NR 509 Comprehensive Assessment Results and Focus Notes
NR 509 Comprehensive Assessment Results and Focus Notes
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Self-Reflection Activity Time: 20 min Sample Solution
Explicitly describe the tasks you undertook to complete this exam.
Student Response: A comprehensive assessment is a complete, all-encompassing, in-depth assessment
that includes a complete health history and physical assessment. Components of the health history are the patient’s personal history of illness, as well as their family medical history, including any current or prior treatments, surgeries, risk factors, and medications or supplements. In addition, it should include details of other aspects of health, such as the patient’s perception of their health, health beliefs, coping mechanisms, support systems, and functional status. The first question I asked was for Tina to verify her name and date of birth. This is a safety check that assures the assessment I am about to conduct, is on the right patient. It also helps me to determine if this patient is alert to self.
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Comprehensive Assessment Results and Focus Notes
Another important question that I started my interview process with was asking the patient the reason for her visit, and if she had any health concerns she would like to discuss. This helps focus the attention on the patient and what he or she needs or hopes to get out of the visit, and also helps guide the interview. Other questions were based on the components of the health history mentioned earlier. For example, I asked Tina how she felt she was doing, to get insight to her perception of health, which can help identify areas of that Tina may need further education on. In addition, I asked Tina what her medical history was, what (if any) medications (OTC, prescribed or supplements) she was currently taking and the reason for taking them, and the dose and frequency. Aside from Tina’s health I asked questions about her personal life, such as who she lived with, what her new job would be, relationship status, and what she enjoyed doing for fun. Again, helping to develop a relationship with the patient, but also providing me with insight to her functional status, support systems, and so on. Other questions asked pertained to risk factors or unhealthy/unsafe behaviors. For example, asking Tina is she currently smoked, or used illicit drugs, or had unprotected sex helps determine if she partakes in unhealthy/unsafe behaviors.
Once subjective data was collected, I performed the comprehensive physical assessment, which according to Jensen (2015) should be a complete head-to-toe examination.
Head/Neck: I examined the patients head/face for general appearance, symmetry, expression, etc. I
assessed her skin, hair, and scalp. I estimated her eyes for equality, pupil response, eye movements, and
vision; her ears, nose, mouth, and throat. I palpated her lymph nodes and carotids. I tested her neck strength and ROM.
Chest: I examined the patient’s chest, in the following sequence, first anteriorly, then posteriorly. First I
inspected the pt position and appearance, to see if the patient appeared comfortable. Noting for any signs of respiratory distress. Then I examined the patient’s chest for symmetry, size, shape, and muscle use. Next, I auscultated the patient’s heart and lung sounds. After auscultation, I palpated PMI, and tactile fremitus anteriorly, and palpated posteriorly for tactile fremitus, symmetry, and expansion and palpated for CVA tenderness; Last, I percussed all lung fields.
Abdomen: I examined the patient’s abdomen in the following order: inspection, auscultation, percussion, and palpation to include the general appearance of ( scars, masses striae, etc.) symmetry, shape, and size.
Explain the clinical reasoning behind your decisions and tasks.
Student Response: Student Response: I started this exam by first collecting the health history from the
patient, which is subjective data. Subjective data provides insight to the patient and can provide context to how any current problems may be related. Also, personal data collection helps to guide the physical
assessment and the nursing process. “The nurse’s role in collecting subjective data is to use it to improve the patient’s health status and to determine the cause of the patient’s current symptoms” (Jensen, 2015). For example, When asking about Tina’s medical history I wanted to know if she had any conditions, and if so how long has she had them, the severity of any illness, symptoms, aggravating factors, and if she was currently receiving treatment for it. I also inquired about any allergies, what happens with exposure, the severity of allergies, and how allergies are/have been treated. Other questions I asked included a social history, such as if she smokes and for how long. This helps me to identify any personal risk behaviors Tina may participate in or any environmental risk factors that she may expose herself to.
After conversing with the patient, I started to collect my objective data through physical assessment. Before performing the physical assessment, I made sure that the patient was comfortable and that her room temperature was adequate. Also, before starting the nursing comprehensive assessment, I organized my physical assessment from head to toe, instead of systems. This helps the assessment go more smoothly. For purposes of explanation, I will do it based on systems. Of note, The physical assessment is done using four techniques: inspection, palpation, percussion, and auscultation. During the assessment, the patient was told everything that was going to be done before doing it and was assessed for signs of discomfort. Once the assessment was complete, I made sure that the patient was comfortable and had everything she needed, and all of her questions were answered. NR 509 Comprehensive Assessment Results and Focus Notes.
