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MrsNerVousReck

ER Assessment

Name: Mrs. NerVous Reck

Age: 54 years

Gender Identity: Female

Pronouns: She/Her

Address: 123 Anxious Lane, Worryville, CA 90210

Contact:

Presents with increasing abdominal distension and a low-grade fever.

Missed her scheduled peritoneal dialysis session two days ago due to nausea and fatigue.

Reports increased secretions from her tracheostomy and mild shortness of breath.

Temperature: 99.8°F

Pulse, BP, RR, O₂ sat: Not yet documented

Respiratory assessment priority due to trach and shortness of breath

Appears anxious and fatigued

Audible congestion from tracheostomy

Mild abdominal guarding noted

Alert and oriented x4

Tracheostomy in place (long-term)

Peritoneal dialysis catheter (PD cath) in abdomen

Reports abdominal bloating, pain and discomfort

Denies vomiting

Decreased appetite, general malaise

Enjoys reading and gardening (limited due to health)

Active in online book club since mobility became limited

Tobacco: Smoked 1 pack/day for 30 years; currently still smoking occasionally

Alcohol: Occasionally (1–2 glasses of wine/week)

Caffeine: 2 cups coffee/day

Recreational Drugs: Denies use

Lisinopril 10 mg daily (this morning)

Metformin 500 mg BID (this morning)

Sertraline 50 mg daily (this morning)

Insulin glargine 20 units at bedtime (last night)

Multivitamin daily (this morning)

Calcium carbonate 500 mg with meals (this morning)

Albuterol nebulizer PRN for shortness of breath (last used this morning)

Penicillin (rash)

Shellfish (hives)

Pollen (seasonal allergies)

Latex (General edema)

Flu vaccine: Oct 2023

COVID-19 booster: Jan 2024

On peritoneal dialysis x2 years for end-stage renal disease (ESRD)

Missed last dialysis session due to nausea and fatigue

Increasing abdominal distension, low-grade fever, and trach secretions

History of Type 2 Diabetes Mellitus and poor glucose control

Ongoing management of chronic respiratory insufficiency due to long-term smoking

Type 2 Diabetes Mellitus (diagnosed at age 45)

Hypertension (diagnosed at age 40)

End-stage renal disease (diagnosed at 52)

Chronic obstructive pulmonary disease (COPD), oxygen-dependent at times

Tracheostomy placed 1 year ago due to prolonged intubation and respiratory failure

Cholecystectomy at age 50

Hysterectomy at age 48

Tracheostomy at age 53

G2P2, no miscarriages or abortions

Generalized Anxiety Disorder (diagnosed at 38)

Hospitalized at 42 for acute anxiety

Ongoing SSRI therapy and counseling

Mammogram: March 2023 (Normal)

Colonoscopy: June 2022 (Normal)

Mother: Deceased at 78 (heart disease)

Father: Deceased at 80 (stroke)

Brother: Age 60, healthy

Children: Ages 15 and 12, both healthy

Married for 25 years, lives with spouse and children

Was primary caregiver for her mother until her passing

Reports frequent stress and anxiety related to chronic illnesses and caregiving role

Follows renal and diabetic diet

Monitors blood glucose and BP regularly

Missed last dialysis appointment

Uses deep breathing and meditation for anxiety

Currently non-compliant with smoking cessation despite education

Patient is primary informant. Occasionally supplemented by spouse (Mr. Jerry Reck, husband of 25 years).

"I didn’t feel well enough to do my dialysis. My belly feels tight and warm."

Needs tracheostomy care and monitoring to maintain airway and prevent complications.

Suspected peritonitis secondary to missed peritoneal dialysis session in the setting of ESRD.

Type 2 Diabetes Mellitus

Hypertension

Generalized Anxiety Disorder

Tracheostomy status (chronic)

History of smoking (30 pack-years)

Obesity

Chronic fatigue

Penicillin → Rash and hives

Date Noted: Approx. age 35

Reviewed: Yes

Allergen added/edited: Yes – documented in EMR

Also allergic to shellfish (causes hives) and pollen (seasonal)

Location:

  • Lower abdomen, centralized around peritoneal dialysis site. No radiation to back or chest. Ostomy site non-tender.

Duration:

  • Symptoms began approximately 24–36 hours ago.
  • Increasing distension, mild nausea, and loss of appetite noted since missing dialysis 2 days ago.

