Mr. FT is an active independent 76-year-old who lives with his wife of 50 years in a two-bedroom ranch home. He normally walks two miles each day but has been barely moving as he sprained his left ankle four days ago dancing with his wife.
Patient denies problems to HEENT except needing reading glasses to read and work on the computer. Patient denies problems to the neurological, musculoskeletal, integumentary, cardiac, respiratory, GU and mental status systems.
Chief Complaint: Patient states that he is having crampy lower abdominal pain with a sense of fullness, lack of appetite and fatigue. The abdominal pain has been occurring for 48 hours and initially started as a discomfort and is constant and intensified to a score of 5/10. The patient is supporting and guarding his lower abdomen as he speaks to the nurse. The pain is relieved with passing gas and ambulation but intensifies with sitting still. He has been drinking hot tea and taking Tylenol for the pain and again rates the pain at a 5/10 now.
PMH: HTN and mild chronic renal disease.
PSH: Surgical repair of a right femoral fracture 40 years ago from a car accident.
FH: Father died of colon cancer and mother died of a stroke 30 years ago.
Social history: Smoked for 10 years in his twenties and quit when he was admitted with the femoral fracture after the car accident. He has a beer with old college buddies once a week. He tried the drug PCP once in the 1960s and did not like the effects, so he never tried any other illicit drug.
Occupation: He was a Certified Public Accountant for 40 years but is retired and now tutors local children two days a week at the local YMCA.
Allergies: Toradol- lips and tongue swell up.
Code Status: Full Code
Race/Ethnicity: Black Latino
Marital Status: Married to the same wife for 50 years.
Support System: First born son lives two blocks away and is the primary support.
Medication: Norvasc 25 mg po BID. HCTZ 12.5 mg po daily, Nephro-vite 1-tab po daily.
Patient is alert and oriented x4. Speech is clear and judgment is normal. Affect is appropriate. Patient is corporative and follows commands well. Short- and long-term memory intact. Negative Romberg’s noted. Ambulates with a limp to left leg. Upper and lower extremity strength is 4/5 bilaterally. No joint swelling or pain noted. Cranial nerves II-XII are grossly intact. Sensation assessed with sharp and dull technique and sensation is normal to face, upper and lower extremities.
No secretions or abnormalities to eye, ears, nose, and throat. Teeth are intact, buccal membranes are pink and moist, Uvula is midline, lips are dry. Lymph nodes to the face, neck and clavicular area are non-palpable.
Heart sounds S1 and S2 with regular, rate, rhythm and without ectopy. Peripheral pulses with amplitude 2+ bilaterally. Lungs are clear with regular, rate, rhythm, and depth. Capillary refill to upper and lower extremities are less than 3 seconds.
Abdomen is firm, distended, rounded, and tender to touch with decreased bowel sounds to lower abdominal quadrants. Umbilicus is midline. Patient is guarding his lower abdominal area. Urine is clear yellow without sediment, hematuria, or stones. Patient urinated 50 mls of urine in two hours. Skin is warm, dry, and intact.
After the Primary Care Provider examines the patient, he was diagnosed with Acute Constipation and an enema is ordered. An abdominal Xray confirms the diagnosis. If the patient has a large bowel movement, after the enema then the patient will be put on a stool softener and discharge home.
Sodium 136 mEq/L
Potassium 5 mmol/L
Chloride: 100 mEq/L
Carbon Dioxide 100 mEq/L
BUN 30 mg/dL
Creatinine 2 mg/dl
Glucose 80 mg/dL
Calcium 9 mg/dl
Phosphate 4 mg/dl
Magnesium 1.9 mg/dl
Student’s name: ______________________________________ Date:_______________________________
SAMPLE FORMAT: Nursing Diagnosis ________R/T _____________AEB_______________
Risk for Nursing Diagnosis ________R/T _____________
|Independent Nursing Interventions (at least 2)||Rationale||APA In-text Citation|
|Discharge Planning/ Patient teaching (at least 2)|
|Collaborative Team (at least 1)|
|Medication Management (at least 1)|
Nursing Process Instructions:
|Grading Criteria||Excellent||Average||Satisfactory/ Passing||Unsatisfactory||Student grade:|
|Complete Primary Medical Diagnosis and Diagnostic Criteria
|1.5 pts||1.275 pts||1.125 pts||0|
|List of 3 appropriate Nursing diagnoses properly written||1.75 pts||1.488 pts||1.313 pts||0|
|Supporting data is documented in Docucare||1.5 pts||1.275 pts||1.125 pts||0|
|Includes at least one SMART (specific, measurable, attainable, reasonable, and timely) outcome.||1.75 pts||1.487 pts||1.312 pts||0|
|Includes at least six (6) relevant interventions with their rationale AND Includes a citation for each of the interventions and their rationale
|2.5 pts||2.125 pts||1.875 pts||0|
|Includes a statement that evaluates whether the outcome was met, partially met, or not met with justification||1 pt||0.85 pts||0.75 pts||0|
|8.5 points (85%)||7.5 points
DocuCare will be used to chart your individual clinical patient’s physical assessment. DocuCare is a form of electronic charting and will help prepare you for the type of charting that you will see in hospitals once you graduate.
Once hospital clinical experiences begin, you will be expected to chart in DocuCare per assignment guidelines. Initially, you will be expected to document the following information:
In addition to the basic information listed above, you will chart on a new body system each clinical week in DocuCare, as it correlates to the new body system that you are learning to assess in Health Assessment (NURS 121). You will be responsible for documenting on the following systems:
Each clinical instructor will provide instructions regarding additional required documentation.