Neuro- I asked Tina questions to inquire about any risk factors that she may have of developing a
neurological condition, such as head trauma and any signs or symptoms of neurological or neuromuscular complications. During subjective data collection an informal neurological assessment was being performed, such as assessing the patient’s speech, alertness, etc.
Obtaining subjective is important because it provides insight to the patient, and to any potential or current risk factors they may have towards developing or worsening neurological disorders. It also allows for an informal neurological assessment of LOC, speech, general knowledge, etc. This can be helpful in things like determining safety hazards/risks, and when providing education. The cerebellar function was tested by having the patient do a finger-to-nose test and heel-to-shin test. Performing this test not only tests for possible cerebellar lesions/dysfunction but may also help identify safety hazards (such as being a fall risk, or needing assistance at home for an unsteady gait). Sensory function was tested to check for sensory deficits, perception so the patients clinical situation should be considered when testing it. For example, Tina has diabetes and is more likely to have the peripheral sensory loss. Peripheral sensory from diabetic neuropathy is usually distal, whereas someone with the sensory loss caused by spinal trauma will have sensory loss specific to the area of the skin that is supplied by nerves from the affected spinal root (Jensen, 2015). Testing sensory loss can help identify educational points, for example, Tina had a sensory loss on the balls of her feet, so following up by asking her if she performs daily feet assessments is important (Jensen, 2015).
Respiratory: To assess the patient’s respiratory system I asked questions regarding her respiratory status, and history. By inquiring if she has ever had a respiratory disease, it helps identify the potential for developing subsequent respiratory conditions. Tina, has asthma, which is a chronic respiratory disease in which the upper airway is overly sensitive to different environmental stimuli and allergens. This is one reason why I asked Tina if she had any allergies and what reactions she has had in the past to the allergens. Cats and dust are two of her allergies that trigger her asthma. I also asked Tina about her lifestyle choices and environment.
For example, I asked her if she has ever used or smoked tobacco, because smoking poses many risks to a
person’s health. Smoke inhalation can irritate air passageways, and trigger asthma exacerbations. It can also lead to other respiratory conditions, such as lung cancer. Asking questions such as these, helps to identify current and potential risk factors the patient has that can have a negative impact on her health status. It also helps to identify nursing interventions and education that that can potentially benefit the patient and promote health. For the objective portion of the examination, I inspected her general appearance and position, noting if she appeared comfortable. Noting for any signs of respiratory distress. For example, is she lying or sitting comfortably or sitting upright in a tripod position? Does she need to catch her breath while talking? Are her lips pursed? What is her respiratory rate? Inspection starts as soon as I enter the room, but continues throughout the entire assessment. Then I inspected the patients chest for symmetry, size, shape, and muscle use. For the remaining parts of the respiratory assessment I started from the top of the lung fields and worked downwards, making sure to compare the right and left. Palpation was done to assess chest expansion and for tactile fremitus. Palpating the chest for expansion helps feel if breaths are symmetrical, and tactile fremitus helps to evaluate lung density. Percussion was done to evaluate how dense lung fields are. According to Jensen (2015) the sounds that are revealed during percussion can help determine whether tissue is dense due to fluid collection, air collection, or is solid. Normally the sounds should be resonant and symmetrical (although in heavier patients it may not be). I listened to the patients lung sounds by placing a stethoscope directly on her skin, which helps to get a better seal and listen. I listened to lung sounds on the right side and left side starting from the top (upper airway) and working my way toward the bottom. I moved from left to right, and right to left so that I was able to compare both sides.I also had the patient use the incentive spirometer. An incentive spirometer is a tool that helps the patient to take slow deep breaths while
also providing useful data to the healthcare team about a patient’s respiratory function.
Cardiac: I was asking Tina about her personal and family history of heart disease, to determine if she is likely to develop or have cardiovascular disease. We already know she has type two diabetes, which is one risk factor for developing heart disease (as well as many other diseases). By asking her about her weight, exercise habits, if she smokes, etc. it helps to identify if she has any other risk factors for heart disease.
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Auscultating heart sounds to identify if the patient has an irregular heartbeat or any causes for concern.
Similarly, assessing for things like peripheral edema in patients with cardiac history can help to put pieces together that may form a diagnosis of things like congestive heart failure.