Timing:

  • Worse in the evening, after meals and during dwell times.
  • Pain more noticeable when changing positions or doing dialysis exchanges.

Quality:

  • Constant dull ache, described as “tight” or “bloated,” with intermittent sharp jabs.

Severity:

  • Pain rated 4/10 at rest, 6/10 with movement or during PD exchange.
  • Able to sleep lightly, but fatigue increasing due to discomfort and malaise.

Description of Illness:

  • Reports feeling unwell and too nauseated to complete PD 2 days ago.
  • Did not notify home dialysis nurse.
  • Over the past day, has experienced low-grade fever, abdominal bloating, and generalized weakness.

What Makes It Better/Worse:

  • Worse: Movement, peritoneal fluid dwell time, sitting upright
  • Better: Lying still, rest, warm compress

Signs and Symptoms:

  • Low-grade fever (99.8°F)
  • Abdominal distension
  • Mild nausea, no vomiting
  • Decreased appetite
  • Fatigue and general malaise

Comments:

  • States, “I just couldn’t bring myself to do the dialysis. I felt so tired.”
  • Mild anxiety about condition worsening.

Interpretive Services Needed:

  • No – English is primary language

Admitted Via:

  • Emergency Department (ED)

Admitted From:

  • Home

Contact Person:

  • Jerry Reck (Spouse) – Primary caregiver, emergency contact

Orientation to Environment:

  • Patient oriented upon admission
  • Provided safety instructions, nurse call button, and explained surroundings

Belongings Accompanying Patient:

  • Reading glasses
  • Cell phone
  • Personal pillow

Valuables – Disposition:

  • No valuables declared
  • Wearing only hospital gown and personal undergarments

Valuables – Comments:

  • Patient keeps valuables at home; states, “I don’t bring anything important with me.”

Which Do You Have?

  • Durable Power of Attorney (Medical)
  • Living Will

Comments:

  • Copies on file at primary care clinic; patient aware of choices and prefers comfort measures if prognosis is poor

Marital Status: Married (25 years)

Primary Language: English

Preferred Language if not English: N/A

Educational Level: Some college

Religion/Spirituality: Christian – attends church occasionally

Occupation: Retired administrative assistant

Race/Ethnicity: White / Caucasian

Comments: Former caregiver for elderly mother; finds purpose in helping others despite personal health struggles

Lisinopril 10 mg daily

Metformin 500 mg twice daily

Insulin glargine 20 units at bedtime

Sertraline 50 mg daily (for anxiety)

Calcium carbonate 500 mg with meals

Multivitamin daily

Albuterol nebulizer PRN

Occasional acetaminophen for discomfort

Head, Face: Normocephalic, symmetrical, slight facial puffiness; anxious expression

Anterior Fontanel: Not applicable (adult)

Neck: Tracheostomy present with redness and mild swelling around the site; neck ties secure; limited ROM due to discomfort

Comment: Tracheostomy site has serous drainage, surrounding erythema—monitor for infection

Eyes: Pale conjunctiva; PERRLA

Eyes Comments: Pale conjunctiva may indicate anemia from ESRD

Ears: No drainage; dry cerumen noted

Ears Comments: Bilateral hearing WNL, reports occasional tinnitus

Nose, Throat: Dry mucosa; foul breath odor (uremic fetor); tracheostomy affects speech

Nose, Throat Comments: No sinus tenderness, speech slightly hoarse due to trach

Level of Consciousness: Alert

Orientation: Oriented x4 (person, place, time, situation)

Cognitive: Mildly slowed responses; appropriate thought process

Speech: Slightly hoarse, soft due to trach

Pupil Response: Brisk and equal

Pupil size (mm): 3 mm bilaterally

Deep Tendon Reflexes: WNL

Neurological Comments: Mild tremor in hands possibly from fatigue or glucose variation

Best Eye Response: 4 – Eyes open spontaneously

Best Verbal Response: 5 – Oriented and converses normally

Best Motor Response: 6 – Obeys commands

Glasgow Total: 15

Interpretation: Normal

  • Respiratory Effort/Pattern: Mildly labored with exertion
  • Breath Sound, Comments: Diminished bases, coarse crackles upper lobes
  • Cough: Productive cough
  • Sputum: White, thick
  • Respiratory Airways/Drains: Tracheostomy in place
  • Respiratory Interventions: Trach care, humidified oxygen PRN, cough coaching
  • Intervention, Comments: Suctioning performed this shift, tolerating well
  • Airway/Drain Comments: Neck ties secure; monitor for further redness or drainage
  • Oxygen Source: Room air, humidified trach collar PRN
  • Oxygen Rate & Comments: O2 sat 92% RA; oxygen PRN at night via trach collar at 2 L/min

