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Care of the Adult I – Clinical Care Plan

Everest
COLLEGE Date Submitted: ____________
School of Nursing (to be filled out by instructor)
On time late
Kanesha Pittman
Student Name______________________ 09 March 2011
Dates of care_______________

Patient’s Data
WM
Patient initials _____________ Married
Marital Status________________
M
Gender______________ 69
Current age__________________
21-A
Unit & Room #_____________ 71.83 Kg (measured or reported)
Weight: ______
NKDA
Allergies: _____________________________________________________________________
Soft Mechanical
Diet: _________________________________________________________________________
Bedrest, activity as tolerated
Activity Level: _________________________________________________________________
PT, OT, Speech Therapy
Multidisciplinary Treatments: _____________________________________________________
Vital Signs: Day 1 98.5 °F/C
T_____ 75 bpm R____
P ____ 22 /min BP 120/65
____ mm/Hg none
Pain_______

Day 2 T_____°F/C P ____ bpm R____/min BP____ mm/Hg Pain_______

Chief Complaint (why is the patient here… write in narrative form):


Patient presented with painful micturation, AMS, nausea and vomiting, fever
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Admitting Diagnoses: (from chart) 06 March 2011


Date of Admission: ______________________________________

1. UTI
_______________________________________________________________________________________
2. Dehydration
_______________________________________________________________________________________
3. AMS
_______________________________________________________________________________________

Past Medical/Surgical History: (previously diagnosed conditions/surgeries)

 Parkinson Disease
_______________________________________________________________________________________
 GI Bleed
_______________________________________________________________________________________
 _______________________________________________________________________________________
 _______________________________________________________________________________________
 _______________________________________________________________________________________

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Care of the Adult I – Clinical Care Plan
Check with your clinical instructor before choosing which Diagnosis to write up.
(Textbook information, use another page if you need more space)

Cystitis (UTI)
Pathophysiology of: _______________________________________
An inflammation of the bladder caused by irritation or by infection from bacteria. Infectious agents, bacteria, move up the urinary tract
__________________________________________________________________________________________
from the external urethra to the bladder which produces bacteriuria. Bacteriuria without symptoms of infection is called
__________________________________________________________________________________________
colonization. this does not progress to acute infection or renal insufficiency unless the patient has other pathologic problems
__________________________________________________________________________________________
then it requires treatment.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
UTI
Etiology of: ________________________________________________
It is a result of a high bacterial virulence which overcomes normal strong host resistance. Common organisms are Escherichia coli,
__________________________________________________________________________________________
Klebsiella pneumoniae, and staphylococcus saprophyticus. Invading bacteria are more likely to cause ascending UTIs that
__________________________________________________________________________________________
start in the urethra or bladder and move up into the ureter and kidney. They move into the urethra from the perenial area as
__________________________________________________________________________________________
a result of irritation, trauma or catheterization.
__________________________________________________________________________________________
Pt risk factors: (modifiable and non-modifiable)
With age enlarged prostates may obstruct the normal flow of urine, producing stasis. Neuromuscular conditions cause
__________________________________________________________________________________________
incomplete bladder emptying, such as Parkinson disease and strokes, affect older adults more frequently.
__________________________________________________________________________________________
UTI
Medical Treatment of: _____________________________________________________________________________
Drug therapy - antimicrobials treat bacteriuria and analgesics and antispasmodics promote comfort.
__________________________________________________________________________________________
Urinary elimination management - maintain an optimal elimination pattern.
__________________________________________________________________________________________
Nutrition therapy - a diet with all food groups and added calories for increased metabolism due to the infection
__________________________________________________________________________________________
Comfort measures - a warm sitz bath. Surgery - removal of obstructions and repair of the vesicoureteral reflux.
__________________________________________________________________________________________

Medical Treatments: Actual: Things ordered by MD


 nutrition therapy by way of dietitian referral, fluid IV to prevent dehydration
_______________________________________________________________________________________
 Drug therapy - antiemetics, antibiotics and analgesics for comfort
_______________________________________________________________________________________
 Urinary elimination management by way of foley catheter
_______________________________________________________________________________________
 _______________________________________________________________________________________
 _______________________________________________________________________________________
 _______________________________________________________________________________________
 _______________________________________________________________________________________
 _______________________________________________________________________________________
 _______________________________________________________________________________________
 _______________________________________________________________________________________
 _______________________________________________________________________________________
 _______________________________________________________________________________________

