NURS 3620 Health History Collection Pt. Initials: ____ Age: ___ Gender ID: ____ Actual Sex: ____ Race: _______________ Data Collection Date: _______ H

NURS 3620 Health History Collection

Pt. Initials: ____ Age: ___ Gender ID: ____ Actual Sex: ____ Race: _______________ Data Collection Date: _______

Health History

Allergies (Food, drug, or other serious history with reactions):

Past Medical History:
• List here and put year diagnosed
•
•
•

Past Surgical History (with dates):
•

Family Medical History (Maternal & Paternal hx x2 generations, siblings, offspring):
•

Past Social History:
Marital status: Religion: Occupation current/previous:

Tobacco use/amount/length: Alcohol/Illicit drug use/amount:

Mobility:
Activity (Up ad lib, total bed rest, etc.):
•

Ability to complete ADLs
•

Assistive Equipment Needed: (List type):

Other Therapies (Respiratory, PT, OT, Dressing Changes, Wound Care): PT, OT, Wound Care.

Pathophysiology (select one major co-morbidity from above list, describe and cite source):

Social Determinants of Health Affecting Care:

Economic Stability:

Education Access and Quality:

Health Care Access and Quality:

Neighborhood and Built Environment:

Social and Community Context:

Sister Roy:

Physiologic Mode Self-Concept Mode Role Function Mode Interdependence Mode
Focal Stimuli
Altered tissue perfusion r/t decreased peripheral blood flow secondary to scleroderma, AEB gangrene on fingertips.
Powerlessness r/t disease progression AEB words of discouragement.
Role failure r/t disease exacerbation secondary to disrupted role as primary income earner and inability to work.
Ineffective pattern of dependency and independency r/t functional capacity AEB performing ADLs with minimum assistance.
Effective Responses -Pt wears mittens to keep her hands warm which decreases her pain.
-Pt takes nifedipine daily which helps to dilate vessels so blood can flow.
-Pt attempts to ambulate daily to improve blood circulation.
-Pt seeks education about managing this disease.
-Pt states, “I’m ready to go to Touro and get started with rehab.”
-Pt understands that she will not have the same functional abilities that she did prior to the exacerbation of this disease.

-Pt applied for social security.

-Pt states, “I am in the process of canceling my insurance and getting Medicare to hopefully deduct some of my healthcare cost.”

-Pt retired early from her job once her disease became unmanageable. -Pt does as much as she can on her own to remain as independent as possible.

-Pt is very cooperate with staff when needing assistance.

-Pt can recognize when she is too weak to get out of bed on her own and calls for assistance.
Ineffective Responses -Pt states, “The cold water from the shower has my hands in so much pain.”
-Pt states, “I’m too tired to do my physical therapy today.”
-Pt’s pedal pulses are thready and weak bilaterally.
-Pt states, “I used to work 3 jobs now I can’t do anything.”
-Pt becomes withdrawn when discussing how to protect her skin’s integrity from further breakdown.
-Pt disregards the provider’s order to change positions in bed frequently. -Pt expresses sorrow about not being able to help her kids out financially anymore.
-Pt states, “I worked 3 jobs in 2020 so I could save and buy a house, but I ended up spending my savings on medical bills.”
-Pt is dismayed when recalling her last few weeks at work, stating that, “I couldn’t use my hands for anything because my fingers would hurt so bad, but I really was not ready to retire.” -Pt states, “I know how busy everyone is so don’t worry about coming help me shower. I think I can make it by myself.”
-Pt will take pain medication then try to ambulate alone.
-Pt is dependent on staff to care for her skin lesions.

Nursing Care Plan:
Assessment Nursing Diagnosis Objective Discharge/Teaching
Needs Interventions Evaluation
S: Pt reports a burning and tingling pain in her fingers and toes that gets worse when pt is cold.

S: Pt reports this pain as an 8 on a scale of 0-10.

O: Pt has dry gangrene on the 4th fingertip of each hand.

O: Pt’s extremities are cold and dry to touch.

O: Pt’s pedal pulses are a 1+. They are weak and thready upon palpation.

O: Pt has a stage 4 pressure injury on her left buttocks despite being up ad lib with assist.

O: Pt has areas on her lower legs that are pink and look like the beginning stages of skin breakdown.

Ineffective peripheral tissue perfusion r/t decreased peripheral blood flow secondary to Scleroderma, AEB paresthesia in hands and feet. STO 1- Pt’s pain rating will go from an 8 to 4 on a scale of 0-10 by the end of the shift.

STO 2-Pt’s extremities will feel warm and dry to touch 30 minutes after her shower. Pt will display an adequate comfort level.

LTO- Pt’s pressure injury will improve from a stage 4 to a stage 3 by discharge. 1. “Instruct the patient to inform the nurse immediately if symptoms of decreased tissue perfusion persist, increase, or return.” (Gulanick, Myers 2017)
Informing the nurse of worsening tissue perfusion can allow for early intervention and treatment to hopefully maintain/restore as much function to the extremity as possible.