GI/GU similarly to the other systems, the patient was asked questions related to GI/GU system. For example, if she had any nausea, vomiting or abdominal pain; or any urinary symptoms such as burning or frequency.
The physical assessment portion was performed in the abdominal area and in the following order: inspection, auscultation, percussion and light (1-2 cm) and deep (4-6 cm) palpation. First, the abdomen was inspected for symmetry, shape, and abnormalities. Next, auscultation of the abdominal quadrants was performed using the diaphragm of the stethoscope. During auscultation, bowel sounds are assessed to assess for peristalsis.
For example, if bowel sounds are absent or decreased, this could indicate that the patient has an ileus.
Vascular sounds were also auscultated for bruit or hums. Bruit is abnormal and indicates turbulent blood flow and can mean there is an obstruction or dilation of a tortuous vessel, like the renal artery. Third, was percussion. As mentioned in the respiratory portion of this description, percussion is useful to determine tissue density. Percussion within the abdominal cavity can help identify if there is any fluid, air or possible masses anywhere. It can also help estimate organ size, and/or determine if there is any tenderness within a organ. For example, if percussion at CVA causes pain/tenderness it can indicate a kidney infection or kidney stones. (During this exam, I performed percussion for CVA tenderness during the posterior chest assessment.) Last, was palpation. Palpation is done two ways: light and deep. Light palpation is done first and is 1-2 cm deep. Light palpation helps to ease the patient, instead of jumping right into a deep palpation.
It also helps the assessor get a general idea of what the patient’s abdomen feels like. The patient should be assessed for any signs of discomfort, and pain, asked if there is discomfort. In a normal exam, there should be no tenderness or discomfort present.
After light palpation, deep palpation should be performed. Deep palpation is 4-6 cm deep and is done to assess for tenderness and masses. Using the kidney again as an example, in hydronephrosis, the patient’s
kidney may be enlarged and palpable. Of note, auscultation, percussion, and palpation of the abdomen should be done by first starting at the RLQ and moving in a clockwise fashion (RLQ, RUQ, LUQ, LLQ). Musculoskeletal: To assess the patient’s musculoskeletal system, I asked questions such as if the patient had any signs or symptoms of musculoskeletal disorders (stiffness, weakness, swelling, etc.). During the physical assessment, the musculoskeletal system was assessed using inspection and palpation as well as a measurement of ROM (Jensen, 2015). First, a general inspection of the patient’s posture was assessed during the subjective data collection and throughout the exam. During the exam, the patient was instructed to do a range of motion exercises. During range of motion, the joints and muscles were palpated, and strength was tested. This helps to identify things such as arthritis, pain, tenderness, swelling, deformity or any other abnormalities.
For example, inspection of extremities can reveal current or past injury such as asymmetry which can occur after wearing a cast because of muscle wasting from not using it. Palpating extremities can reveal areas of tenderness or pain, as well as swelling and may indicate infection. ROM in tested in all areas with joints, such as the neck, shoulder, elbow, wrist, hip, spine, knee, and ankle. As well as all areas of the spine (cervical, lumbar, and thoracic). When testing active ROM in the extremities, both extremities should be assessed simultaneously to check for symmetry. During ROM, signs of discomfort, limited movement, or crepitus/cracking should also be noted. If passive ROM is performed, extremities should be handled gently, stopping when resistance is met or if the patient demonstrates/verbalizes signs of discomfort. Muscle strength is tested against resistance.”When testing muscle tone and strength, it is necessary to compare one side with the other” (Jensen, 2015, p. 617). Normal muscle strength would be complete ROM against full resistance and gravity.
Skin: Data collected about the integumentary system included the patient history of skin disease or skin cancer, as well as any family history. Also, I asked Tina questions to follow up on her current skin conditions such as her excessive hair growth, moles, and neck discoloration, and her leg wound from her last hospitalization. Last, I asked questions regarding her skin care, and if she performed skin assessments and used sunscreen when outdoors. During the physical assessment, the skin was assessed through inspection and palpation. I performed a generalized inspection as well as a comprehensive assessment of all areas, from head to toe. I palpated Tina’s scalp, assessed her face and hair, assessed her nails, and checked capillary refill on her nail beds. I evaluated and palpated her scalp for any hair loss or dandruff, or any scalp tenderness. Excessive hair loss can mean the patient may have an endocrine or metabolic dysfunction. I inspected the patient’s nail beds for a capillary refill which checks vascular supply. This is assessed in the hands and feet because when the vascular amount is decreased, it is often noted in the extremities first. I also evaluated the nails for color, texture, and shape and asked her about nail breakage. Breakage can mean there is a nutrition deficiency.