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Care of the Adult I – Clinical Care Plan

List all Laboratory Tests done on your pt: (CBC, CMP, UA, etc…) most current values:
UA with microscopy, CBC with differential, CMP, Urine culture and sensitivity
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

LIST ALL ABNORMAL LABORATORY TESTS

Lab value that is Probable reason this is abnormal for your pt:
Test Name: abnormal for your pt:

What is the
Normal Value:
(reference ranges)

What is your
Patient Value:

Lab value that is Probable reason this is abnormal for your pt:
Test Name: abnormal for your pt:

What is the
Normal Value:
(reference ranges)

What is your
Patient Value:

Lab value that is Probable reason this is abnormal for your pt:
Test Name: abnormal for your pt:

What is the
Normal Value:
(reference ranges)

What is your
Patient Value:

References (APA format):

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Care of the Adult I – Clinical Care Plan
LIST ALL ABNORMAL LABORATORY TESTS

Test Name: Lab value that is Probable reason this is abnormal for your pt:
abnormal for your
pt:

What is the
Normal Value:
(reference ranges)

What is your
Patient Value:

Lab value that is Probable reason this is abnormal for your pt:
Test Name: abnormal for your
pt:

What is the
Normal Value:
(reference ranges)

What is your
Patient Value:
Lab value that is Probable reason this is abnormal for your pt:
Test Name: abnormal for your
pt:

What is the
Normal Value:
(reference ranges)

What is your
Patient Value:
Lab value that is Probable reason this is abnormal for your pt:
Test Name: abnormal for your
pt:

What is the
Normal Value:
(reference ranges)

What is your
Patient Value:
Lab value that is Probable reason this is abnormal for your pt:
Test Name: abnormal for your
pt:

What is the
Normal Value:
(reference ranges)

What is your
Patient Value:

References (APA format):

4
Care of the Adult I – Clinical Care Plan

List all diagnostic tests done on your pt: (x-rays, endoscopy, cat scans, stress tests, etc…..
1. ____________________________________________________________________________
abdominal ultrasound

2. ____________________________________________________________________________
3. ____________________________________________________________________________
4. ____________________________________________________________________________

LIST ALL ABNORMAL DIAGNOSTIC TESTS

Test Name: Your pt’s result: Probable reason abnormal for pt:

Normal Findings for this test:

Test Name: Your pt’s result: Probable reason abnormal for pt:

Normal Findings for this test:

Test Name: Your pt’s result: Probable reason abnormal for pt:

Normal Findings for this test:

Test Name: Your pt’s result: Probable reason abnormal for pt:

Normal Findings for this test:

Test Name: Your pt’s result: Probable reason abnormal for pt:

Normal Findings for this test:

Test Name: Your pt’s result: Probable reason abnormal for pt:

Normal Findings for this test:

Test Name: Your pt’s result: Probable reason abnormal for pt:

Normal Findings for this test:

References (APA format):

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Care of the Adult I – Clinical Care Plan

Document on the Nurse’s Note: narrative charting


 Your assumption of the care of the pt. – report received
 Condition of pt. – on initial contact of shift
 Pt. contact – when you go into the room and note pts condition – at least every 2 hours
 Changes in pt. condition – complaining of pain, nausea, dizziness… etc.
 Follow up action/intervention – document the condition of the pt. after intervention for any complaint
 Multidisciplinary treatments – i.e. pt. gone to PT; OT in with pt.; pt. gone to hemodialysis
 Visitors – make a note of anyone that comes in to see your pt. (family, friends)
 Dr in to see pt – make a note of any MD, PA, or ARNP that comes in to see your pt.
 Emergency – document any instance of the pt having to be sent out to the hospital for further treatment

Date Time Notes


03/09/2011 0900 Check IV lines and tubing
0910 take vitals, perform full assessment
0955 check foley bag
1000 AM care - Jess (spouse) came to visit
1030 AM meds given
1100 Bathroom - large, very formed BM, walked with a lot of assistance due to
inability to support weight fully on lower extremeties.
1130 change IV dressing
1230 Assist with feeding lunch
1330 Straighten up room, patient wants to nap

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Care of the Adult I – Clinical Care Plan
IV access PIV #1
Type of access: ___________________________________________
Right hand
Location: ___________________________________________
poorly dressed, no redness, + tenderness
Condition of site: ___________________________________________
0.5% dextrose/ 0.45%NACL (1/2 Normal Saline)
Type of IVF: ___________________________________________
60 ml/hr
Rate of IVF: ___________________________________________

