MEDICAL/SURGICAL
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
PATIENT DEMOGRAPHICS:
Student Name: Camille Gladney Clinical Date: 1/29/2025 Clinical Faculty Name: Getahun
Patient Initials: JE Admission Date: Allergies/Reactions to: NKA
1/28
Age: 67 Gender: F LMP: 2014
(Mark NA if not applicable)
Pain: scale used- 0-10 Gravida: Height: 157.48 cm
Location: Abdomen
Characteristics: Sharp Para: Weight: 68.4 kg
Rating: 7
Duration:
Non-verbal: AB: BMI: 27.6
Religion: How does it affect their care?
Pt is not religious
Cultural Considerations:
Pt has no cultural considerations
Psychosocial Considerations (family, financial, social, etc that may impact care and discharge planning)
Pt has 5 children, 3 of whom came to visit her. Spouse status unknown
CHIEF COMPLAINT: (in pt’s own words)
Dyspnea, cough, insomnia
HISTORY OF PRESENT ILLNESS: (How, when, where, what and why of the chief complaint)
Pt was driving to hospital due to dyspnea and insomnia. AKI and thrombocytopenia are also noted prior to
pts hospital visit
PAST MEDICAL HISTORY:
Stomach cancer
Cervical cancer
CURRENT ORDERS:
Diet: Regular IV access/fluids: RAC 20g
Activity: Bedrest Treatments: Medication, coughing, and deep
breathing
Vital Signs: q3hr O2: Room air
1 MSW 4/21
Isolation/Type: Neutropenic Other:
Risks: FALL High SKIN Bed sore, bruise Safety: Safety not at risk
risk
PATIENT ASSESSMENT:
VITAL SIGNS:
TIME BP TEMP HR RESP O2 SAT
0730 151/73 97.0 F 112 34 94
1000 147/83 97.8 F 119 29 95
1335 137/73 97.9 F 108 24 96
BLOOD GLUCOSE MONITORING:
COVERAGE
TIME BLOOD GLUCOSE
(Insulin type and amount)
NA NA NA
NA NA NA
NA NA NA
INTAKE AND OUTPUT:
INTAKE OUTPUT: Urine BOWEL MOVEMENTS
Breakfast: None Foley Voided Incontinent Last BM: continent Incontinent
Purewick Yes No 1/29 yes no
Lunch: 2oz sherbert Amount: 52mL Date: 1/29
Dinner: None Color: Dark yellow Amount: x1
Fluids: 35oz water Clarity: Clear Color: Brown
Enteral: (NG/PEG) None Symptoms: None Consistency: Formed
IV fluids-Type/Volume: Emesis: None Ostomy: None
250ml normal saline
NG: None
IV Push meds: None Drains: None
2 MSW 4/21
PHYSICAL ASSESSMENT:
(Complete head to toe assessment. WNL is not accepted. Normal is not acceptable. Please be specific.)
Neurological: Pt is AOx 2- person and place. Pt is capable of speaking, but gestures a majority of
Orientation, Level of the time during interactions. Pt can follow commands and has limited ROM in the
Consciousness LOC,
Speech, Affect/Behavior, legs. Equal pupils react to light accommodation. Pt follows commands
Appearance, Pupils, appropriately with no signs or complaints. GCS: 12
Ability to Swallow,
GCS (Glasgow Coma
Scale)
HEENT: Mucous membranes are moist, pink, and intact. No reports of ocular or nasal
Head, ears, eyes, nose, drainage. Symmetrical face with no lesions or scratches present. Upon palpation—
throat, neck, thyroid,
lymph nodes no abnormal findings regarding the thyroid or lymph nodes.
