DEPARTMENT OF NURSING
CLINICAL ASSESSMENT TOOL
Subjective Data (Basic Conditioning Factors)
Date of Care: 10/03/09
Patient’s Initials: P. V.
Room #: 3114 Bed 1
Admitting Diagnosis: Pancreatitis
Developmental Stage (Erickson and Havinghurst): (List Developmental stage and tasks, assess each task) 1. Selecting a mate: Although patient is single, she has many friends. Patient was happy to introduce her friends that came to visit. Introductions were all made as friends, no boyfriend or husband mentioned. 2. Starting a family and raising children: Patient is not interested in these aspects of life. Patient is more concerned over her friends and their activities that they do together. 3. Managing home: While the patient lives alone, she would prefer to have a roommate to share housekeeping tasks and rent. 4. Taking civic responsibility: Patient is not interest in helping out community. 5. Starting occupation: Patient has been a Title Researcher for two years, she claims that it is just a job to pay the bills. 6. Finding congenial social group: Patient claims that she has a tight group of friends that she enjoys going out with. While the patient was agreeable, she wanted to be left alone.
The Erickson stage that the patient is in is adulthood; Intimacy vs. Isolation. I find that Miss F.V. to be in isolation, developmentally. She wanted no socialization from myself, lives alone, and works alone. She is not actively looking for a mate and was demanding to have her door shut my entire shift, which was the norm since she was admitted 20 days ago.
History of present illness: On 9/13/09 patient presented with severe ABD pain in ED. A computed tomography Scan (CT-Scan) of the abdomen and pelvis with contrast was performed; showing severe pancreatitis with prominent pancreas demonstrating significant edema. Moderate to large amounts of ABD ascites demonstrating simple fluid attenuation was noted. Peritoneal enhancement was predominantly noted within the left ABD, reflecting significant peritonitis. No bowel obstruction was noted and pancreatic necrosis was not excluded. Moderate bilateral pleural effusions were also noted.
Past medical history :
Irritable Bowel Syndrome
Cocaine use (1998)
Past surgical history:
Esomeprazole Mag Trihy
PRN Opioid Analgesic Ergocalciferol
Complementary/Alternative Medical Practices
Herbal Remedies: None
Vitamins/Minerals: Daily multivitamins
Health Care Systems (Current orders and role of health care members): Low fat diet
IV TPN@83cc/hr q24h
Double Lumen PICC line Left AC
Sociocultural / spiritual orientation: none
Family system: Patient has family support, however lives alone in a walk up apartment.
Patterns of Living:
A. Employment: Title Researcher
B. Education: Some college
C. Hobbies / interest: None
D. ETOH / drug use: Social only
Environment (Conditions of living and working): Client lives alone, although the answer changed from 9/13/09 to 9/14/09 to lives with a friend. Family is supportive. Friends are supportive.
Available Resources (Economic, personal, agencies): Primary Insurance: Primary Insurance is a HMO with BlueCross BlueShield.
Objective Assessment of the USCR's
Pt: F. V. Room 13314 Bed 1 Jennifer Hughes...
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