Date Time Notes


noticed KCL hanging - finished
- nutriceutical/potassium supplement for electrolyte imbalance
noticed Rocephin - 1g/50 mL - finished
-antibiotic for UTI

Patient/family teaching: (describe at least one point of patient education that you implemented)
Explained to spouse that the patient was moved to a different room because he was a fall risk and
__________________________________________________________________________________________________
__________________________________________________________________________________________
needed closer monitoring and needed to be closer to the nurse's station
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

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Care of the Adult I – Clinical Care Plan

LIST ALL MEDICATIONS

Generic Name Dose, Route and Class Action Side Effects Nursing Implications Evaluation
Also list at least Frequency List any medication What do you check for to be What is the desired
one trade name & side effects that are aware of as the nurse outcome of the
diagnosis why pt is both severe and caring for a pt on this medication? Was it
on medication common first, then medication? achieved?
list common
stimulates dopaminergic orthostatic hypotension, reduction of exprapyramidal movements
Carbidopa/Levodopa 25/100 (1 tab) PO 4x/a day antiparkinsoni receptor compensating rigidity, tremor, gait disturbances
increase neurologic
- Sinemet an for the depleted supply dyskinesia, orthostatic intraocular pressure changes, GI bleeding transmission to improve
of enogenous dopamine hypotension renal, liver, hematopoietic function neuromotor function

Citalopram antidepressant potentiates the pruritus, constipation, rhinitis, reduction or resolution of signs decrease serotonin
30mg PO QHS serotonin URI, fatigue, headache, worsening depression, suicidality,
Hydrobromide serotonergic dizziness, tremor, unusual behavior reuptake to increase mood
reuptake inhibitor
- Celexa activity in CNS somnolence withdrawal symptoms

Galantamine cholinestrase improves cholinergic weight loss, dizziness, improvement in cognitive performance,
Hydrobromide
4 mg PO Q12H inhibitor function by increasing headache, diarrhea, nausea, hepatic function, renal function, signs of
- Razadyne acetylcholine levels vomiting, heart failure bradycardia & GI bleed

antipsychotic blocks dopamine and hypertension, abdominal pain,


Quetiapine Fumarate 52 mg PO QHS assess for neuroleptic malignant
dibenzothiazepine
serotonin receptors in the
cholesterol and triglycerides syndrome, worsening of
help sleep
- Seroquel pt to get 1 tab in AM and 2 brain; also acts as a receptor
antagonist at histamine and raised, weight gain,
tab in PM adrenergic receptor sites constipation depression, orthostatic hypotension

supresses the final step abdominal pain, flatulence, decreased abdominal and
Pantoprazole Sodium 40 mg PO Daily proton pump in gastric acid production Prevent GI bleed from
headache, diarrhea, gastroesophageal discomfort
- Protonix inhibitor and leads to inhibition of
thrombocytopenia endoscopic improvement hypergastric activity
acid secretion transaminase levels

laxative, stool actively draws water abnormal taste in decreased abdominal discomfort
Docusate Sodium 100 mg PO Q12H into the stool, softening and pain, BM in 12-72 hrs
Keep bowels moving
softener mouth, diarrhea,
- Colace it and easing a bowel
movement nausea, cramp reassess if rectal bleeding or no BM

Enoxaparin Sodium 40 mg subQ daily anticoagulant diarrhea, nausea, anemia, CBC, liver function tests, blood
low molecular
prevents bleeding, thrombocytopenia pressure
prevent DVT from
- Lovenox weight Heparin clotting hemorrhage, pneumonia symptoms of bleeding, PT, PTT immobility

References (APA format):

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Care of the Adult I – Clinical Care Plan

LIST ALL MEDICATIONS

Generic Name Dose, Route and Class Action Side Effects Nursing Evaluation
Also list at least Frequency List any medication Implications What is the desired
one trade name & side effects that are What do you check for to be outcome of the
diagnosis why pt is both severe and aware of as the nurse medication? Was it
on medication common first, then caring for a pt on this achieved?
list common medication?

