Expected Outcome grimacing face and Pt will be able to move complaining of pain. Nursing Diagnosis #1

freely and comfortably without discomfort of Nursing Diagnosis #2 grimacing face with every Acute pain related to movement after the pain effects of right hip surgery as evidenced by medication take effect at subjective pain scale 1400 H today 7/10 at rest and 10/10 on movement.

#3 Expected Outcome Pt will sleep comfortably throughout the night after medication is given @1000 H tonight

Pt was admitted to rehab unit for server acute pain following right hip surgery. The purpose is 9

Analysis

#1. Nurse will monitor pt’s pain level every hour by using PQRSTU pain assessment. Rational: The only valid measurement of pain is the pt’s experience and their perception of their pain (Kozier, et, al, 2018). #2. Nurse will give pt pnr pain medication Percocet (Confirm MAR before giving the medication. Rational: Percocet is an opioid analgesic use to reliever moderate to server opioid pain reliever. This medication will provide the pt with pain relief form the surgery (adams, 2013). #3. Nurse will reassess pt’s vital signs 30 minutes after giving the medication. Rational: Vital signs such as HR, BP, and RR will increased because the sympathetic nervous system will be active

Needs Affected

The nursing implement was effective and reduced the secondary factors associated with the nursing diagnose. And all the expected outcomes were met. The pain level was reduced to 2/10 at movement resulting in the pt becoming more comfortable and rest. Pt also became more activate and free range of moment of the pain area. Pt was no longer guarding his right hip. Due to the effectiveness of the implement, pt will become less restless and will be more comfortable to sleep.

System

Assessment (Must use proper termislogies)

Assessment Finding

Analysis

during a stress situation (Kozier, et, al, 2018). . #4. Nurse will perform some deep breathing excuses with the pt Rational: Nonpharmacological techniques such as death breathing will reduce and control the severity of the pain (Kozier, et, al, 2018). . #5. Nurse will provide pt with external stimuli such as music, tv or a discussion. Rational: According to Kozier providing pt with an external stimuli will distract the pt of the severity of their pain (Kozier, et, al, 2018). . #6. Nurse will assess pt for restlessness. Rational: Pt that are experiencing pain will become restless due to noxious and will affect the pt’s ability to for normal actives (Kozier, et, al,

to manage or relief pain to give control pt more control of their movement and activities. If the underlying issues of pain is managed, pt will be able to restore his day-to-day activities such as sleeping and movement.

10

Needs Affected

System

Assessment (Must use proper termislogies)

Assessment Finding

Analysis

2018).

11

Needs Affected...