2. “Educate patient about nutritional status and the importance of paying special attention to obesity, hyperlipidemia, and malnutrition.” (Wayne 2019) In my patient’s case, she needs to pay attention to manifestations of malnutrition. She has anemia which also negatively effects tissue perfusion due to lack of oxygen in the blood. Not getting enough iron and B12 will further worsen her condition and make it harder for her pressure injury to heal.

1. Administer medications as prescribed to treat the underlying problem, which in this case is her scleroderma.
• Specifically, her nifedipine, which is a vasodilator, will enhance arterial dilation and improve peripheral blood flow.
• Administer pain medication as needed.

2. Monitor room temperature and give patient extra bedding to support an adequate comfort level.
• Offer patient extra thick blankets.
• Make sure she has socks and mittens on or available.

3. Assess the patient’s pain.
• It is an aching pain?
• Is it a throbbing pain?
• Is it a burning/ tingling pain?

4. Assess the patient’s perception of the intensity of the pain using a standardized rating scale.
• Pain scale from 0-10, with 0 being no pain and 10 being extremely painful.

5.Assist with position changes.
• Make sure to remind pt to turn in bed often to prevent further skin breakdown.
• If pt is feeling too weak to turn herself, provide assistance.

6. Take vital signs every 2-4 hours and assess for signs of inadequate or worsening perfusion.
• Check capillary refill
• Grade peripheral pulses
• Assess skin color and temperature
STO 1- This objective was achieved by giving prn pain medication as well as giving the patient an extra blanket and gloves. The patient’s pain level went from an 8 to a 4, thirty minutes after these interventions. This objective was realistic and successful and does not require modifications.

STO 2- This objective was successful as the patient’s extremities were warm and dry to touch after warm shower and new bedding was provided. This objective was realistic and requires no modification.

LTO-This objective was not met because pt was discharged earlier than originally presumed. However, this objective was realistic and appropriate and does not require modification.
S: Pt states that she is “exhausted” after getting up and going to the bathroom.

S: Pt states that she feels “Short of breath” after ambulating.

O: Pt’s respiratory rate is 24 breaths per minute.

O: Pt’s blood pressure is 130/81

O: Pt ambulates very slowly and with extreme caution.

O: Pt’s pulse is 98 bpm.

Impaired physical mobility r/t hardening and tightening of the skin secondary to scleroderma, AEB impaired ability to do ADL’s w/o overwhelming fatigue. STO 1- The patient will be able to reposition herself from supine to a sitting position w/o becoming SOB, by the end of the shift.

STO 2- The patient will exercise daily within the limits of disease. The exercise will be going from supine to a sitting position then dangling her feet off the side of the bed for 5 minutes. She will demonstrate this technique properly before the end of the shift.

LTO- Patient will be free of complications of immobility by discharge. This will be evidenced by intact skin, absence of thrombophlebitis, normal bowl pattern, and clear breath sounds. 1. “Explain progressive activity to the patient. Help the patient or caregivers establish reasonable and obtainable goals.” (Gulanick, Myers 2017) Even small mobility interventions like dangling her feet on side the bed and changing positions is progressive activity which will benefit her condition.

2. “Instruct the patient or caregivers regarding hazards of immobility. Emphasize the importance of measures such as position changes, ROM, coughing, and exercises.” (Gulanick, Myers 2017) Making sure the bed is in the lowest position, that nothing is on the ground for her to trip over, and that she is actively participating in ROM activities will promote safety and mobility.

1. Assess the pt’s ability to perform ADLs effectively and safely daily.
• Grade muscle strength
• Assess ability to perform ROM to all joints
• Assess for drowsiness or fatigue before ambulating

2. Assess for developing thrombophlebitis.
• Calf pain
• Redness, localized swelling
• Homans’ sign

3. Assess skin integrity for signs of redness and tissue ischemia.
• The six P’s (pain, pallor, pulselessness, paresthesia, poikilothermia, and paralysis)

4. Perform passive or active ROM exercises to all joints.
• Promotes increased venous return
• Prevents stiffness
• Maintains muscle strength

5. Encourage ambulation and assist with initial position changes.
• Dangling legs of the bed
• Sitting in the chair
• Getting out the bed

6. Provide a safe environment.
• Bed rails up per protocol
• Bed at the lowest height
• Call light and other necessary items within reach
STO 1- This objective was successfully met by getting the pt to move around and reposition herself more often. I would encourage her to reposition when she was relaxed and not experiencing SOB. This objective was realistic with no modifications necessary.

STO 2- This objective was successfully met. The pt was able to demonstrate to me before the end of shift her performing this exercise No modifications necessary.

