UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Gianna Constantine

PATIENT ASSESSMENT TOOL .

Assignment Date: November 3, 2015

Agency: St. Josephs Hospital

1 PATIENT INFORMATION
Patient Initials: AF

Age: 44

Admission Date: 10/29/2015

Gender: Female

Marital Status: Single

Primary Medical Diagnosis with ICD-10 code:

Acute Cholecystitis: K81.0

Primary Language: English

Level of Education: College

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Health Care Professional

N/A

Number/ages children/siblings: Two children (10 and 13); 5

brothers
Served/Veteran: No

Code Status: Full Code

Living Arrangements: Lives with her two children at an apartment

complex

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: 11/2
Procedure:
Laparoscopic Cholecystectomy

Culture/ Ethnicity /Nationality: African American

Religion: Baptist

Type of Insurance: UHC CHC CHC Plus Atlanta

1 CHIEF COMPLAINT:
Severe abdominal pain

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
This 44 year old, single, African American female presented to St. Josephs Emergency Department on October 29 th with
severe abdominal pain bilaterally. The pain started on October 27 th and was persistent. The patient described the pain as
stabbing, and then dull, and then sharp. Breathing aggravated the abdomen, and nothing made it better until she came to
the hospital and received pain medication. She originally believed her abdominal pain was gas pain, so she drank Ginger
Ale hoping that the pain would go away. However, after a full day of this pain, the patient determined that it wasnt gas
and figured it must be more serious, so she drove herself to the Emergency Department.
Patient was diagnosed with acute Cholecystitis after her CT scan on 10/29. And was scheduled for a laparoscopic
Cholecystectomy after her endoscopy (10/30) revealed that the patients gallbladder was severely damaged. Patient is
currently in pain post-op, she speaks quietly, and needs some assistance with the bathroom. Her pain medication relieves
some of the pain, and she will be discharged tomorrow.
The pain medication that the patient has been receiving is morphine.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation

Father

N/
A

Mother

54

Brother

64

Heart
Attack
N/A

Brother

55

N/A

Brother

53

N/A

Brother

52

N/A

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Asthma

Cause
of
Death
(if
applicable
)

Arthritis

2
FAMILY
MEDICAL
HISTORY

Anemia

Cesarean Section
Tubal ligation after cesarean section

Environmental
Allergies

9/2/2005

Alcoholism

Cesarean Section

Age (in years)

2002

Cancer

Operation or Illness

Bleeds Easily

Date

N/A

Brother

47 N/A
Comments: Include date of onset
Patient does not know her father.
Patient states that the mental health problems that her siblings have are not serious, they are just learning disabilities.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

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NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKA
Medications
Environmental
allergies (dust,
pollen, etc.)

Other (food, tape,

latex, dye, etc.)

Chronic sneezing

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
In most patients, acute Cholecystitis is caused by gallstones. Gallstones will cause a physical obstruction in the
gallbladder, resulting in increased pressure. If there is complete obstruction and it is of long duration, the patient will
develop acute Cholecystitis (Gadacz et al, 2007). The longer the patient waits to receive treatment, the more serious the
Cholecystitis is, and side effects start to occur. In my patients case, the surgeon stated that if she had waited a day or two
longer to have the surgery, she would have suffered serious side effects because of how seriously damaged her gallbladder
was. There are four types of acute Cholecystitis, and my patients type was emphysematous Cholecystitis. In this type, air
appears in the gallbladder wall due to an infection with anaerobes. This form typically progresses into sepsis and
gangrenous Cholecystitis, and is often seen in diabetic patients (Gadacz et al, 2007). Although my patient does not have
diabetes, she does have a family history. The prognosis for acute Cholecystitis reveals a mortality rate of 0-10%.
Comorbidity such as diabetes increases the mortality rate. Acute Cholecystitis is typically treated with a cholecystectomy.
Post-operation complications include cholangitis after cholecystectomy, but it is difficult to determine if a patient will get
it.

