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UNIVERSITY OF SOUTH FLORIDACOLLEGE OF NURSING

Student: Emily Morgan

PATIENT ASSESSMENT TOOLLONG FORM FUNDAMENTALS

Assignment Date: 06/38/13

Agency: Sarasota Memorial

Patient Initials: G.G. Age: 79 Admission Date: 6/26/13

Gender: F Martial Status: Married Occupation: Retired Nurse

Primary Language: English Level of Education: Bachelor’s of Science

Number/ages children/siblings: 1 Son: 52 1 Daughter: 48 Primary Medical Dx with ICD-10 code: Myasthenia Gravis G70.0

Living Arrangements: Lives at home with husband. Advanced Directive: Yes.

Immunizations: Yes. Code Status: Full.

Culture/ Ethnicity /Nationality: Swedish Surgery Date: N/A Procedure: N/A

Religion: Catholic Type of Insurance: BCBS, Medicare

± 2CC: “Weakness” “Seeing double, headache” “Dizziness”

+3 HPI: OLD CART Onset: Patient started to experience her symptoms 5-6 months ago. Location: Patient states that she felt weak “all over my body.” The right side of her head was in pain and she claims her eyes were seeing double. Duration: According to the patient her symptoms were constant. Characteristics: The patient described her symptoms as “painful and sharp.” The pain in her head would radiate down theright side and lead to trouble swallowing and locked jaw. Associated/Aggravating Factors: According to the patient her symptoms would “worsen as the day progressed.”Relieving Factors: The patient claims that nothing would make her symptoms improve. Treatments: Because we can only relieve the symptoms of Myasthenia Gravis and not cure it, the patient is being treated To reduce the impact it has on her body. She is receiving Prednisone to suppress her immune system’s response as well As intravenous immunoglobulin therapy which temporarily changes the way the patient’s immune system operates. The Patient claimed that “I already feel 30% better” after she had been receiving a couple rounds of treatment.

University of South Florida College of Nursing – Revision May 2012 1

2 PMH/PSH Hospitalizations for any medical illness or operationDate Operation or Illness Management/Treatment

2013 Anxiety Lorazepam 2013 Mild Depression Not managed 3-4 years ago TIA Anticoagulants 6/26/13 Myasthenia Gravis Prednisone/IgG

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Father 54 Alcoholism

Mother ? TB

Brother 72 Cancer

Brother 74 AlcoholismSon 52 N/Arelationship

relationship

Comments: Patient couldn’t recall exactly how old her mother was when she passed away. Patient couldn’t recall what kind of cancer

her brother died from.

1 IMMUNIZATION HISTORY YES NO

Routine childhood vaccinationsRoutine adult vaccinations for military or federal serviceAdult Diphtheria (Date) Patient can’t recall date. Adult Tetanus (Date) Over 5 years ago. Influenza (flu) (Date) Last Flu Season. Pneumococcal (pneumonia) (Date) Patient can’t recall date.Have you had any other vaccines given for international travel or occupational purposes? Please List


1 Allergies or Adverse Reactions

NAME of Causative Agent Type of Reaction (describe explicitly)

Medications

Liptor Patient couldn’t recallZocor Patient couldn’t recall“Others I can’t UnknownRemember”

Other (food, tape, dye, etc.)

No known allergies

5 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis, prognosis or treatment) According to Heuther and McCance (2012, pp. 399), more common in women, Myasthenia gravis is an acquired chronic autoimmune disease mediated by antibodies fighting the acetylcholine Receptor (AChR) at the neuromuscular junction. The disease is characterized by muscle weakness and fatigability. Ocular myasthenia involves weakness of the eyelids and eye muscles, and, as in my patient, may include swallowing Difficulties. A defect in nerve impulse transmission at the neuromuscular junction leads to the post synaptic AChRs on The muscle cell’s plasma membrane to no longer be recognized as “self” which elicits the production of autoantibodies. Therefore, the binding of acetylcholine is blocked by IgG antibodies that fix themselves onto the AChR sites. This Ultimately leads to the destruction of receptor sites. The resulting destruction of sites then progresses to diminished Transmission of the nerve impulse across the neuromuscular junction and lack of muscle depolarization. MyastheniaGravis manifests clinically as muscle fatigue and general weakness. The muscles that tend to be affected first are in the Eyes, face, mouth, throat, and neck. Weakness of the throat muscles can make swallowing difficult. In my patient’s case,She lost 30 pounds over the last couple of months due to the difficulty of swallowing. Myasthenia gravis can be diagnosedSeveral ways. In the case of my patient, her blood work detected the presence of anti-AChR antibodies. The disease can Relapse and patients may experience symptom-free intervals ranging from weeks to months. Over time the disease can Progress, leading to death. Myasthenia gravis is treated using steroids, anticholinesterase drugs, and immunosuppressant Drugs. In my patient’s case, she is receiving immunosuppressants to alter her immune response (Heuther and McCance, 2012, p. 400).Heuther, S & McCance, K. (2012) Understanding Pathophysiology. 5thEdition.(pp.399-400) St. Louis, MO: Elsevier

