Patient Assessment and Care Planning Forms

Personal Profile

[Health History and Health Perception]

X , a female Saudi  patient .She is 50 years old . she came from the emergency department . Arrived on Sunday 22- 3-13 at 20:30 ,her vital signs : blood pressure is 130/ 81 mmHg, pulse is 96 beats / minute , temperature is 38 °C , and her Respiratory rate is 22 breath / minute . Patient came with a difficulty in moving her right arm and a pain in her right shoulder. She also complained being depressed. She had a lymph node dissection for breast cancer in her right breast from under her right arm a month ago. The patient had no history of psychological distress in the past. She had swellings and redness yet no neurological symptoms. She stopped taking antibiotics 10 days after the operation.
Initial Assessment
Relevant Medical History: patient had a lymph node dissection for breast cancer in her right breast from under her right arm a month ago. Reason for Admission: Shoulder pain with hot , redness and swelling . with postoperative diagnosis as having lymphydema and psychological distress.	Source of Referral: The patient and the doctor who is specializing in her situation Source of Information: The patient and her family .	Communication: Hearing Problems:    YES NO (if YES provide detail) Visual Problems:     YES NO (if YES provide detail)
Emotional State on Admission: Patient was worried and anxious about her health condition before and after the surgery . She suffered depression after having the surgery . She had worries about death or living in pain for long times. Awareness level:                      the patient's level of awareness and understanding of her health situation is good yet she needs special psychological care from physicians and nurses.	Medication: Prophylaxis (1 g ampicillin- Sulbactam) intravenously at anaesthesia. Cephalexin (capsules-500mg) every 6 hours Prophylactic Antibiotic Letrozole (tablets) (2.5 mg) once a day. Hormone treatment Emla (20g) once daily  Topical cream	Mobility:                                    YES NO Fall Risk done         (Comment)  Patient at risk of fall due to cellulites of lower limb- acute haematogenous, ankle and foot Moving and Handling assessment done:   YES NO (Comment)  Patient need assistance in dressing, eating and hand movements in postoperative stage .
Allergies                     YES        NO (if YES provide brief detail) Redness in skin due to swelling.	General Skin Condition: Skin Intact:                YES        NO (if NO provide brief detail) Condition of Pressure Points: Pressure Sore Risk Assessment Score (Comment)     the patient have a normal of pressure points because she can move well . Scale Used: Braden scale  Risk Status: patient is at risk of having skin infection complications.	Airway/Breathing/circulation: Airway          Breathing Difficulties      YES   NO (if YES provide detail) Smoker:         YES    NO (if YES provide detail) Heart Problems:      YES    NO (if YES provide detail)
Infection Risk:                        YES        NO In postoperative stage Patient is at risk of an infection at the site of the incision due to not having cleaning habits for hands or being in not clean environment.
Preliminary Pain Assessment: In preoperative stage patient has a severe pain in right arm and shoulder , now in postoperative stage patient also has severe pain in same location .