Respiratory: Rhonchus lung sounds in left lower lobe. Right Lung sounds clear. Pt on room air
Lungs Sounds, Oxygen, with SOB. Pt coughs up yellow-brown mucoid sputum. Pt has no chest tubes,
Cough, Sputum,
Symmetry, , Chest Tubes, drains, or dressing. Pt is not on ventilation or assistive devices. Pt is placed upright.
trach, Dressing Deep breathing and coughing is encouraged.
integrity?Mechanical
Support –Ventilator
SettingsNote: Anterior,
Posterior and Lateral;
accessory muscle use,
expansion, tactile
fremitus
Cardiovascular: Pt is tachycardic, average heart rate is 110. S1 and S2 heard upon auscultation. No
S1 S2; Rhythm & *Analysis murmurs or adventitious sounds heard upon auscultation. Peripheral pulses equal,
(PR Interval., QRS;
artificial devices, normal, bilateral. Cap. Refill is 3 seconds. No JVD. Pt has no heart devices.
peripheral pulses-grade,
edema, murmur, JVD,
capillary refill, IV Types:
Peripheral/central
Arterial Venous shunts &
Devices : AV Fistulas
Breast and Axilla Skin intact, no reports of pain or tenderness, no lesions, rashes, or swelling present.
Pain, tenderness, lesions, Pt ad a Medi port places on right side of chest. Port is not tender upon touch, no
lumps, swelling, rashes,
swelling, or irritation. Pt and pt family states that the port if for chemotherapy.
Gastrointestinal: Active bowel sounds x4Q, abdomen soft. No visible s/s of GI bleed. Pt has 7/10 pain
Bowel sounds, Abdomen when eating. Pt daughters informed the staff that the pain is caused by the pts
Soft, Non-tender,Non-
distended Nausea, stomach cancer. Due to stomach pain, pt has difficulty eating and has a poor
vomiting, or visible signs appetite. No ostomy bag, or NG tube present. Abdomen is symmetrical with no
of GI bleeding discolorations. Pt is passing flatus.
(oral/rectal) Ostomy
Type: Iliostomy,
Colostomy All GI
associated lines and
tubes go here! Nasal
Gastric(NG),PEG,
3 MSW 4/21
Genitourinary: Pt is continent. Pt has a Purewick due to high fall risk status. Low urine output with
Indwelling no pain during urination.
Catheter/Ostomy;
continent/incontinent;
Foley; lymph nodes;
Musculoskeletal: No joint swelling or tenderness. Pt has limited ROM in all extremities. Hand grips
Joint Swelling or and foot push/pulls are weak. Pt reports no pain, no numbness or tingling. Pt was
Tenderness; Range of
Motion(ROM) and/or not able to walk due to bedrest order. Pt is high fall risk.
Limitations in all 4
Extremities; Muscle
Weakness (NOT related
to Central Nervous
System Impairment)
Continuous Passive
Motion (CPM) Machine
FALL RISK Assessment
Scale: Safety assessment
and Transfer Method; use
of assistive devices
Pain Assessment: Scale used: 0-10. Pt reports a 7 on the pain scale. Pt grimaces when eating, pt
Pain scale used, rating, reports sharp pain in generalized abdominal area
location, characteristics,
duration, non-verbal,
exacerbating, relieving
factors.
Integumentary: Skin warm and dry. Intact without lesions or rashes. Pt exhibits bruising on right
Warm, Dry and Intact: and left hand from previous IV attempts, and left shin from bumping into furniture.
without rash/lesions or
discoloration. Pressure ulcers and edema not present. Braden scale: 13
Braden Scale Rating;
Pressure Ulcer Staging:
Stage I, Stage II, Stage III,
StageIV; hair, nails,
texture, lesions, nevi,
scars
Psychosocial: Erikson: Integrity vs. Despair
Erikson and Piaget Piaget: Formal Operation
developmental stages
Nutritional: Diet: regular
Diet type, amount eaten, BMI: 27.6, overweight
overweight, underweight,
4 MSW 4/21
MEDICATIONS:
**Don’t copy & paste**
(Include ALL medications patient is currently taking unless otherwise advised by instructor)
Trade Name: Condition That
Mechanism of Potential Adverse Nursing Implications
Patient is
Lopressor Action Effects & Patient Education
Receiving
Generic Name: Blocks beta-1 Medication For
Hypertension Bradycardia, Monitor bp, hr before
Metoprolol adrenergic hypotension, and after
Class: receptors, fatigue, dizziness, administration.
reducing heart bronchospasm, Educate about abrupt
Beta-blocker rate, myocardial heart failure discontinuing, raise
Dose: contractility, and worsening slowly (orthostatic
100mg
cardiac output, hypotension)
lowering blood
Is dose safe?