All of the data collected during the assessment is clustered together to identify any areas of need the patient may have. The nurse develops a nursing care plan with a nursing diagnosis such as activity intolerance, inefficient health maintenance, etc., and applies appropriate interventions to meet patient-specific outcomes that will help improve or maintain the patient’s health status.
References
Jensen, S. (2015). Nursing health assessment: A best practice approach (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
Identify how your performance could be improved and how you can apply “lessons learned” within the assignment to your professional practice.
Student Response: I think overall, my assessment techniques and flow have improved throughout these
past six weeks. I have learned certain skills I did not know how to do before, such as assessing tactile
fremitus, and percussion of the abdomen. I also learned that the abdomen should be assessed in a clockwise fashion starting in the RLQ. During my assessment of Tina, I did not follow this. It was an error, and unfortunately, I could not undo it. This is also the case in real practice, errors and things said cannot be undone. For this, I am glad that I have the opportunity to be able to practice, learn, and strengthen my nursing techniques with the simulation patients in addition to my physical assessment skills, I feel that my data collection ability has also improved. I had actually admitted a patient at work the other day, and I used the skills I learned in this course during the patient interview. I am familiar with all of the questions we need answering for admissions at my job, so I was able to incorporate many of the questions in a way that flowed and in ways that I could ask one broad question to get the answers I needed.
https://www.coursehero.com/file/31663874/Comprehensive-Assessment-self-reflection-pdf/
NR 509 Comprehensive Assessment Results and Focus Notes – Esther Park Format for a Focused Note
Necessary Components for the Subjective information:
Date of encounter: April 21, 2020
Patient Name or initials: Esther Park
Informant: The informant is the patient, a 78 year old woman, who is a reliable historian.
Chief Complaint (CC): “I have pain in my belly and I’m having some difficulty with going to the bathroom.”
History of present illness (HPI): Ms. Park is a 78 year old female presenting to the clinic with reports that reports that she is “having pain in her belly” and “difficultly with going to the bathroom.” At onset, the pain was reported as 3/10 and increased within the last 2-3 days. The pain is currently 6/10 and has lasted for almost a week. The pain is constant, dull and crampy and generalized across her entire abdomen; however, the pain is increased along the LLQ. She denies radiating pain. Her last bowel movement was 5 days ago and reports that it was “normal”. Previously she reports regular brown soft stools every day to every other day. She is also experiencing some bloating. The pain increases with physical activity and eating and is relieved with rest. Ms. Park reports drinking warm water was ineffective in treating the pain. She denies the use of pain medication or laxatives. Her appetite has decreased over the last few days and she is taking small amounts of water and fluids, resulting in a decline in energy level and difficulty participating in usual activities. Ms. Park reports slight decrease in frequency of urination, reporting darker urine than usual but denies any blood in urine. She denies any recent diarrhea since a food poisoning incident six months ago lasting one day with loose, watery stool. Denies drinking caffeine. She denies nausea and vomiting, blood or mucus in stool, rectal pain or bleeding, or recent fever. She denies vaginal bleeding or discharge. Reports no history of constipation, inflammatory bowel disease or GERD. Denies family history of GI disorders. Ms. Park denies any recent travel. Reports history of 2 colonoscopies, with the most recent one 10 years ago. She states the findings showed “nothing to report.” She did not feel her symptoms warranted at trip to the clinic, but her daughter insisted she come. She denies any shortness of breath, nausea, vomiting, diaphoresis, dizziness, fever, chills, or palpitations.
Allergies: Latex (contact dermatitis), NKDA, NKFA
Medications: Accupril 10mg PO daily, last dose 0800 (taken for HTN), denies OTC medications or herbal medications
Past History: Childhood Illnesses: none. Adult Illnesses: HTN diagnosed age 54. Surgical: cesarean section (age 40), cholecystectomy (age 42), denies post-op complications. Ob/Gyn: three pregnancies, two vaginal deliveries, one cesarean section delivery for full term stillborn child. Two living healthy children. No concerns about HIV/HPV. Psychiatric: none. Hospitalizations: denies hospitalizations beyond surgical history and childbirth noted.
Health Maintenance: Immunizations: up to date, denies flu shot this year but has received it in the past, unsure about pneumonia vaccine. Screening tests: up to date with annual physical, sees Dr. Keller with Shadowville Primary Care, last Mammogram >5yrs ago, last pap smear >10 years.