Cardiac Rhythm/Sounds: Irregular rhythm; S1/S2 present, no murmurs

Cardiac Symptoms: Fatigue, mild lower extremity edema

Monitors/Telemetry?: No telemetry in use

Cardiac Comments: Monitor for fluid overload related to ESRD

RUE: Cap refill >3s, radial pulse weak

LUE: Cap refill >3s, bruising from prior blood draws

RLE: Mild edema, pedal pulse weak

LLE: Mild edema, pedal pulse weak

Comments: Skin cool, pulses diminished—vascular compromise related to renal disease

  • Skin Color: Yellowish-brown (uremic tint), pallor
  • Skin Temperature/Condition: Dry, cool to touch
  • Skin Turgor: Slightly decreased (dehydration risk)
  • Skin Comments: Scarring from multiple surgeries; at-risk for pressure ulcers
  • Braden Scale:
    • Sensory perception: 3
    • Moisture: 2
    • Activity: 2
    • Mobility: 2
    • Nutrition: 2
    • Friction and shear: 2
    • Total Score: 13
    • Risk Level: Moderate
    • Braden Comments: Encourage repositioning q2h; protective dressing over sacrum

RUE: Full ROM, mild tremor

LUE: Full ROM, slight weakness

RLE: Slight weakness, shuffles when walking

LLE: Same as RLE

Musculoskeletal Comments: Uses walker at home, unsteady gait, fatigue with ambulation

History of falling: Yes (within past 6 months)

Secondary diagnosis: Yes (ESRD, DM, anxiety)

Ambulatory aid: Uses furniture or walker

IV/Saline Lock: Yes – saline lock in R forearm

Gait/Transferring: Weak gait, needs support

Mental Status: Forgets limitations when anxious

Total Score: 60

Risk Level: High

Comments: Fall risk protocol initiated (bed alarm, close observation)

  • Abdomen: Distended, firm but not rigid
  • Bowel Sounds: Hypoactive in all 4 quadrants
  • Passing Flatus: No
  • Last Bowel Movement: 3 days ago
  • GI Comment: Peritoneal catheter site intact with healed scar tissue; reports nausea and bloating

Urinary Symptoms: None (anuric)

Urine Color: N/A

Urine Characteristics: N/A

Last Menstrual Period: Hysterectomy at age 48

GU Comments: On peritoneal dialysis for 2 years, no urinary output

Pain Location: Lower abdomen near PD catheter

Numeric Pain Rating: 4/10 at rest, 6/10 with movement

Pain Rating (Faces): Mild to moderate discomfort

Pain Relieved by: Rest, lying flat, occasional Tylenol, warmth

Pain Comments: Pain began after missed dialysis, gradually increasing; feels "bloated and tight"

Armbands:

  • Patient ID
  • Allergy
  • Fall Risk

Safe Environment:

  • Call light within reach
  • Bed in low position and locked
  • Falls protocol followed
  • Oxygen in use
  • Side rails up X2
  • Personal alarm: Chair alarm active when up

Safe/Env Comments:
Fall risk protocol in place. Chair alarm in use. Call light accessible. Side rails up x2. Bed locked and in low position.

  • Activity:
    • Up to bedside commode
  • Patient Performance:
    • Limited Assistance
    • One-person assist
    • Unsteady
  • Transfer:
    • With assist X1
    • Nonskid footwear
    • Gait belt used
    • Walker at bedside
  • Position:
    • Supine
    • Semi-Fowler's
    • Up in chair with assist
    • Specialty mattress overlay (pressure relief)
  • Response to Activity:
    • Unsteady
    • Short of breath
    • Complains of abdominal discomfort with movement
  • Antiembolism Interventions:
    • Antiembolism stockings
    • Sequential compression devices
  • Range of Movement:
    • Active ROM (limited)
  • Mobility Comments:
    Patient unsteady with transfers, requires gait belt and assist x1. Short of breath with movement. Uses walker at home. Chair tolerance limited.