Mosby Inc.

5 MEDICATIONS: (Include both prescription and OTC)Name Enoxaparin/Lovanox Concentration Dosage Amount: 40mg

Route: Subcu Injection Frequency: Daily

Pharmaceutical class: Antithrombotic/LMWH Home Hospital or Both: Hospital Indication: Prevention of VTE

Side effects/Nursing considerations: Dizziness, nausea

Name: Prednisone Concentration Dosage Amount: 20mg

Route: PO Frequency: Daily

Pharmaceutical class: Anti-inflammatory Home Hospital or Both: HospitalIndication: Variety of chronic diseases esp. neoplasticity

Side effects/Nursing considerations: Give with food.

Name: Temazepam Concentration Dosage Amount: 15mg

Route: PO Frequency: Daily at night

Pharmaceutical class: Benzodiazepines Home Hospital or Both: BothIndication: Short term management of insomnia


Side effects/Nursing considerations: Dizziness, drowsiness.

Name: Immune Globulin Concentration: 10% in 200mL Dosage Amount: 0.4gm/kg/day

Route: IV Frequency: Daily

Pharmaceutical class: Immune Globulins Home Hospital or Both: Hospital Indication: Pts with immunodeficiency syndromes who are unable to produce IgG antibodies

Side effects/Nursing considerations: Malaise, light-headedness


4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis) Diet ordered in hospital? Low Cholesterol, Low Saturated Analysis of home diet (Compare to food pyramid and Fat Consider co-morbidities and cultural considerations):Diet pt follows at home? Fruits: My patient did not mention any consumption of Breakfast: Coffee and a muffin. Spinach or oatmeal. Fruits in her diet. At her age she needs 11/2 cups daily.

Fruits can greatly decrease the risk of MI and stroke. I would recommend she incorporate more in her diet especially since she has had a stroke in the past. Vegetables: 2 cups is recommended daily for my patient.

Lunch: Ham sandwich with lettuce. Although she eats spinach in the morning sometimes, I am not convinced that she meets her requirements of vegetables. Eating more of this food group also decreases the chance of heart disease. Grains: 5 ounces daily is needed. If she has oatmeal for

Dinner: Sometimes nothing. Sometimes milk and cookies. Breakfast and has her ham sandwich than she meets her requirement. Perhaps she could have her ham sandwich on whole wheat bread instead of white. Protein: Although she has ham on her sandwich for lunch, I

Snacks: Applesauce/pudding/ensure. Do not think she meets her proteins requirements with that. She does occasionally consume ensure which has protein in it, although if she incorporated more high-protein foods in her diet she may have more strength, especially considering her diagnosis. Dairy: 3 cups daily are recommended. Because she does not meet this standard, she could incorporate more into her diet by eating yogurt, having a cup of milk a day, etc. Dairy is high in calcium so it is especially important to prevent osteoporosis in her old age. Oils: Her recommended “allowance” is 5 tsps daily. Too much oil in her diet can cause an increase caloric intake. However, since she has recently lost 30 lbs perhaps including more oils in her diet could be beneficial to her Overall strength.

2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) Who helps you when you are ill? “Friends” “Doctors”

How do you generally cope with stress? or What do you do when you are upset? “Used to talk, then we stopped” “I couldn’t cope eventually”


Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)“Overwhelmed with my health”

+2 DOMESTIC VIOLENCE ASSESSMENT Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are safe.”