Family History: Mother: deceased age 88, hx HTN, T2DM
Father: deceased age 82, hx HTN, hypercholesterolemia
Maternal grandparents: deceased, family hx CAD and T2DM
Paternal grandparents: deceased, family hx obesity, CVA, and HTN
Brother: living age 81, hx HTN
Brother: living age 80, hx HTN, hypercholesterolemia, and prostate C
Son: living age 48, healthy, no known health issues
Daughter: living age 46, healthy, no known health issues
Personal and Social History: Born in San Francisco and grew up in a Korean community. Graduated HS, achieved LVN, and is currently a retired nurse. Married husband, Shin, at age 22 years, widowed 6 years ago. Has two adult children, a son and daughter, and no grandchildren. Lives with daughter, Jennifer, and reports strong family support system. Currently, has a gentleman friend, Max, whom she reports being intimate with. Enjoys gardening, walking, and exercise classes (water aerobics and Pilates). Belongs to Korean Presbyterian Church of Shadowville, although not an active member.
Tobacco Use: Denies past or present tobacco use
Alcohol and Drug Use: Reports 1 alcoholic beverage (white wine) weekly on Sundays. Denies use of marijuana, cocaine, heroin, or other illicit drugs.
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Pertinent Review of systems (ROS):
General: Denies recent weight gain or weight loss. Denies fever, chills, night sweats, palpitations, dizziness, lightheadedness or syncope. Reports recently short-term exhaustion and low energy requiring rest more often. Reports anxiety related to current abdominal pain only.
Skin: Denies rashes, lumps, or sores. Denies hair or nail changes. Reports occasional dry skin.
HEENT: Denies headache, head injury, dizziness or lightheadedness. Denies any use of glasses or contacts, reports no vision deficits. Denies any decrease in hearing or infections. Denies frequent colds or stuffiness. Denies use of dentures, dry mouth, or sore throat.
Respiratory: Denies history of cough, sputum production, wheezing or shortness of breath. Denies DOE or pain with inspiration. No history of chest x-ray.
Cardiovascular: PMH of HTN. Denies chest palpitations, chest discomfort, or fast heartbeat. Denies history of rheumatic fever, murmur, coagulopathy, or edema in hands, feet or ankles. Denies dizziness or syncope.
Gastrointestinal: Reports constant abdominal pain, see HPI. Reports last bowel movement was 5 days ago, normal in color and size. Reports bloating, slight increase in gassiness, and loss of appetite. Reports generalized abdominal pain with increased pain in LLQ. Reports discomfort with defecation but denies pain. Reports increased pain after eating. Denies difficulty or pain with swallowing, heartburn, nausea and vomiting. Denies rectal bleeding, black or tarry stools, hemorrhoids, or diarrhea. Denies food intolerance, jaundice, liver or gallbladder disease, or hepatitis. Last colonoscopy was over 10 years ago, with “nothing to report.”
Urinary: Reports decrease in frequency of urination. Reports darker urine than usual. Denies hematuria and flank pain. Denies history of bladder problems, painful urination, burning with urination, urinary incontinence, history of UTIs, gynecological problems, vaginal bleeding or discharge.
Genital: Reports three pregnancies, with two vaginal deliveries, and one cesarean section at age 40 for stillbirth delivery. Denies any current vaginal bleeding or discharge. Reports menopause at age 54. Currently sexually active, prefers male partners, denies using any form of birth control. Denies history of STI/STD testing.
Musculoskeletal: Reports joint stiffness in the morning upon waking. Denies weakness but reports low energy recently. Denies myalgias, arthralgias, or limitations.
Necessary Components for the Objective information:
Vital Signs: BP 110/73 (83), HR 92, RR 16, O2 saturation 99% on room air, Temperature 37.0C orally, Pain 6/10
Height/Weight/BMI: 5’2”, 120 lbs., BMI 21.9
Physical Exam
Constitutional/General survey: Ms. Park is an elderly woman, alert and oriented to person, place and time. Her speech is clear and coherent, and she maintains good eye contact. She is sitting upright, unassisted, appearing in stable but mild distress with occasional grimaces and slight facial flushing noted. She follows commands and answers questions appropriately. She moves all extremities x4 and appears well groomed.
Skin: Skin warm, pink, and dry per observation. No tenting per palpation. No diaphoresis noted. No edema present. No ecchymosis noted, no clubbing of fingernails on inspection.