References (APA format):

9
Care of the Adult I – Clinical Care Plan

Nursing Diagnoses:
 List 5 Nursing Diagnoses that are relevant for your patient
 These should be problems that can be solved or improved through nursing interventions
 Assign a priority to each diagnosis, considering Maslow’s Hierarchy of Needs
 Pick the number one priority and write expand on this Nursing Diagnosis (using NANDA
terminology)

Priority #______
Altered Mental Status/Acute Confusion
NURSING DIAGNOSIS: ________________________________________________________
Abrupt onset of cerebral hypoxia
Related to: ____________________________________________________________________
dehydration
Secondary to: __________________________________________________________________
UTI
As evidence by: ________________________________________________________________
______________________________________________________________________________
Priority # _______
Constipation
NURSING DIAGNOSIS: ________________________________________________________
decreased peristalsis
Related to: ____________________________________________________________________
immobility, Anti-Parkinson agents
Secondary to: __________________________________________________________________
hard, formed stools and decreased response to urge to defecate
As evidence by: ________________________________________________________________
_____________________________________________________________________________
Priority #______
Risk for falls
NURSING DIAGNOSIS: ________________________________________________________
impaired mobility
Related to: ___________________________________________________________________
arthritis Parkinsonism
Secondary to: __________________________________________________________________
inability to support weight on lower extremities
As evidence by: ________________________________________________________________
______________________________________________________________________________
Priority #______
deficient fluid volume/dehydration
NURSING DIAGNOSIS: ________________________________________________________
vomiting/nausea
Related to: ____________________________________________________________________
negative balance of intake and output
Secondary to: __________________________________________________________________
oliguria
As evidence by: ________________________________________________________________
______________________________________________________________________________
Priority #______
NURSING DIAGNOSIS: ________________________________________________________
Related to: ____________________________________________________________________
Secondary to: __________________________________________________________________
As evidence by: ________________________________________________________________
______________________________________________________________________________

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Care of the Adult I – Clinical Care Plan

Priority #_____
Deficient fluid volume
NURSING DIAGNOSIS: ________________________________________________________________________________________________
nausea and vomiting
Related to: ____________________________________________________________________________________________________________
negative balance of intake and output
Secondary to: __________________________________________________________________________________________________________
oliguria
As evidence by: ________________________________________________________________________________________________________
Patient had not had adequate fluid intake which in turn affected the output of the kidneys causing
Rationale for choosing nursing diagnosis: ___________________________________________________________________________________
dehydration
_____________________________________________________________________________________________________________________
Short Term GOAL (Pt. Centered/Measurable/Time Frame)
Patient will maintain normal/balance fluid volume as evidenced by urine output greater or equal to 720 mL/every day
_____________________________________________________________________________________________________________________

Data Nursing Interventions Rationale Outcome Evaluation


Assessment to support nursing (List at least 3) (give information to support each (for each intervention – were you
diagnosis (Break these down don’t list intervention – how is it going to help able to accomplish it)
interventions too broadly) solve the problem listed in ND)

Subjective Data: 1.
(patient or family says “should be in Monitor I & O daily with 1. Measure intake and output to
quotes”) every shift ensure adequate balance

"He didn't drink much and he


couldn't pee. When he did it 2. Encourage fluid intake with 2. Adequate fluid intake will allow
didn't come easy" thickened liquids the kidneys to function properly
and decrease electrolyte
Objective Data: imbalance
(observed or measured)
3. Assess mucous Was Goal Met: (overall GOAL as it
3. Mucous membranes indicate
membranes for dryness adequate fluid intake and relates to your Nursing Diagnosis) If
every shift not, explain.
distribution to the cells

References (APA format):

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Care of the Adult I – Clinical Care Plan

Priority #_____
Risk for falls
NURSING DIAGNOSIS: ________________________________________________________________________________________________
Impaired mobility
Related to: ____________________________________________________________________________________________________________
Arthritis Parkinsonism
Secondary to: __________________________________________________________________________________________________________
inability to support weight on lower extremeties
As evidence by: ________________________________________________________________________________________________________
Patient was disoriented and very weak when walking assisted to the bathroom
Rationale for choosing nursing diagnosis: ___________________________________________________________________________________
_____________________________________________________________________________________________________________________
Short Term GOAL (Pt. Centered/Measurable/Time Frame)
_____________________________________________________________________________________________________________________

Data Nursing Interventions Rationale Outcome Evaluation


Assessment to support nursing (List at least 3) (give information to support each (for each intervention – were you
diagnosis (Break these down don’t list intervention – how is it going to help able to accomplish it)
interventions too broadly) solve the problem listed in ND)