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name: pantaprazole (Protonix)

Concentration (mg/ml) .4 mg/mL

Route IV injection

Dosage Amount (mg) 40 mg

Frequency Daily

Pharmaceutical class: proton pump inhibitors

Home

Hospital

or

Both

Indication: Prevention of stress ulcers that are typically acquired in the hospital.
Side effects/Nursing considerations: pseudomembranous colitis. Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools can be signs of
pseudomembranous colitis. Patients receiving this medication IV should be converted to PO as soon as possible.
Name piperacillin-tazobactam (Zosyn)

Concentration 50mL

Route IVPB

Dosage Amount 3.375g

Frequency q6 hours

Pharmaceutical class Extended spectrum penicillins

Home

Hospital

or

Both

Indication: Community acquired and nosocomial pneumonia caused by piperacillin-resistant, beta-lactamase-producing bacteria.
Side effects/Nursing considerations: seizures, pseudomembranous colitis, toxic epidermal necrolysis, anaphylaxis, serum sickness; observe pt for signs and
symptoms of anaphylaxis, and d/c drug if rash, pruritus, laryngeal edema, wheezing occur. Keep epinephrine and resuscitation equipment close by. Monitor
bowel function and assess skin reactions.
Name morphine

Concentration 1 mL

Route IV injection

Dosage Amount 2mg

Frequency PRN

Pharmaceutical class: opioid agonist

Home

Hospital

or

Both

Indication: severe pain

University of South Florida College of Nursing Revision August 2013

Side effects/Nursing considerations: respiratory depression, constipation. Assess LOC, bp, pulse, and respirations before and periodically during administration.
If respirations are less than 10, assess level of sedation. Assess bowel function routinely. Might need to give patient laxatives in order to produce bowel
movements.

Name Dextrose 5% with .45% Normal Saline

Concentration 1,000mL

Route IV

Dosage Amount rate= 125mL/hour

Frequency infuse over 8 hours

Pharmaceutical class: carbohydrates

Home

Hospital

or

Both

Indication: Provides hydration and calories

Side effects/Nursing considerations: watch for fluid overload, hypokalemia, hypomagnesaemia, hypophosphatemia. Monitor intake and output and electrolyte
concentrations. Assess IV site frequently for phlebitis and infection. Assess patient for dehydration or edema.
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Was clear liquid, now low fat
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? Poor diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Bagel/Donut/Muffin
Patient does not seem to have a very balanced diet,
according to My Plate. She does not seem very concerned
Lunch: Chef salad
about eating whole grains, fruits, or dairy.
The patient seems to eat the majority of her vegetables and
protein for dinner, but that is the only time she seems to eat
food without empty calories.
Dinner: Salmon with collard greens, cabbage, beans, rice
The chocolate snacks that the patient randomly eats
throughout the day are also not good for her current
condition.
Snacks: Mini snickers
Liquids (include alcohol): Water, tea

Patients cultural stance does not seem to affect her

nutritional status.
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
-Her sons and their father
How do you generally cope with stress? or What do you do when you are upset?
-I go to sleep or I resolve the problem.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
-Anxiety due to the pain and her surgery

+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__________

University of South Florida College of Nursing Revision August 2013

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

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:

Generativity refers to making your mark on the world through caring for others, creating things, and accomplishing
things that make the world a better place (Cherry, 2015).
Stagnation refers to the failure to find a way to contribute. These individuals may feel disconnected or uninvolved with
their community and with society as a whole (Cherry, 2015).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

- I believe my patient is in the generativity stage because she is so involved with her children and cares for them so much.
I can tell that my patient wants to help her children grow and be the best possible versions of themselves. She also works
in the health field as a Certified Nurse Assistant, so caring about the lives of others is very important to her.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

-I do not believe that this hospitalization has impacted my patients developmental stage in life. She had a
cholecystectomy, and that is a procedure that does have an impact on a persons life, but not a large enough impact to
where she will have to drastically change her daily routine. The patient will be able to go on living just fine, and will not
be held back developmentally.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Eating the wrong foods an unhealthy diet.
What does your illness mean to you?
I dont know how to answer that

+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? _Yes______________________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? None______________________________
How long have you been with your current partner? 10 years_________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? Her recent cholecystectomy__

University of South Florida College of Nursing Revision August 2013

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
-Patient wants to know why her vagina wont stay wet and juicy anymore. Wants to know why that happens with age.

University of South Florida College of Nursing Revision August 2013

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
A lot. It is very important to her. I pray, my kids pray, and I came from a praying family and thats just what we do.
Do your religious beliefs influence your current condition?
Yes., as far as my healing.______________________________________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Will have Brandy when she drinks.
How much? (give specific volume)
1 shot (1.5oz or 44mL) in her mixed
drink. About 40% alcohol

For how many years?

(age

thru

-Currently socially
If applicable, when did the patient quit?
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
My apartment complex. I dont know that for sure, but theres definitely something.