Have you ever felt unsafe in a close relationship? _________No______________________________________________

Have you ever been talked down to?____No___________ Have you ever been hit punched or slapped? __No________

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? ___________No_______________________________ If yes, have you sought help for this? ______________________

Are you currently in a safe relationship? Yes

5 DEVELOPMENTAL CONSIDERATIONS: Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. DespairGive the textbook definition of both parts of Erickson’s developmental stage for your patient’s age group:Older adults need to look back on life and feel a sense of fulfillment. Success at this age leads to feelings of wisdom, while failure results in regret, bitterness, and despair.

Describe the characteristics that the patient exhibits that led you to your determination: I had to check both for my patient because she Is in limbo between the two. She would go from describing her happy life and all the things she has accomplished to alsoTelling me, very bitterly, about her hardships. I think that she is currently conflicted; however, now that she is on her roadto “recovery” I truly believe that she will start to look at the bright side of life more than not. She was very reminiscent When I was talking to her and I could feel her sort out her issues and accept her situation as we talked.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: The impact of this Disease on my patient is very intense. For a while she did not want to live anymore. It was hard for her to cope with beingtold nothing was wrong for so long. Now that she is being treated, she is appearing to be more optimistic about life. Shehas a great support system at home. +3Cultural Assessment: “What do you think is the cause of your illness?” “Disease, I don’t know”

What does your illness mean to you? “It meant that my life was over, and I was going to die”

+3 Sexuality Assessment: (the following prompts may help to guide your discussion)Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life. All of these questions are confidential and protected in your medical record”

Have you ever been sexually active?____Yes_____________________________________________________


Do you prefer women, men or both genders? __Men_____________________________________________________Are you aware of ever having a sexually transmitted infection? No____________________________________________ Have you or a partner ever had an abnormal pap smear?_________ No_______________________________ Have you or your partner received the Gardasil (HPV) vaccination? ___No________________________________________ Are you currently sexually active? _______No____________________When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? ____________N/A______________________

How long have you been with your current partner?______32 years__________________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? ________No___________________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?No


+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES: 1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? No If so, what? How much? For how many years?

(age thru )

If applicable, when did the patient quit?

Does anyone in the patient’s household smoke tobacco? If so, what, and how much? Has the patient ever tried to quit?

No

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes What? How much? For how many years?Wine Very little on special occasions (age thru )

N/A If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No If so, what?

How much? For how many years?(age thru )

Is the patient currently using these drugs? Yes No If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/RisksAlthough this patient feels weak and jittery, she is an independent walker and can ambulate with little assistance.

University of South Florida College of Nursing – Updated April 2012 8

REVIEW OF SYSTEMS (TO BE USED FOR DATA COLLECTION ONLY) General Constitution Gastrointestinal Immunologic

Recent weight loss or gain Nausea, vomiting, or diarrhea Chills with severe shakingIntegumentary Constipation Irritable Bowel Night sweats

Changes in appearance of skin GERD Cholecystitis Fever Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS Dandruff Hemorrhoids Blood in the stool Lupus Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis Hives or rashes Pancreatitis Sarcoidosis Skin infections Colitis Tumor Use of sunscreen SPF: 45 Diverticulitis Life threatening allergic reaction

Bathing routine: 1x daily Appendicitis Enlarged lymph nodesOther: Abdominal Abscess Other:

Last colonoscopy? Pt couldn’t recallHEENT Other: Hematologic/Oncologic

Difficulty seeing Genitourinary Anemia Cataracts or Glaucoma nocturia Bleeds easily Difficulty hearing dysuria Bruises easily Ear infections hematuria Cancer Sinus pain or infections polyuria Blood TransfusionsNose bleeds kidney stones Blood type if known: Post-nasal drip Normal frequency of urination: 4 x/day Other: Oral/pharyngeal infection Bladder or kidney infections Dental problems Metabolic/Endocrine Routine brushing of teeth 2 x/day Diabetes Type: Routine dentist visits 1-2 x/year Hypothyroid /HyperthyroidVision screening Intolerance to hot or cold

Other: Slight right facial droop OsteoporosisOther:

Pulmonary Difficulty Breathing Central Nervous System Cough - dry or productive WOMEN ONLY CVA Asthma Infection of the female genitalia Dizziness Bronchitis Monthly self breast exam Severe Headaches Emphysema Frequency of pap/pelvic exam Migraines Pneumonia Date of last gyn exam? 2012 Seizures Tuberculosis menstrual cycle regular irregular Ticks or Tremors Environmental allergies menarche age? 13 Encephalitislast CXR? menopause age? 50 Meningitis

Other: Date of last Mammogram &Result: 2-3 yrs ago. Negative. Other:

Date of DEXA Bone Density & Result: Pt counldn’t tell me.

