ADULT /SURGICAL NURSING ASSESSMENT TOOL CLINICAL EXAMINATION

STUDENTS NAME: ABC NAME OF SCHOOL: West bay school of nursing

(Please tick appropriate box): 1st sitting 2nd sitting 3rd sitting
CLIENT DATABASE
DEMOGRAPHIC DATA
Name of patient (use initials) MUH AGE: 35 DOB: May 23,1982
Gender: Male Ethnicity: African descent. Admission Date: June 30, 2018
Time: 11:00am Number of days or months since admission: 3 days
Marital Status: Married. Occupation: Customer care rep
Religion: Christianity (Pentecostal).
Current living situation (environmental data, owns home, pays rent): Patient lives in a three-
bedroom rent house of concrete structure with his two children and baby mother. He receives
legal light from JPS, sewerage disposed of and running water in pipes from the NWC. Garbage is
collected every two weeks By NSWMA, OR burns garbage twice weekly.

HEALTH HISTORY: (symptoms and duration)

Reason for this (current) visit (primary concern /chief complaint): Shortness of breath and
leg edema x4/7 day.
History of present illness (what were the antecedents) (what they did before admisssion):
Patient was well ( or relatively well) until four days (PRIOR) to admission when he was arguing
with an employee at work and develop S.O.B. It was relieved by sitting up and aggravated by
lying down. It was associated with palpations, ne noticed the swelling of his legs at the same
time, 4 days (PRIOR), to admission but couldn’t say what brought it on or what made it worst.
(ALWAYS USE PRIOR TO ADMISSION) (KEY): IN THIS SECTION YOU MUST HAVE
THE FOUR MAIN THINGS: PRECIPITATING FACTOR, AGGREVATING FACTOR,
RELIEVING FACTOR AND (ASSOCIATED FACTOR---ANY SYMPTOMS WITH THE
MAIN SMPTOMS).

Cultural/Health concerns (relating to healthcare decisions, religious concerns, pain, child

birth, family involvement communication and so on): Patient doesn’t want to have treatment
involving surgery. OR Patient will not have any blood transfusion, patient doesn’t want anything
to relieve pain that involves injection OR Patient doesn’t want to be resuscitated if the need
arises, he doesn’t want to die in the hospital. If there are no cultural concerns JUST STATE: NO
CULTURAL CONCERNS EXPRESSED.
Previous illness: Hospitalization and surgeries (indicate date/year): Patient was hospitalized in
2000 for appendicitis and had appendectomy done at that time. Was also treated for allergic
reactions in 2012 but not hospitalized.
Client/Family medical history- (for e.g. Hypertension, diabetes, cancer and alcoholism):
Patient-HTN x10yrs
Family: Mother and brother has HTN, Father has Diabetes. Maternal grandfather has
hypertension.
Immunization/exposure to communicable disease: Patient can only recall receiving DPT
POLIO has no known contact with any communicable disease. E.g. TB AIDS/HIV. (DO NOT
WRITE IMMUNIZATION CARD NOT SEEN PATIENTS DON’T WALK WITH
IMMUNIZATION CARD TO HOSPITALS, DO NOT WRITE PATIENT IS FULLY
IMMUNIZED)
Allergies: No known allergies
Current Medications (note/compliance) (indications & side effects): Panadeine, Panadol,
omeprazole, flagyl. he claims compliance with medications. Based on medication Kardex,
patient has been fully compliant.
Developmental level: PLEASE STATE REASON FOR ANSWERS
Generativity patient is gainfully employed supports family and is contributing to society.

According to Erikson’s psychosocial stages of development, the patient’s focus at this age is on
intimate relationships; conflict is intimacy vs isolation. The patient is on the more favorable side
of intimacy because he is in a happy relationship with his baby mother and he plans on proposing
soon.
40-65 yrs- focus is on work and parenthood; conflict is generativity vs stagnation. The patient is
on the more favorable side which is generativity because the patient was able to provide
something of value as he is gainfully employed, supports family and is contributing to society by
paying taxes.
65 years+- focus is on reflection on life; conflict is ego integrity vs despair. The patient is on the
more favorable side which is ego integrity as he has lived a full life and feels a sense of
fulfillment by having assisted the needy in his community, is always smiling and states his job
was rewarding.
Psychosocial history: (state how the illness affects any relationship) e.g.

My wife has not visited me since hospitalization 10 days now because she is upset that am in the
hospital and won’t give her the bank book. OR my son has withdrawn since my hospitalization
because my wife works in the days and it’s the neighbor that keeps him.
(state how the patient copes with stress)
Patient admits to undergoing stress sometimes, as his job and baby mother can be stressful at
times. He tries to cope with his stress at work by taking breaks when tired, with his baby mother
by avoidance when she is miserable, and occasionally by smoking.
Socio-cultural history: cultural practices that may impact on health like alternative medicine or
the food they eat
Complimentary or Alternative therapy use: Occasionally approximately 3 months uses of
Cerasee and Moringa tea. Guinea hen weed root tea for pain, cerasee for purging blood.