Subjective Data: 1.
Offer assistance to toilet every 2 1. To prevent incontinence
(patient or family says “should be in hrs and PRN. Use BSC as
quotes”) causing skin breakdown
needed. Assist to toilet after
meals and at HS

2. Keep call bell within reach 2. To prevent the patient from


at all times; frequently having to get up unnecessarily
remind patient to call for and so assistance can be
Objective Data: assistance provided safely
(observed or measured)
Patient's legs were very weak 3. Orient patient to hospital Was Goal Met: (overall GOAL as it
3. To keep the patient from being
and unable to support his environment frequently relates to your Nursing Diagnosis) If
confused and wanting to go to
not, explain.
weight familiar surroundings

References (APA format):

12
Care of the Adult I – Clinical Care Plan

Priority #_____
Constipation
NURSING DIAGNOSIS: ________________________________________________________________________________________________
decreased peristalsis
Related to: ____________________________________________________________________________________________________________
immobility, Anti-Parkinson agents
Secondary to: __________________________________________________________________________________________________________
hard, formed stools and decreased response to urge to defecate
As evidence by: ________________________________________________________________________________________________________
Patient has not had bowel movement in days
Rationale for choosing nursing diagnosis: ___________________________________________________________________________________
_____________________________________________________________________________________________________________________
Short Term GOAL (Pt. Centered/Measurable/Time Frame)
The patient will report bowel movements every 2-3 days
_____________________________________________________________________________________________________________________

Data Nursing Interventions Rationale Outcome Evaluation


Assessment to support nursing (List at least 3) (give information to support each (for each intervention – were you
diagnosis (Break these down don’t list intervention – how is it going to help able to accomplish it)
interventions too broadly) solve the problem listed in ND)

Subjective Data: 1.
(patient or family says “should be in Review list of foods high in 1. A daily diet of fiber, 6-8 glasses
quotes”) fiber and discuss dietary of water and exercise will
preferences maintain a normal bowel
elimination pattern.
2. 2. Help the patient in producing a
Administer a mild laxative
bowel movement by absorbing
or stool softener
water into the stool
Objective Data:
(observed or measured)
Patient hasn't had a bowel 3. Was Goal Met: (overall GOAL as it
Explain techniques to 3. Sedentary lifestyle, inadequate
movement in days relates to your Nursing Diagnosis) If
reduce the effects of stress fluid intake, inadequate dietary
not, explain.
and immobility fiber, and stress can contribute to
constipation

References (APA format):

13
Care of the Adult I – Clinical Care Plan
SBAR SHIFT REPORT
06 March 2011
Date: ________ Room #__________ Gu:
WNL ______ ASSESSMENT ____________________
WM
Name: _______________________ 69
Age: __________ FOLEY ________________ OSTOMY _____________
24 HR INTAKE ____________ OUTPUT ___________
UTI
Diagnosis: ___________________________________ LAST SHIFT: I/____________ O/_________________
NKDA
Allergies: __________________ 71.83 kg
Weight: __________
No
MD: __________________ Isolation: _____________ Skin/Wound:
Patient has a history of Parkinson's disease and
WNL _______ ASSESSMENT ___________________
History: _____________________________________
WOUND _____________________________________
GI bleeds.
____________________________________________ DRSG _______________________________________
____________________________________________
Drains: NONE_______
Procedure: ___________________________________
NG_____________ HEMOVAC __________________
Vitals: JP___________ PERCUTANEOUS________________
98.5 HR_______
TMAX _____ 75 22
RR______ 120/65
BP______ CT __________________________________________

Pain: ✔
NONE_______ IVs/Lines:
LOCATION ___________________________________ PIV #1 ________________ PIV #2_________________
PICC/CVL___________ DRSG CHG ______________
SCALE _________________ SCORE_______________
IVF __________________________________________
MED/CONTROL ______________________________ BOLUS_______________________________________

Cardiac/Neuro: Labs:
none
WNL_________ LOC___________________________ CBC_________________________________________
A&O X 1
DEFECT______________________________________
none
MURMUR ___________ Yes
PERLA__________________ BMP_________________________________________
none
SEIZURES _________________ BC_____________________ UC__________________

Respiratory: PRN or One Time Meds: (list below)