Cardiovascular MEN ONLY Mental IllnessHypertension Infection of male genitalia/prostate? Depression Hyperlipidemia Frequency of prostate exam? Schizophrenia Chest pain / Angina Date of last prostate exam? AnxietyMyocardial Infarction BPH Bipolar CAD/PVD Urinary Retention Other:CHF MusculoskeletalMurmur Injuries or Fractures Childhood Diseases Thrombus Weakness MeaslesRheumatic Fever Pain Mumps Myocarditis Gout Polio Arrhythmias Osteomyelitis Scarlet Fever Last EKG screening, when? 6/26 Arthritis Chicken Pox


Other: Other: Other:

PHYSICAL EXAMINATION (TO BE USED FOR DATA COLLECTION ONLY ) Orientation and level of Consciousness: Alert General Survey: Height: 64 inch Weight:117.8 BMI: 20.21 Pain: (include rating & location)

1, headPulse: 84 BloodPressure: 104/69, right arm(include location)

Temperature: (route taken?)97.8o F, oral

Respirations: 17

SpO2: 98 Is the patient on Room Air or O2: RAOverall Appearance: [Dress/grooming/physical handicaps/eye contact]

clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] awake, calm, relaxed, interacts well with others, judgment intact

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud

Other:Integumentary

Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin

Peripheral IV site Type: 18 Location: Left peripheral atecubital fossa Date inserted: 06/26/13 no redness, edema, or discharge Fluids infusing? no yes - what?

Peripheral IV site Type: Location: Date inserted: no redness, edema, or discharge Fluids infusing? no yes - what?

Central access device Type: Location: Date inserted: Fluids infusing? no yes - what?

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness

Functional vision: right eye - left eye - without corrective lenses right eye - left eye - with corrective lensesFunctional vision both eyes together: with corrective lenses or NA

PERRLA pupil size / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches Weber test, heard equally both ears Rinne test, air time(s) longer than bone Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions

Dentition:Comments:


Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric Lungs clear to auscultation in all fields without adventitious sounds

CL – Clear Percussion resonant throughout all lung fields, dull towards posterior bases WH – Wheezes Tactile fremitus bilaterally equal without overt vibrationCR - Crackles Sputum production: thick thin Amount: scant RH – Rhonchi Color: clearD – Diminished S – Stridor Ab - Absent

Cardiovascular: No lifts, heaves, or thrills PMI felt at: Heart sounds: S1 S2 Regular No murmurs, clicks, or adventitious heart sounds No JVDRhythm (for patients with ECG tracing – tape 6 second strip below and analyze)

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]

Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3No temporal or carotid bruits Edema: +1 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]

Location of edema: ankles non-pitting

Extremities warm with capillary refill less than 3 seconds

GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly Liver span cmPercussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation

Urine output: Clear Cloudy Color: yellow Previous 24 hour output: N/AFoley Catheter Urinal or Bedpan Bathroom Privileges with assistance CVA punch without rebound tenderness

Last BM: (date 06 / 28 / 13 ) Liquid Color: Light brown

Hemoccult: negativeGenitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems Other – Describe:


Musculoskeletal: Full ROM intact in all extremities without crepitus- weakness in extremities Strength bilaterally equal at __4_____ in UE & __4_____ in LE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]vertebral column without kyphosis or scoliosisNeurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias

Patient experiencing numbness in feet.

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam

CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride

DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]Triceps: 1 Biceps: 1 Brachioradial: 1 Patellar: 1 Achilles: 1 Ankle clonus: positive negative Babinski: positive negative

+10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS: (include rationale and analysis) -CT of the brain showed chronic microangiopathic disease. This is actually a somewhat normal finding as we Age. However, since my patient has a history of a stroke, this could be a complication.