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 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: Showers every day
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other: Endoscopy 10/30

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

5 x/day

Hematologic/Oncologic

Metabolic/Endocrine
2 x/day
2 x/year

Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other:

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam: Annual
Date of last gyn exam? 10/13
menstrual cycle
regular
irregular
menarche
age? 12
menopause
age?
Date of last Mammogram &Result: Last
year; normal
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain: 9
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision August 2013

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No

Any other questions or comments that your patient would like you to know?
No

University of South Florida College of Nursing Revision August 2013

10

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: A&O x3
Appears in pain
Temperature: (route taken?)
Oral 98.1

Height: 53
Pulse: 69
Respirations: 19

Weight: 190lbs BMI: 34

Blood
Pressure: 141/85 Brachial

Pain: (include rating & location)

9- stomach, back, head

(include location)

SpO2: 99
Is the patient on Room Air or O2: Room air
Overall 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
apathetic
bizarre
agitated
anxious
tearful
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: 22G

no redness, edema, or discharge

Location:

Fluids infusing?
no
yes - what? D5 with NS
Peripheral IV site Type:
Location:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Fluids infusing?
no
yes - what?

talkative
withdrawn

L forearm

quiet
boisterous
aggressive
hostile

Date inserted:

flat
loud

11/2/15

Date inserted:
Date inserted:

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
PERRLA pupil size 2 / 2 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without
nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 12
inches & left ear- 12
inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Teeth white, good oral hygiene
Comments: Patients surgical site has no redness, edema, or discharge. It is not bleeding and skin is intact around the incision.

University of South Florida College of Nursing Revision August 2013

11

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
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th intercostal space, midclavicular line
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 2+ Carotid:2+ Brachial: 2+
Radial: 2+
Femoral: 2+
Popliteal: 2+ DP: 2+ PT: 2+
No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color: dark yellow
Previous 24 hour output:
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 11 / 1 / 2015 ) Formed
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe: Patient is on menstrual cycle.
Cannot palpate abdomen due to recent surgery and abdominal pain

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __4____ RUE ____4__ LUE ___3___ RLE

& ____3__ in LLE

[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 scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias

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
Rombergs 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: +2 Biceps: +2 Brachioradial: +2

Patellar: +2

Achilles:

+2 Ankle clonus: positive negative Babinski: positive negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
HgB 8.7 L
10.9 L
13.6 Normal
11.5 L
9.0 L

Dates
10/30
10/31
11/1
11/2
11/3

Trend
Upon admit, the patients
HgB count was low, it
steadily got higher on
11/1, then went back low
again on 11/2

HCT 24.3 L
27.8 L
31.5 L
28.7 L
27.5 L

10/30
10/31
11/1
11/2
11/3

Upon admit, patients

HCT levels were low, and
they were getting better
until surgery, when the
levels started decreasing.

BUN 6 L
4.4 L
3.4 L
3.6 L
4L

10/30
10/31
11/1
11/2
11/3

Patients BUN levels got

low until surgery, and
then started increasing.
The low levels could
have indicated
malnutrition or a lowprotein diet.

Analysis
These levels can be
caused by gastrointestinal
blood loss/kidney
problems. Because the
patient had problems wit
her gallbladder, and just
had surgery, it makes
sense that her hemoglobin
levels would be off.
The patients red blood
cells in the blood got
increasingly better
throughout her
hospitalization, but after
surgery, the levels went
back down.
Since BUN levels are
getting back to normal, it
could mean that the
patients protein levels are
stabilizing, and the
patient is receiving more
of the correct nutrients.

Calcium 7.6 L
7.9 L
8.0 L
8.2 L
8.4 L

10/30
10/31
11/1
11/2
11/3

Patients calcium levels

have been gradually
increasing this admission.
Hypocalcemia on
admission could have
been caused by
malnutrition or the acute
Cholecystitis.

Albumin 3.2 L
2.9 L
2.6 L
2.5 L
2.4 L

10/30
10/31
11/1
11/2
11/3

The patients serum

albumin level has been
gradually decreasing
since admission.

Alk Phos

176 H
165 H
161 H
158 H
154 H

10/30
10/31
11/1
11/2
11/3

Patient came into hospital

with high ALP levels.
They have been gradually
decreasing throughout
admission.

Lymphs

17
23.4
27
16.3
11.9

10/30
10/31
11/1
11/2
11/3

Gradually increased until

surgery, then on 11/2,
levels shot back down.