Student:………………………………     Date:……………… 

In-depth Assessment
Safe Environment (risks): Patient at risk of infection in intraoperative stage due to a lymph node dissection for breast cancer in her right breast from under her right arm. In postoperative stage patient at risk of infection due to the wound of the operation being liable to air and germs.		Elimination (including incontinence): Bowel Function: every 24 hours. Bladder Function: 7-8 times daily , continued  and urinary appearance is yellow .  Urinalysis: Within normal limits .		Pain: (use appropriate assessment tool) Location: Right  arm and shoulder. Severity: Severe pain ,  it  comes from swelling , and movements . And she takes intravenous advil ibuprofen  every 6 hours . Aggravating factors: daily life sensation. Frequency: before medication that is every 6 hours Patient’s description: severe pain
Skin: Skin is intact , red colour , warm. Wound Assessment (if applicable): Patient had a wound that had a long thin plastic drainage tube attached to a bottle in which fluid coming from the wound pours, it should have been removed after a week to ten days from the end of the operation , and she needed dressing change daily .		Level of orientation and neurological state: Patient is confused and depressed. She is suffering difficulties moving her right arm and shoulder, she has death fears and depression.  She came on foot
Diet: Antioxidants , with the adequate nutrients , vitamins , minerals, fruit , and vegetables . Low fat protein. Fluid intake is usually 6 glass of water daily . Nutrition/Fluid/Metabolism: She is obese class 1 Fluid intake is usually 6 glass of water daily . Weight: 126 kg   Height: 160 cm   BMI:49 Blood Sugar (if appropriate)  11.8 in preoperative stage                                           9.8  in recovery room                                           7.7 in postoperative stage		Communication: patient at risk of  mis communication due to depression and stress , patient can read and write Arabic and English . she is preferred to communicate with Arabic nurses.
In-Depth Assessment (continued)
Values-Beliefs-Culture: she is Muslim and it is important for her to do the five daily prayers and Veils from foreigners . Special Considerations:  The patient maintains a  personal hygiene . She does not eat sea food.	Sleep-Rest: patient sleep very well at night , she sleeps 8 hours almost daily and she takes some rest at afternoon .  she does not need any medication to help sleep .		Coping and stress tolerance: patient is coping well with her health condition , and she feels better gradually with therapy . she does not have any difficulties at hospitalization period, and she like nurses and communicates kindly with them . Perceptions of self and identity: She is a teacher patient has a large family that takes care for her responsibilities .
	Activity-exercise / mobility: she is a teacher in hospital she spends her time with her sister usually and talks a little. she is doing some  activities with Physical Therapy
Family/carer perspectives and needs: Her husband will take care if she need discharge . patient was with social worker services about one hour , she was cooperating and deal kindly with her , she is giving  emotional support to patient. The key people of the patient is her husband and sister , they are very good at coping with the least difficulty. She communicates with them through the phone. They make regular visits to her.

Care Planning

Care Need / Problem / Potential Problem	Goals of Care	Nursing Actions	Evidence-base for Actions
Patient at risk of  increased of pain and infection related to right lymph node dissection for breast cancer in her right breast from under her right arm.	To prevent infection goal throughout hospitalization . To relieve pain and to present psychological therapy.	Nurse must observe the temperature and colour every 4 hours. Monitor for record signs of allergies from or around wound  and skin colour. Report abnormal changes in temperature. Use high hand hygiene techniques , or hand washing before and after patient care .	Giving careful assessment to patient ,  monitor the signs and symptoms of high temperature,  note the warmth of skin and assessing breathing by monitoring chest movements (Krag DN, Weaver DL, Alex JC, et al.) Observe factors of causing infections such as white cells of blood. (Schmitz KH, Ahmed RL, Troxel AB, et al.: 2010) Advising to use antiseptic solution , and teaching techniques of rubbing hands to maintain hygiene , having regular evaluation on patients hygiene techniques. (Miller SR, Mondry T, Reed JS, et al.1998)

Care Planning

Care Need / Problem / Potential Problem	Goals of Care	Nursing Actions	Evidence-base for Actions
		Encourage soy and beta-carotene foods or fluids , when indicated . Encourage patient for being careful in moving and helping her walk and eat. Provide adequate education for  patient and members of family to learn about the infection symptoms such as fever , swelling , redness , hot , etc . The persons who are liable to be infected should be banned from contact with patient. .	Observing patient weight and giving advice concerning health food habits. Observe food habits and ban bad eating habits. (rock CL, Doyle C, Demark-Wahnefried W, et al 2012)

I confirm that the work presented relates to a person in this unit who the student has cared for and is the work of the student

Mentor:………………………………              Student:……………………………………         

 

Care Planning

Care Need / Problem / Potential Problem	Goals of Care	Nursing Actions	Evidence-base for Actions
Depression distress	To help patients understand what depression is  and how it is treated, this including antidepressants, and provided strategies for problem-solving to help patients overcome their feelings of sadness, upset and helplessness.	Monitor patient's behaviour with others in clinic and record it daily. Educate patient about the advances and progress she makes daily in weight and health generally.	This is by detecting emotional distress to reduce psychological morbidity and collecting past information about the patients clinical experiences and if the curing climate was a financial stringency. (E.M.A. Bleiker et al.) . Review and document the current dietary goals with the patient and family, assessment of fat and blood sugar. Improve food habits, advise doing exercises, reducing bad food habits as fat and sugar high consuming. Getting rid of some weight by following  nutrients that are healthy .Giving some tranquilizers when needed. (Cimmino VM, Brown AC, Szocik JF, et al.2001)