WNL____________ BBS________________________ MEDS___________________ LAST DOSE _________


TRACH/SIZE ___________ CHANGED____________ MEDS___________________ LAST DOSE _________
AEROSOL/CPT _______________________________
MEDS___________________ LAST DOSE _________
X-RAY ______________________________________
93 RA
MEDS___________________ LAST DOSE _________
Pulse ox sats _____________ OXYGEN ____________
Gastro:
WNL______ ASSESSMENT_____________________ Goals/Progress: _______________________________
Bowel Sounds______________ BM ________________ Tests/X-rays/Procedures scheduled_________________
DIET/FEEDS: PO/NG/GT _______________________ _____________________________________________
_____________________________________________ CONSULTS/NEEDS____________________________
CONT’ _______________ EMESIS ________________ FAMILY NEEDS ______________________________
TPN_________________ LIPIDS__________________ _____________________________________________
D/C planning/Home Health_______________________
14
Care of the Adult I – Clinical Care Plan
SBAR SHIFT REPORT
CHIEF COMPLAINT/PRESENT ILLNESS (why the patient is here)
_____________________________________________________________________________________
Patient presented with painful micturation, AMS, nausea and vomiting, fever

_____________________________________________________________________________________
_____________________________________________________________________________________
HISTORY (past illness, injuries, hospitalizations, surgery, sleep patterns, family)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

GENERAL: Normal Weight _______ B/P ________ Pulse_______ Respirations _______ Temperature ______
SKIN (rashes, itching, hives, bruising, eczema, dryness, skin color changes, hair texture changes, nail
texture changes, appearance of nails (including toes), previous skin disorders, lumps, use of hair dyes)
EYES, NOSE, EARS (eyeglasses, redness, problems with vision, eye discharge, glaucoma, cataracts, last PERRLA____
yes
eye exam, eye injuries, nasal discharge, nosebleeds, sinus infections, hay fever, nasal obstruction, frequency
of colds, hearing aid, hard of hearing, deafness, ringing in ears, dizziness, ear discharge, pain in ears)
MOUTH AND THROAT (condition of teeth and gums, bad breath, problems with chewing or
eating, last dental exam, frequency of sore throats, changes in voice, persistent hoarseness, thyroid
problems, goiter, lumps, pain in neck, swollen glands)
BREAST (lumps, discharge, pain, frequency of self exam)
CARDIOVASCULAR (chest pain, palpitations, murmurs, high blood pressure, shortness of breath HR regular
with exertion or lying down, history of heart attack or rheumatic fever, varicose veins, pain in legs or irregular ______
calves with walking, swelling in legs or feet, coolness of an extremity, loss of hair on legs, S3____ S4 _____
murmur
discoloration of an extremity, ulcers)
RESPIRATORY (cough, wheezing, sputum amount and color, bloody sputum, shortness of breath, Pulse Ox ____
asthma, pleurisy, bronchitis, TB, last chest X-ray, last TB skin test) O2 _______

GASTROINTESTINAL (recent weight loss, appetite, heartburn, belching, nausea, vomiting, flat/round/
abdominal pain, constipation, change in color or consistency of stool, frequency of stool, hemorrhoids, distended
rectal bleeding, use of laxatives, jaundice, hepatitis, gallbladder problems) Bowel sounds?
yes no
Pain location
GENITOURINARY (color and odor of urine, frequency, urgency, difficulty starting stream, stress Last BM _____
incontinence, excessive, painful or burning urination, blood in urine, flank pain, waking at night to
urinate, retention, kidney stones, UTIs, STDs, MALES prostate problems, self exam of testicles,
FEMALES onset of menses, frequency and length of periods, date of menopause,
pregnancies/miscarriages, use of birth control, date of last PAP)
MUSCULOSKELETAL (pain or stiffness in joints, weakness, deformities, limitations in ability to
ambulate and transfer, joint clicking, muscle cramps or spasms, use of assistive devices, use of
prosthesis, problems with balance, history of gout, arthritis, bursitis or fractures, ability to carry out
ADLs)
NEUROLOGICAL (headache, fainting, dizziness, ataxia, blackouts, paralysis, numbness, tingling, Orientation
burning, tremors, memory loss, mood changes. Nervousness, speech problems, loss of consciousness, Hand grips? L R
hallucinations, visual disturbances, disorientation, history of brain injury or stroke) Facial symmetry
DISCHARGE
PLANNING: ________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

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