Patient came into the

hospital with
hypocalcemia, and
because the patient has
been consuming the
correct nutrients
throughout this
admission, her calcium
levels are stabilizing.
Patients serum albumin
levels might be
decreasing due to the
shock from surgery. It
also can be caused by
inflammation or the
malnutrition that may still
be occurring in the
patients diet.
The patients high ALP
levels could have been
caused by biliary
obstruction or a fatty diet.
After treatment, the
patients levels have been
declining to reach
homeostasis.
The increase in
lymphocyte level could
have been caused by a
viral infection in the
gallbladder. After surgery,
the level went down and
that might be due to the
removal of the
gallbladder

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)

Educational video on pain management; ambulate 2x daily; out of bed to chair 3x daily; activity with
assistance; advance diet as tolerated end goal= soft low fat diet; compression device intermittent
pneumatic bilaterally routine; dressing change and clean incision with NSS; outpatient pharmacy consult;
vitals q4 hours; braden score daily; fall risk scale q12 hours.

 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1.Pain related to cholecystectomy as evidenced by verbalization of pain and decreased range of motion.
2. Impaired physical mobility related to cholecystectomy as evidenced by decreased range of motion, anxiety, and pain.
3. Risk for infection related to surgical incision as evidenced by open skin and limited bandage covering.
4.Risk for electrolyte imbalance related to not eating as evidenced by fear of eating post-surgery.

 15 CARE PLAN
Nursing Diagnosis: Impaired physical mobility related to cholecystectomy as evidenced by decreased range of motion, anxiety, and pain
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Short term: After 30 minutes of
nursing interventions, the patient
will verbalize understanding on
improvement of activity
intolerance within her limitation.

Establish rapport; monitor vital

signs; assess patient condition;
assess pain level

Patient will demonstrate a positive

emotional response after
cholecystectomy and will be
hopeful.

Assess emotional response to

cholecystectomy.

Long term: After 1 day of nursing

interventions, the patient will
participate in programs that will
enhance her physical abilities, such
as rehabilitation.

Adjust activities to enhance ability;

encourage patient to maintain a
positive outcome; assist patient to
learn and demonstrate safety
measures; administer medication
prior to activity as needed.

To establish nurse-patient
relationship; to establish baseline
data; pain is subjective data that
should be reported and used to
determine a patients pain level.
Pain may be causing the patient
fear of moving (Vera, 2013).
Feelings of anxiety and
powerlessness may impede
attainment of goals (Vera, 2013).

This was unsuccessful today, as

patient still had a lot of anxiety and
fear in response to her surgery.
Patient did not want to move
around too much because she was
too afraid.

To prevent fatigue and conserve

energy; to participate in activities;
to enhance sense of well being; to
prevent injuries; for pain relief
(Vera, 2013).

Was unable to determine if this was

successful or not because I was not
with the patient for more than 1
day. However, the patient did not
seem to show any interest in
physical activities due to her pain
and anxiety.

Patient had a negative emotional

response to cholecystectomy. She
feels that she will not be able to do
certain things like she used to prior
to the surgery (ex. Sex).

2 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 patients medications available at a discount pharmacy? Yes No

Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Pain related to cholecystectomy as evidenced by verbalization of pain and decreased range of motion
Patient Goals/Outcomes

Nursing Interventions to Achieve

Goal
Assess degree of pain; establish
rapport; note emotional responses
to problems of immobility; monitor
vital signs

Rationale for Interventions

Provide References
To establish nurse-patient
relationship; to establish baseline
data; to determine appropriate
interventions; feelings of anxiety
and powerlessness may impede
attainment of goals (Vera, 2013).

Patient will have a respiration rate

of less than 20 but more than 14.

Monitor vital signs.

If patients vital signs are in

between the range of 14-18, this
means the patient is breathing
normally without extra effort.
Higher respiratory rates may
indicate pain (Vera, 2013).

Long term: After 1 day postoperatively, the patient will

demonstrate movement and
behaviors that enable resumption
of activities.

Provide divertional activities such

as reading; provide nonpharmacological interventions such
as healing touch and frequent
change of position;

Short term: After 30 minutes of

nursing interventions, the patient
will be able to identify appropriate
measures in order to move safely
and freely.

Evaluation of Interventions on
Day care is Provided
After 2 hours of nursing
interventions, the patient will report
relief from pain. Patient did not
report relief from pain after two
hours this shift.

Goal was achieved this shift

because respirations were at 19, but
that level is still a little too high.
Patient also told me that she needed
oxygen while I was interviewing
her because it was too hard for her
to breathe.
To divert the patient from the pain
After 4 hours of nursing
they are feeling; to provide comfort interventions, the patient will report
(Vera, 2013).
that pain is being controlled
effectively. Patient did not report
that her pain was being controlled
effectively this shift.

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 patients medications available at a discount pharmacy? Yes No

Rehab/ HH
Palliative Care

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