Yes pressure
Route:
Oral
Form:
Pill
Frequency:
BID
Trade Name: Mechanism of Condition That Potential Nursing Implications
Vancocin Action Patient is Adverse Effects & Patient Education
Receiving
Generic Name: Inhibits Pneumonia For
Medication Nephrotoxicity, Monitor renal
Vancomycin bacterial cell ototoxicity, red function.
wall synthesis man syndrome Educate pt to report
Class:
Glycopeptide antibiotic (if infused too ringing in ears
quickly), immediately
Dose:
500mg hypotension
Is dose safe?
Yes
Route:
IV
Form:
Power drug reconstituted
with Normal saline
Frequency:
TID
5 MSW 4/21
Trade Name: Mechanism of Condition That Potential Nursing Implications
Action Patient is Adverse Effects & Patient Education
Platelet transfusion
Receiving
Generic Name: Increase Low
Medication
platelet For Febrile reaction, Monitor for
Platelet transfusion circulating levels allergic reaction transfusion reactions,
platelet count, check baseline and
Class:
Blood Component which post-transfusion
Therapy promoting clot platelet count.
Dose: formation and Educate pt and pts
reducing family on signs of a
3,000 units bleeding risk reaction
Is dose safe?
Yes
Route:
IV
From:
Liquid blood product
LAB DATA & DIAGNOSTIC EVALUATION:
If the patient does not have recent labs/diagnostic tests,
Write what would be indicated for a patient with this diagnosis
Include diagnostic test like X-rays, CTs, and MRIs
Lab Data
Date Reason for lab: Normal Values Client Results Reason for abnormal results
(or n/a if normal)
LAB Ordered: WBC: 5-10 WBC: 11.91 bone marrow suppression
CBC Assess pts blood health RBC: 4.7-6.1 RBC: 2.99 (RBC + WBC, pt is on
Hgb: 12-16 Hgb: 9 chemotherapy),
Hct: 36-48 Hct: 27 thrombocytopenia (Plt)
Plt: 150-450 Plt: 7
Date Reason for lab: Normal Values Client Results Reason for abnormal results
Assess pts liver for (or n/a if normal)
LAB Ordered: dysfunction, toxicity, Creatinine: 0.6-1.2 Creatinine: 1.9
Renal organ impairment BUN: 7-20 BUN: 62 Acute kidney injury
function
Diagnostic Tests
6 MSW 4/21
Date: Reason for test: Nursing Considerations Client Results
Verify pts medical history, Consolidation in pts left lung- lower
Test Ordered Confirm Dx, ensure pt remains still, provide
assess and comfort for pt, educate pt anf
CT scan of lungs evaluate family on procedure
severity.
MEDICAL DIAGNOSIS:
List all current medical diagnoses.
MEDICAL DIAGNOSIS TEXTBOOK CLINICAL PICTURE CLIENT’S ACTUAL CLINICAL PICTURE
(Current) Include definition, signs, and symptoms What Signs and Symptoms your patient
that should be seen actually exhibited
Infection (bacteria, viruses, or Confusion (although it is
fungi) that inflames the alveoli in unconfirmed if it is caused by
the lung(s), which may fill with pneumonia or a different disease
fluids or pus. process), productive cough, SOB
Pneumonia Signs and symptoms: fever, chills,
cough, SOB, chest pain (worsens
with breathing or coughing),
confusion, fatigue
Acute fluctuating disturbance in Slight confusion, disorientation to
attention, awareness, and date
cognition.
Signs and symptoms: acute
Delerium confusion, difficulty focusing,
disorientation, hallucinations or
delusions, impaired memory
7 MSW 4/21
PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS:
List all nursing diagnosis relevant to patient condition & based on assessment
1. Ineffective breathing patterns RT impaired gas exchange AEB dyspnea and mucous cough
2. Altered nutrition RT abdominal malignancy AEB low appetite and pain when eating.
3. Impaired Skin Integrity related to immobility and thrombocytopenia, as evidenced by bruising easily
4. Risk for bleeding RT low platelet count levels
5. Risk for infection related to chemotherapy induced immunosuppression and low WBC levels
8 MSW 4/21
NURSING CARE PLAN
Student Name: _______Camille Gladney______________ Date: _____1/30/2025_____________Class: ___NUR258__________ Patient Initials: _____JE____
A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include “related
to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write at least one short term and one long term (“expected outcome”) measurable goal per
nursing diagnosis stated in terms of client achievement (“the client will…”). List at least 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific
rationale for selecting the action you will use to work toward that goal, along with the cited reference of that rationale. Evaluate if goal was met and list specific assessment data to
support it (How did you know goal was met?)