LTO- This objective was partially met. While the pt did not have any signs or symptoms of thrombophlebitis, she still had a pressure injury at discharge. She also had a normal bowl pattern. Pts breath sounds were improving but slight crackles were still heard in lower lung fields upon last assessment. I would modify this objective by aiming for improvement of these findings instead of absence, given the patients condition.

Medication Sheet (add additional rows as needed)

Drug Name (Trade and Generic)
Generic-Mycophenolate
Trade-Cellcept

Dose (mg), Route, Frequency
1,500 mg, PO, BID

Dilution: (What fluid and how much?)
N/A

Rate of Administration:
(Know for each IVF, IVPB, IVP)
Classification of Drug
Immunosuppressant

Action: Inhibits the body’s inflammatory responses that are mediated by the immune system. Can also be used after transplants to prevent rejection.

Why is your patient receiving this drug?
My patient is receiving this drug because she has an autoimmune disease. This means that her immune system is attacking itself. This drug weakens the immune system in attempt to suppress it.
Side Effects: Tremor, dizziness, insomnia, headache, fever progressive multifocal leukoencephalopathy, asthenia, paresthesia, hypertension, chest pain, hypotension, edema, nausea, vomiting, diarrhea, constipation, GI bleeding, UTI, hematuria, renal tubular necrosis, polyomavirus-associated nephropathy, leukopenia, thrombocytopenia, anemia, pancytopenia, rash, hypercholesterolemia, increased cough.

Nursing Implications: (how do you give it, any interactions, pt teaching)
-Progressive multifocal leukoencephalopathy may be fatal! Monitor pt for ataxia, confusion, apathy, hemiparesis, and visual problems. Must be reported to FDA.
-Obtain pregnancy test 1 week prior to initiation of treatment. Do not use in pregnant women.
-Toxicity is increased when taken with antiviral drugs.
-When given PO, do not crush, chew, or open capsule. Give alone for better absorption.

Vitals/Labs Monitored:
-CBC monthly during treatment

Drug Name (Trade and Generic)
Generic- Nifedipine
Trade-Adalat

Dose (mg), Route, Frequency
60 mg, PO, daily

Dilution: (What fluid and how much?)
N/A

Rate of Administration:
(Know for each IVF, IVPB, IVP)

Classification of Drug
Calcium channel blocker, antianginal, antihypertensive

Action:
Inhibits calcium influx across cell membrane during cardiac depolarization, relaxes coronary vascular smooth muscle, dilates coronary vascular arteries, and dilates peripheral arteries.

Why is your patient receiving this drug?
My pt is receiving this drug to relax her vessels and arteries to help promote blood flow. Commonly with scleroderma, the vessels in your fingers and toes will contract preventing blood flow, which can ultimately kill the tissue. This is what caused the gangrene on my pt’s fingers.

Side Effects:
Headache, dizziness, light-headedness, dysrhythmias, nausea, rash, pruritus, flushing, Stevens-Johnson syndrome, toxic epidermal necrolysis, exfoliative dermatitis.

Nursing Implications: (how do you give it, any interactions, pt teaching)
-With HF, stop use if peripheral edema, dyspnea, weight gain over >5lb, jugular vein distension, or rales occur.
-Stop use if rash develops suddenly.
-When given PO, do not use immediate release caps within 7 days of MI.
-Do not use sublingual caps to reduce severe hypertension, may cause death.
-Use as directed and do not discontinue abruptly
-Do not take with grapefruit juice

Vitals/Labs Monitored:
-Causes an increase in CPK, LDH, AST levels.
-Monitor for orthostatic hypotension

References
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier.
Nursestudynet@gmail.com. (2021, March 15). Scleroderma nursing care plans diagnosis and interventions. NurseStudy.Net. Retrieved September 29, 2021, from https://nursestudy.net/scleroderma-nursing-care-plans/.
Scleroderma Foundation Home Page – Scleroderma Foundation. (n.d.). Retrieved September 29, 2021, from https://www.scleroderma.org/site/SPageServer/;jsessionid=00000000.app30118b?NONCE_TOKEN=02A4E2991604F3A429F6A5E5152C07CB#.YVIzT9NKi3I.
Skidmore-Roth, L. (2021). Mosby’s Drug Guide for Nursing Students. Mosby.
Wayne, G. (2019, February 12). Ineffective tissue perfusion – nursing diagnosis & care plan. Nurseslabs. Retrieved September 29, 2021, from https://nurseslabs.com/ineffective-tissue-perfusion/.
Werdati, S., Pramanik, S., Maray, Piyu, Anniegrace, & Jolly, J. (2019, March 18). Impaired physical mobility – nursing diagnosis & care plan. Nurseslabs. Retrieved September 29, 2021, from https://nurseslabs.com/impaired-physical-mobility/.
Wielosz, E., & Majdan, M. (2020). Haematological abnormalities in systemic sclerosis. Reumatologia. Retrieved September 29, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362277/.