-Chest x-ray showed no acute cardiopulmonary disease. It is important to know everything that is going on witha patient, so this result confirms that she has no acute cardiopulmonary disease process going on.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:To manage the patient’s Myasthenia Gravis, she is receiving treatments that suppress her immune system’s Response to her disease. She is receiving prednisone and immunoglobulin treatment to alter how her body’sImmune system operates. When she is discharged she will require intensive physical therapy and occupationalTherapy.


2 Medical Diagnoses (as listed on the chart)

8 Nursing Diagnoses(actual and potential - listed in order of priority)

1.Myasthenia Gravis 1. Imbalanced nutrition less than body requirements related to dysphagia as evidence by recent drop in weight.

2. 2. Self-care deficit related to muscle weakness, general fatigue as evidence by need of assistance.

3. 3.

4. 4.

5. 5.


± 15 for Care PlanNursing Diagnosis: Imbalanced Nutrition…

Patient Goals/Outcomes Nursing Interventions to Achieve Goal

Rationale for InterventionsProvide References

Evaluation of Interventions on Day care is Provided

-Caloric intake will be adequate -Measure the patient’s body weight -Tracking of body weight daily -Patient’s body weight was taken To meet the metabolic needs. Every day. Helps to evaluate the success of And it seems that she is gaining -Improved energy due to increased -Perform nutritional consultation to The interventions. Weight slowly. Intake of food. Evaluate calories. -Nutritional consultation to -The healthcare team was aware

-Assess cough reflex and Evaluate calories gives the health- Of how many more calories she Swallowing disorders before Care team an idea of how many Should be consuming and is Administration by mouth. Calories the patient needs. Continually working of increasing-Give small meals eaten per- -Assessing cough reflex and Her intake. Interval if there is dysphagia. Swallowing disorders is extremely -The patient’s cough reflex is intact

Important to that the patient’s plan And she has problems swallowing Of care is tailored for them. At night time. The healthcare team-Small meals several times a day Tries to avoid giving her meds tooCan be easier and more achievable Late.For the patient. -Smaller meals are being given,

Although the patient continues to Not eat very much of her food.

± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)

Consider the following needs:□SS Consult: No*□Dietary Consult: Yes *□PT/ OT: Yes □Pastoral Care: No□Durable Medical Needs: No□F/U appts: Yes. □Med Instruction/Prescription: Yes

□ are any of the patient’s medications available at a discount pharmacy? □Yes □Rehab/ HH: No□Palliative Care: No


Nursing Diagnosis: Self-care deficit…Patient Goals/Outcomes Nursing Interventions to

Achieve GoalRationale for Interventions

Provide ReferencesEvaluation of Interventions

on Day care is Provided-Patient will be able to do at least -Give a patient a break in between -A break between events allows -Breaks were giving to the patient25% of the activities themselves Events. For the patient to rest and regain And she was allowed to rest and And dress up. -Demonstrate energy saving Some energy that was lost during Relax. -Patient will be able to plan when Techniques. Exertion. -The patient was educated aboutIs the best time to perform -Perform self-care for the patient -By teaching the patient energy The timing of her exertion and howActivities and when it is time to During a very excessive muscle Saving techniques, the healthcare To plan out her days.Rest. Weakness or include family. Team is providing the patient with -The patient was assisted the

-Create maintenance schedule A strategy to improve their Bathroom when she was feeling To the interval. Conservation of energy. Rather weak. Other than that she

-In the event of intense weakness, Was able to do most everythingIt is important to assist the patient Else.When they cannot do it themselves. -It was discussed with the patient -If a schedule is created that How creating a schedule for herIncludes when to exert and when to Daily activities can work to her Relax, the patient will have an Advantage in managing her Easier time managing their Weakness. Weakness.

± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)

Consider the following needs:□SS Consult: No*□Dietary Consult: Yes*□PT/ OT: Yes □Pastoral Care: No□Durable Medical Needs: No□F/U appts: Yes□Med Instruction/Prescription: Yes

□ are any of the patient’s medications available at a discount pharmacy? □Yes □Rehab/ HH: No□Palliative Care: No


Nursing Diagnosis: Patient Goals/Outcomes Nursing Interventions to

Achieve GoalRationale for Interventions

Provide ReferencesEvaluation of Interventions

on Day care is Provided

± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)Consider the following needs:□SS Consult □Dietary Consult □PT/ OT□Pastoral Care □Durable Medical Needs □F/U appts □Med Instruction/Prescription

□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No □Rehab/ HH □Palliative Care


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