Create an assessment in writing

1. Pick any chapter as your system to explore
2. Give a clear, detailed description of your patient (age, sex, ethnicity, neighborhood, living arrangement, health problems, etc.) and the problem(s) they are coming in for today.
3. Develop at least 5 specific questions that you would ask your specific patient about the identified problem(s).
4. Develop your plan of care/assessment for your patient for this visit.  Include all health promotion and preventative care as applicable. Indicate what method(s) you would use for your education:
   1. Develop an initial nursing diagnosis list
   1. What are your goal(s) for this patient for this visit
   1. What are your nursing Interventions, assessments performed and findings for this visit
   1. Evaluation of diagnoses list
   1. Revision of plan and goals
   1. Health promotion and prevention applicable for this patient overall
5. Develop a nursing care plan using nursing diagnosis

Very Brief Example Below:

Respiratory System:

84 year old white male who comes in to the clinic with new complaints of shortness of breath and cough.  He lives alone in an apartment in Washington Heights.  He has a history of smoking but has quit for the last 20 years. 

1. How long have you had this cough?
2. Are you coughing anything up?
3. Do you have any fevers?
4. Do you cough more while eating?
5. Are you short of breath at all times, lying down or with exertion?

Assessment plan:  Look at vital signs for today.  Assess patient’s overall appearance and work of breathing.  Assess chest (heart and lungs) completely.  Assess for new edema in lower extremities.

Interview assessment questions/answers:  He has had this new cough for about 2 weeks.  He reports that he is coughing up thick, yellow sputum mostly in the mornings but also throughout the day.  He does not have a thermometer at home so is unaware of any fevers.  He does cough some while eating and drinking.  He denies any congestion or other signs and symptoms.

Vital signs: Temp 99.8 oral, HR 86 regular, RR 20, B/P 110/76, pulse oximetry 90% on room air

Initial Medical Diagnosis List

1. Pneumonia
2. COPD
3. Aspiration 
4. Heart failure

Assessment and findings:

Low grade fever in clinic w/ vital signs

Productive cough reported

Hypoxemia as measured via pulse oximeter

Use of accessory muscles observed and reports shortness of breath

Dullness in right lower lobe with percussion

Diminished breath sounds in both bases of the lungs with auscultation

Airways cleared with simple cough

No edema in lower extremities with palpation

Heart assessment w/o murmurs, rate/rhythm regular

Further work up:

1. Chest X Ray
2. Sputum culture for infection
3. Swallow test for aspiration
4. Blood work
5. Overall safety in the home and need for any assistance (TUG testing)

Final working diagnosis:  pneumonia

Follow up results of swallow study to see if he is aspirating

Follow up results of sputum to identify any organisms

Follow up blood testing results indicating infection

Health promotion:

Remain upright for at least 30 minutes after eating

Take all prescribed antibiotics for the time prescribed even if you feel better sooner

Pneumonia vaccination if needed

Influenza vaccination if needed

Add PSA blood test with bloodwork today if needed

Colonoscopy if needed

Lung cancer screening at next appointment

Provided education with teach-back method for medication and post meal positioning

Provided education with written brochures for vaccinations

Appointment for colonoscopy and lung cancer screening

Plan of Care Template:

Nursing Diagnosis	Planning (Goal Setting)	Implementation (Intervention)	Evaluation
Impaired gas exchange related to altered oxygen supply related to pneumonia AEB abnormal breathing patterns, nasal flaring, and restlessness.	Patient maintains optimal gas exchange as evidenced by usual mental status, unlabored respirations at 12-20 per minute, oximetry results within normal range, blood gases within normal range, and baseline HR for patient.	Assess respiratory rate, depth, and effort, including the use of accessory muscles, nasal flaring, and abnormal breathing patterns.Monitor oxygen saturation continuously, using a pulse oximeter.Assess the patient’s ability to cough out secretions. Take note of the quantity, color, and consistency of the sputum.	Patient maintains his optimal gas exchange as evidenced by unlabored respirations, O2 sat > 92%, and restlessness resolved.