NURSING DIAGNOSIS EXPECTED OUTCOME NURSING RATIONALE EVALUATION
(NANDA APPROVED) (Measurable Goal with dates) INTERVENTIONS (Why are you doing this?)
(If goal not met, need to evaluate why?
ST: within time frame of (What do you plan to do for (Citation for each rationale) And what to do to meet goal?)
clinical the client to accomplish the
LT: can be outside of time goal? Be specific and include
frame of clinical time frames)
1. Ineffective breathing ST: Pt will demonstrate 1. Monitor RR, O2 stat, 1. Monitoring resp. status ST: Goal has been met
pattern RT impaired gas improved breathing and lung sounds q3hours helps assess effectiveness
exchange AEB dyspnea patterns with a of interventions and
and mucous cough respiratory rate of 18-20 detect early signs of
and O2 stat above 92% worsening manifestations
within 12 hours
2. Encourage deep 2. Deep breathing and
breathing and coughing coughing helps to
promote oxygen
exchange
LT: Pt will maintain (Overbaugh et al., 2021) LT: Ig goal not met, pt should
normal breathing increase fluid intake to thin
patterns with no signs of mucous, and should be reassessed
dyspnea or oxygen for worsening symptoms or possible
desaturation ↓ 92% airway obstruction
within 1 week
9
2. Altered nutrition RT ST: Pt will consume at 1. Collaborate with a 1. Dietitians can help with ST: Goal not met- consult dietitian
abdominal malignancy least 50% of a prescribed dietitian creating meals that are and pts primary care provider
AEB low appetite and diet within 12 hours easy for the pt to digest regarding discomfort while eating
pain when eating and nutrient-dense
2. Offer small frequent 2. Small frequent meals
meals may reduce discomfort
and improve intake
LT: Pt will increase food (Brown & Green, 2016) LT: If goal is not met, reassess pt to
intake and maintain see if weight is gained or food
stable weight within 2 intake has increased. Assess for
weeks discomfort
3. Impaired skin ST: Pts skin will remain 1. Perform new skin 1. Continuous assessment ST: Goal has been met
integrity RT immobility free from pressure ulcers assessment identify areas of
and thrombocytopenia or excessive bruising breakdown
AEB bruising easily within 12 hours
2. Reposition the pt every 2. Repositioning reduces
2 hours the risk of bed sores and
promotes circulation
LT: Pt will maintain intact 3. Implement fall 3. Fall precautions LT: if goal is not met, reassess pt
skin integrity, with no prevention strategies to prevent injury and positioning, and reeducate about
new bruising or lesions, minimize risk of injury additional bruising fall percautions
within 1 weeks (Overbaugh et al., 2021)
10
REFERENCES:
(APA format)
Brown, S. J., & Green, A. E. (2016). Principles of clinical nutrition for the cancer patient.
Springer Publishing.
Drug Bank Online | Database for drug and drug target info. (n.d.). Drug Bank.
https://go.drugbank.com/
Overbaugh, J.L.H.K.H.C. K. (2021). Lippincott CoursePoint Enhanced for Brunner & Suddarth's
Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer Health.
https://bookshelf.vitalsource.com/books/9781975186722
Vancomycin: Package insert. (2024). Drugs.com. https://www.drugs.com/pro/vancomycin.html
11
Care Plan Grading Matrix:
Section Score Possible Points
Demographic Data
10
Physical Assessment
25
Medications
10
Lab & Diagnostic Evaluation
5
Medical Diagnosis
5
List of Prioritized Nursing
5
Diagnosis One-part statements
Nursing Care Plan
• (3) 3 part nursing diagnoses
• (1) Short Term goal with
Evaluation
30
• (1) Long Term goal with
Evaluation
• (5) Nursing interventions for
each nursing diagnosis
Citations, References & APA
10
format
100%
Total
Comments:
12
