HEALTH ASSESSMENT

NURSING ASSESSMENT & NOTES

2/19 1600

Nursing Note: Client reports urge to void but is unable. Reports history of stress incontinence, "I had five children." Client also reports, “I am not a big water drinker, just with my medicines. I do like coffee, but I only drink 2 cups per day. I don't drink otherwise. Maybe juice at lunch and a glass of wine at dinner.” Nurse Practitioner called and notified of assessments. Awaiting prescriptions.

2/19 1600

Neuro/Cognitive: Alert and oriented x 4. PERRLA.

Cardiovascular: Normal rhythm, S1, S2.

Respiratory: Lung sounds clear; lung expansion is equal bilaterally; some upper airway congestion which the client reports as baseline.

Gastrointestinal: Abdomen firm and distended, bowel sounds + in all quadrants.

Genitourinary: Voiding small amounts every 6 hours. Denies urgency, frequency, hematuria, or leaking of urine. Does have hesitancy. No dysuria. Bladder scan at 1620 noted 465 mL urine in bladder after 1610 void in toilet of 45mL.

Musculoskeletal: Moving arms and legs, grip strength strong in hands, left dorsiflexion strong, right leg slightly weaker.

Pain: 2/10 “ache in the hip”

VITAL SIGN TREND

Date

Temp

HR

RR

BP

SpO2

O2

2/19 1600

98.7 °F (37.1 °C) Temporal

86

18

132/76

98%

RA

2/24 0900

98.7 °F (37.1 °C) Temporal

96

20

92/52

98%

RA

intake and output

Date

Intake Source & Amount

Output Source & Amount

Total

2/23 - 2/24 1900 - 0700

Oral – 180 mL

Void – 220 mL Bladder scan – 65 mL Void – 120 mL>

2/24 0700 - 1900

Oral – 320 mL

Void – 200 mL Bladder scan – 65 mL Void – 180 mL Void – 120 mL Bladder scan – 90 mL Void – 220 mL Refused Void – 120 mL Bladder scan 90 mL

PROVIDER PRESCRIPTIONS & NOTES

2/19 1700

Prescriptions:

· Tamsulosin 0.8 mg daily by mouth

· Bladder scan q8h

· For urine volumes greater than 350 mL, insert intermittent catheter and measure urine volume

· Consult physical therapy for pelvic floor protocol

· Encourage fluids

2/24 0915

Prescriptions:

· Reduce daily tamsulosin to 0.4 mg/day by mouth

· Hold 2/24 dose of tamsulosin

· Encourage fluids

· Maintain bed rest today with one-person assist to bathroom as needed.

· Encourage voiding every four hours

· Monitor urine output

LAB RESULTS

Date

Lab

Normal

Result

2/19 1700

Urinalysis

Color

Yellow

Yellow

Clarity

Clear

Clear

pH

4.5-8

5.2

Specific Gravity

1.005 - 1.030

1.024

Glucose

Negative

Negative

Ketones

Negative

None

Nitrites

Negative

Negative

Leukocyte esterase

Negative

Negative

DIAGNOSTIC TEST RESULTS

Date

Diagnostic Test

Findings

2/19 1700

Urine Culture

No growth

MEDICATION ADMINISTRATION RECORD

Medication

0900

Medication: Multivitamin Dosage: One Tablet Route: By mouth Frequency: Daily, morning Parameters: N/A

AFW

Medication: Vitamin C Dosage: 500 mg Route: By mouth Frequency: Daily, morning Parameters: N/A

AFW

COLLABORATIVE CARE

2/19 1500

Physical Therapy Note: Working with Mrs. Powell on ambulation, getting in and out of car, steps, and turns. Also consulted for pelvic floor exercises. Instructed on Kegel exercises and provided tracking grid and pamphlet with instructions. Will add to the Plan for Care and continue reinforcing frequent use of pelvic floor contractions. Maintaining one-person assist on all transfers and ambulation.

2/24 0930

Physical Therapy Teaching Plan:

· Instruct on effective voiding, which includes taking time on toilet, double voiding, leaning forward while on toilet, body positioning, gentle bladder pressure while voiding, warm cloths to the bladder.

· Consuming non-caffeinated fluids and increasing oral water intake.

· Encourage use of acetaminophen if pain while sitting on toilet or with pain assessment. Take 650 mg every 6 hours, not to exceed eight tablets (2600 mg) per day.

· Safety precautions with dizziness