Activities of daily living (Clients ability to care for self): Patient is able to care for self, able to
perform activities of daily living, but needs help sometimes to bathe and eat.
Patient is ambulant and self-caring.

Use /History of alcohol, drug abuse (including over the counter); Stopped drinking alcohol 10
yrs. ago doesn’t use drug or smoke for 5yrs.
Social history-job, smoke, married/single- flesh out and link-e.g. the patient
has been a smoker for 15 years leading to his hypertension.

Diet/ Nutritional history; Breakfast: coffee and toast bread with eggs.
LUNCH: Sautéed veg and grilled chicken with mango juice.
Dinner and supper Chicken pasta and bully beef and bread with choc tea.
patient states that he does not always eat breakfast during the week but when he does, it typically
consists of bread with eggs or sausage with milo tea, for lunch he buys box food of fried chicken
with rice and peas, and for dinner he has white rice or dumplings with fish or meat. He
occasionally eats vegetables.
Source of information; Patient Reliability Scale (1-4 with 4 = very reliable): 4
Current Medical Diagnosis/s: (from other health care personnel): DECOMPENSATED CCF
2’ HTN.
(PLEASE: CHECK DOCKET AND LOOK FOR THE LAST WRITTEN DOAGNOSIS AND
PLAN 4 THE PATIENT).
FINDINGS ON ADMISSION: Compare initial findings with that of the current diagnosis.
E.g. O/A the initial diagnosis was Plueral effusion following further test it was changed to
Decompensated CCF 2’ HTN. ALWAYS CHECK TO ENSURE THE MEDICAL DIAGNOSIS
ARE MATCHING UP CHECK WARD GUIDE TO DOCKET.

Current medical Management (including medication): Maintain bedrest, weigh alternate

days, Restrict Na + fats.
Commence ant failure therapy: Lasix, Digoxin and Slow k. Add Captopril to regimen.
Patient is on antibiotics for prophylaxis, or an infection. What is the plan, the way forward and
what is done already?
State medication indications and side effects

INVESTIGATION: (write labs, their interpretation and their significance): a CBC was done

and the results show that platelets were low indicating the patient has reduced clotting factors,

this being at a high risk for bleeding. This was an important test to be done, as a CBC is done to

monitor your health if you take medicines that increase or decrease your blood cell levels.

Lab results esp.: WBC, PLATELETS

Procedure: CXR, U-Sound, ECG.

Please know lab values you might be able to retrieve a diagnosis from it depending on the

patient’s values.

Ethical and Legal considerations: The patient’s consent form is signed

Ethical considerations:
- Veracity was maintained: I was honest about the side effects of the medications
 - Beneficence: I was doing good as I conducted health promotion teachings, ensured
privacy, and advocated for the patient when needed.
- Non-maleficence: I ensured no harm was done as I ensure to promptly update the RN
with my abnormal patient findings, promoted safety by preventing falls by ensuring bed
rails were up, prevented hypoxia by ensuring patient does deep breathing and incentive
spirometry.
- Fidelity: I adhered to what I told my patient I was to do for them- assessment, give
medication, dressing, TPC
Legal considerations:
- Justice: equal treatment was given to patients as the same levels of respect and dignity
was given to each, and excellent medical care was provided regardless of age, race,
ethnicity, or religious beliefs.
- Autonomy: I allowed the patient their right to make decisions regarding their care as I
asked the patient if they wanted their medication, ensure their consent form to care was
signed.
- Confidentiality: I ensured the patient’s information was not shared with anyone not
involved in the patient’s care unless consented by patient to do so as I used his initials
while presenting his information to examiners, and asked him if it was ok to update his
mother on his condition.
- Legal Documentation: everything that was done for the patient was documented with
date and time, and my signature at the end of each new entry.

Health Promotion teaching: teaching persons how to do these themselves: prevention of

disease, illness and injury
Prevention of post-surgery complications, promote physical and mental health
Find out if a patient is overweight, at risk of under-nutrition, physically inactive, daily smokers
or hazardous drinkers, how do they cope with stress and how often are they stressed.
Patients who did abdominal or chest surgery- Encourage breathing exercises such as
diaphragmatic deep breathing every hour and spirometry (to detect lung efficiency) to prevent
hypoxia post-surgery.
Promotes relaxation, improve lung expansion, helps the lungs to fill more efficiently: Deep
breathing
Promotes lung expansion to prevent lung infections like pneumonia after surgery: Incentive
spirometry
Prevent DVT: Early ambulation and lower extremity exercises done hourly.
Prevent infection: Encourage patient prevent dressing from getting wet, proper hand hygiene,
vitamin C
Promote abdominal wound healing- prevent Valsalva maneuver by splinting dressing with hands
at strong coughing, high fiber diet to prevent constipation. Encourage high calorie high protein
diet.
Blood sugar maintenance: diabetic low sugar diet, together with exercising, teach how to do
Blood sugar monitoring and administer insulin if not used to doing it. Avoid smoking, follow up
dressing at the clinic.
Reduce alcohol consumption to 1-3 days a week to prevent cancers, cirrhosis of the liver, high
bp, stroke
Smoking increases lung cancer, discolor teeth, delays healing as it may reduce the oxygen
carrying capacity of the blood, stroke and MI. advise persons with chest tube to refrain from
smoking and second hand smoke, avoid lying on tube, hold camber below heart, deep breathing
and coughing exercise.
DISCHARGE PATIENT HEALTH PROMOTION:
PHYSICAL ASSESSMENT