 

Care Planning

Care Need / Problem / Potential Problem	Goals of Care	Nursing Actions	Evidence-base for Actions
		Observe and monitor the signs and symptoms of depression . Measure depression levels . Monitor and document patient's medication history , her understanding level and her submission .	Observe depression symptoms and signs regularly to stop any suicide attempts if occurred. Assessment of the patient involuntary symptoms such as straying, being anxious, having bad temper, being introvert, nervous and crying. Assess voluntary signs such as poverty of speech, psychomotor retardation, poor social functioning) document the result and make evaluation for them. Assess the patient information about her history of depression and how she deals with it and understand it. Document all necessary information in a file that is available when needed. (Prieto JM, Blanch J, Atala J, et al.2002)
Considerable disability due to Chronic pain	Identifying current sources of pain and help patient change life style in order to stop future pain problem.	Monitor patient response to treatment. Help using special techniques for letting patient get used to move her arm through simple easy exercises and give special sessions to train her. Encourage the patient to co operate with the physiotherapy. Checking fluid collecting around the wound if any.	assess  the patient condition through receiving treatment like Emla, her skin colour and her feel of pain and make assessment by questioning the patient about her feeling of pain and her comfortable positions.( Witt A, Yavuz D, Walchetseder C, et al.) Help patient to get used to light exercises and focus on gentle contraction of muscles. Teach the patient how to change bandages gently by wrapping the entire limb and make bandages tight around fingers and loose as patient move her arm. Making sure that fluid around the wound move away by using a special massage called manual lymph drainage.

I confirm that the work presented relates to a person in this unit who the student has cared for and is the work of the student

Care Need / Problem / Potential Problem	Goals of Care	Nursing Actions	Evidence-base for Actions
		Provide healthy dietary that helps raise patients endurance. Assist patient to use her arm easily with comfort and help eat and drink.	Monitor patient's eating habits as she needs to be stronger and consider having adequate food for helping getting rid of obesity. Provide help when needed to let patient use her arm in the way that does not cause pain. advise having special sponge baths instead of showers and provide help when needed.

Care Planning

Care Need / Problem / Potential Problem	Goals of Care	Nursing Actions	Evidence-base for Actions
Patient at risk of having  Hematoma	Provide care to prevent having hematoma	Provide guidelines to patient to use supportive brassiere. Monitor patients skin closure in order to prevent having seroma. Teach patients how to call nurses. Educate the patient and family about how to help the patient and not let her do hard works. Advise the patient about the necessary exercises to relieve pain and let muscles be in their best cases.	Assessing patient movements of her arm and shoulder while using a special support brassierewill bolster efforts in order to sustain hemostasis. This can help relieving the tension on the patient skin caused by the weight of breasts as she is fat.  Assessing the skin condition regularly and measuring temperature in order to prevent hotness and redness of the skin. Assess how the patient is comforted with nurses calling. Give enough information for family about how to let the patient rest and do her exercises to avoid future pain and complications. Guide the patient in doing the proper light exercises to have better muscles and reduces her weight.

Evaluation

Date and Time	Needs / Problem No	Comments	Signature
18 / 4/ 13 18 /4/13 10 /4/13 10/4/2013	1-Patient at risk of infection related to right lymph node dissection for breast cancer in her right breast from under her right arm. 2-Patient at risk of depression. 3-Patient at risk of Chronic pain disability. 4-Patient at risk of hematoma.	The risk of having infection decreased now due to monitoring patient's temperature, skin condition, food and hygiene habits and putting her in private room. Patient psychological state is now improving very well due to psychological sessions with the psychologist's techniques of psychological therapy and the intensive nurse help and advice. Patient now feeling comfortable due to light exercises and massage done with the use of Emla to relieve pain and due to the techniques and advice she learnt to use her arm and limb correctly. The patient now is feeling very well and her skin is not red anymore , she is comfortable with the use of the support bra and the wound site is not swelling at all.

I confirm that the work presented relates to a person in this unit who the student has cared for and is the work of the student

Mentor:………………………………              Student:……………………………………              Date: ………….

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