HEENT: Head: Scalp without lesions, normocephalic/atraumatic. Nose: Mucosa pink, septum midline. No sinus tenderness. Mouth: Oral mucosa pink, moist, and intact without lesions. Dentition good. Tongue midline.
Thorax: Patient breathing unlabored, able to speak full sentences. Symmetrical chest expansion anteriorly and posteriorly with good excursion on inspection. Lungs resonant. Vesicular breath sounds auscultated anteriorly and posteriorly at right and left upper lobes, and right middle lobe anteriorly and posteriorly. No adventitious sounds noted.
Cardiovascular: S1, S2 noted without murmurs with patient is supine position. No S3, S4, gallops or rubs. No upper or lower extremity edema noted. PMI non-displaced.
Abdomen: Symmetrical, flat abdomen with hypogastric distension noted on inspection with patient supine and flat. Well healed 6 cm scar in RUQ and 10cm scar at midline in suprapubic region. No abdominal discoloration. Bowel sounds normoactive in all 4 quadrants per auscultation. No abdominal bruits noted on auscultation. No friction rub noted on auscultation to liver or spleen. No bruit noted on auscultation at bilateral renal, iliac, and femoral arteries. Tympanic throughout abdomen with scattered dullness over LLQ per percussion. Abdomen soft in all 4 quadrants. Nontender and no masses detected to light and deep palpation in RUQ, LUQ, and RLQ. A firm, oblong mass measuring 2×4 cm noted in LLQ with deep pressure and mild guarding and distension noted with light pressure. Liver palpable 1cm below right costal margin, MCL. Liver span noted to be 7 cm at MCL line on palpation, no hernias noted. Aortic width is 2 cm without lateral pulsation. Unable to palpate spleen, bilateral kidneys, or bladder. No organomegaly; no CVA tenderness.
Rectal: Digital rectal exam revealed strong sphincter tone and fecal mass present in rectal vault. No hemorrhoids, no fissures or ulceration.
Pelvic: External genitalia intact without lesions. No inflammation or irritation of vulva, abnormal discharge, or bleeding. No masses, growths, or tenderness upon palpation.
Urinalysis: Urine clear, dark yellow, normal odor. No nitrates, WBCs, RBCs, or ketones detected; pH 6.5, SG 1.017
Necessary Components for the Assessment information:
– Diverticulitis, likely due to LLQ mass and pain accompanied by tenderness, prolonged constipation, nausea and risk factor of advanced age (Goolsby & Grubbs, 2015).
– Intestinal obstruction, r/o in setting of history of abdominal surgery, distension and palpable mass on examination with constant cramping periumbilical pain and dehydration. Intestinal obstructions can some present as constipation, especially in the older population (Goolsby & Grubbs, 2015).
– Colorectal cancer, r/o in presence of patient’s symptoms of fatigue and constipation, as well as the palpation of an abdominal mass with LLQ tenderness (Goolsby & Grubbs, 2015).
– Constipation, likely due to no bowel movement in 5 days, scattered dullness in LLQ during percussion suggesting feces in colon and digital rectal exam revealing fecal mass in rectal vault.
– Dark urine on urinalysis possibly related to dehydration. The patient reported decreased fluid intake and urination in the last week due to increased discomfort and abdominal pain.
Necessary Components for the Plan:
Obstruction – mass on examination, constant LLQ pain and tenderness, afebrile
– Admit to hospital
– Remain NPO
– IVF for hydration
– General surgery consult for evaluation
Constipation – no bowel movement for 5 days, dullness on percussion, feces in rectal vault
– Increase fluid intake
– Increase fiber intake
– Consider fiber supplements or the use of OTC laxatives.
– Increase activity as tolerated
– Follow-up with PCP as needed for worsening symptoms
Dehydration
– Increase fluid intake as tolerated
– Monitor for symptoms of dehydration in eldlery: dark urine, confusion, dizziness, headaches, low urine output, dry mouth, low blood pressure, and increased heart rate.
– Keep water bottle nearby and drink even when not thirsty.
HTN – BP stable 110/73 (83)
– Continue Accupril 10mg PO daily
– Monitor BP at home daily
– Initiate heart healthy diet, utilize ChooseMyPlate.org for reference
– Monitor salt intake
– Follow up with PCP within one month
Diabetes – at risk with maternal family history
– Check fasting glucose and A1C
– Provide education on S/S of hypoglycemia and hyperglycemia
– Follow-up with PCP within one week for results
Self-Assessment:
References: NR 509 Comprehensive Assessment Results and Focus Notes