1) BRIEF HEAD TO TOE ASESSMENT & FOCAL ASSESSMENT OF PRIORITY

SYSTEM. State priority need and why
The focused system for the patient with diabetic infected foot is the cardiovascular. This
is so because overtime, high blood glucose levels result in damaged blood
vessels can become damaged which can lead to plaque forming in the blood vessels,
making them narrow, rendering them unable to deliver a sufficient amount of blood to
neighboring cells.
The priority need for this patient is oxygen (primarily admitted for infected foot that was
due to impaired peripheral circulation) or nutrition (the unstable blood glucose is not the
primary reason patient is admitted for)?
If the oxygen need is priority, I am not able to use ineffective peripheral tissue perfusion
because the goal cant be met in 4 hours, it’s long term and the interventions are geared to
health promotion- which requires teaching (making deficient knowledge a
priority)?????????????????????????????????????????????????

The focused system for bowel obstruction is the gastrointestinal

 2) Nursing Diagnosis: 3 diagnosis (minimum) ensure 1 actual and 1 risk is present.

QUESTIONS

For the chest tube patient, their oxygen need at the moment has been maintained and it is there

but not currently affecting them, so the next priority could be 1st? If the patient has a RR of 27

and SPO2 on and off O2 is 99%, is the NDx still ineffective breathing pattern? Still use said

NDx even if vitals are normal i.e. if rr is 20?

You can still use risk for infection even if patient is on Abx because an intervention is to

administer Abx, but it can’t be priority because Abx is maintaining the safety and security need.

So, for this said patient, if they are stable in general (spo2 99%, WBC in range), and without

complaints those above diagnosis could be used in same order priority. But if they are

experiencing pain, it would be priority. If ineffective coping instead of pain, would the coping be

1st priority? SAME for deficient knowledge on Tx, Condition, would either be priority over the

stable infection and oxygen need?

Blood sugar is a bit elevated (14.9mmol/L), should risk for unstable blood glucose be used? If

not, could risk for FVD if polyurea is associated? Risk for injury if dizziness/ weakness?

Patient with diabetes with infected foot due to decreased peripheral perfusion on heparin. We are

unable to improve tissue perfusion in 4hrs, intervention more long term and dependent on patient

actions (health promotion teaching) with blood thinner admin, could deficient knowledge be

used after asking patient if they know how to promote circulation OR readiness for enhanced
learning be used if patient says “I want to know how to enhance circulation in my foot/ how do I

enhance circulation in my foot?

WOULD RISK FOR DEFIECIENT FLUID VOLUME BE A PRIORITY RISK OVER a

high RISK FOR INFECTION? – in a patient with an ileostomy proximal to the abdominal
incision site, that is experiencing diarrhea.
- Patient risk for infection is reduced if they are on Abx (specially for preventing skin
infection for this case) however, if nothing has been done yet to reduce the risk for
FVD (like no maintenance fluids or oral hydration), this risk supersedes infection?

Use “recheck” a value if it was normal and not stated as an “AEB” in the diagnosis- as only

abnormal values are put there. E.g. SPO2 was checked and it was normal, for someone with

ineffective breathing pattern (increased RR), so rechecking the SPO2 is crucial in evaluating

IBP.

Use “reassess” for an abnormal value that was stated in the diagnosis. E.g. SPO2 was 90%, so

you reassess SPO2 bcuz it was abnormal and was an AEB in the diagnosis.

Use “monitor” when u need to recheck/ reassess more than once based on the

The priority need for this patient (diabetic infected foot) is oxygen (primarily admitted
for infected foot that was due to impaired peripheral circulation) or nutrition (the unstable
blood glucose is not the primary reason patient is admitted for)?
If the oxygen need is priority, I am not able to use ineffective peripheral tissue perfusion
because the goal can’t be met in 4 hours, it’s long term and the interventions are geared to
health promotion- which requires teaching (making deficient knowledge a
priority)?????????????????????????????????????????????????
To prioritize patients, use information from the change of shift report and patient’s acuity
level below:
 High risk patients:

Patients who have unstable vital signs, are on O2 via face mask, chest tube drainage greater than

50mls/hr- high risk for respiratory compromise, uncontrolled pain with multiple medications,

complicated post-op, active drainage (wound/ostomy/ continence); tid or change every 30mins.

Any one of these indicate high risk