🍽️ Nutrition

  • Feeding:
    • Independent
    • Aspiration precautions (due to trach)
  • Appetite:
    • Poor
  • Diet Type:
    • Diabetic
    • Renal diet
    • Diet restrictions: Low sodium, potassium, fluid
  • Nutrition Comments:
    Poor appetite. Consumed ~25% of breakfast. Aspiration precautions observed. Renal/diabetic diet in place.
  • Bathing:
    • Physical help to transfer
    • Physical help in bathing
    • Bed bath (bag bath)
    • Pericare
  • Oral Care:
    • Assisted care
    • Toothettes
    • Oral rinse
    • Lip moisturizer
  • Grooming:
    • Grooming-Assist
    • Moisturizing lotion applied
    • Hair care
  • Toileting:
    • Bedside commode
    • Incontinence/pericare
    • Moisture barrier applied
  • Hygiene Comment:
    Full assist required for bathing and pericare. Incontinence brief used overnight. Moisture barrier applied. Oral care performed with toothettes.

Meal: Lunch

Percent of Meal: 25%

Oral (ml): 180 mL (small sips of water, renal-safe juice)

GI Tubes – Type: None

GI Tube Feed (ml): 0

GI Tube Irrigation (ml): 0

Oral Intake Total (ml): 180 mL

  • IV Intake (ml): 500 mL 0.9% NS
  • IVPB Intake (ml): 100 mL (antibiotic)
  • Blood Intake (ml): 0
  • IV Intake Total (ml): 600 mL

Hourly Intake Total (Sum of Oral and IV): 97.5 mL/hr

8 Hour Intake Total: 780 mL

24 Hour Intake Total: (pending completion of full 24 hrs)

Hourly Output Total: 6.25 mL/hr

8 Hour Output Total: 50 mL

24 Hour Output Total: (pending full cycle)

Voided Urine (ml): 0 (anuric due to ESRD)

Urine per cath (ml): 0

Drain – Type: Peritoneal drain (Tenckhoff catheter – manual outflow)

Drain (ml): 50 mL clear-yellow dialysate returned (delayed exchange)

Blood (ml): 0

Emesis (ml): 0

Stool – Liquid (ml): 0

Output Total: 50 mL

Patient anuric due to ESRD.

Dialysate exchange returned 50 mL—less than expected; notify nephrology.

Poor oral intake post-op due to nausea.

No emesis, no bowel movement documented yet.

Continue monitoring for abdominal distension and fluid retention.

Stool: None since surgery

Urine: None (anuric)

Emesis: None

  • Wound Type: Pressure injury – Stage 3
  • Wound Location: Coccyx/sacral region
  • Wound Present on Admission? Yes (chronic, worsened during hospitalization)
  • Action: First assessment
  • Wound Length: 4.2 cm
  • Wound Width: 3.8 cm
  • Wound Depth: 1.5 cm
  • Wound Edges: Rolled
  • Undermining Location: 6 o'clock
  • Undermining Depth: 1.0 cm
  • Tunneling Direction: None
  • Tunneling Length: 0 cm
  • Wound Bed Description:
    • 60% slough
    • 30% granulation
    • 10% necrotic tissue
  • Exudate:
    • Moderate
    • Serosanguineous
    • Faint odor present
  • Surrounding Skin:
    • Erythema
    • Edema
    • Excoriated
  • Treatment/Dressing/Packing:
    • Cleanse with normal saline, pack with damp-to-dry gauze
    • Apply hydrocolloid over intact surrounding skin
    • Cover with foam dressing; change every 2 days or PRN drainage

Incision Type: Surgical incision

Incision Location: Left lower quadrant (PD catheter site)

Incision Action: Reassessment

Incision Length: 2.5 cm

Incision Width: 0.5 cm (small separation at site)

Incision Depth: 0.3 cm

Incision Healing By: Secondary intention

Closure: Sutures intact with slight separation at distal end

Skin: Erythematous and mildly swollen

Comments:
Mild purulent drainage noted on gauze; culture pending

Dressing/Packing:

  • Cleanse with sterile saline
  • Apply silver alginate dressing
  • Cover with sterile dry gauze and abdominal pad
  • Secure with tape

Ostomy Type: Colostomy

Ostomy Location: Left lower abdomen

Ostomy Action: Assessment

Inserted By: Surgeon (previous hospitalization)

Stoma Size: 2.2 cm

Stoma Assessment:

  • Red mucosa
  • Moist
  • Moderately protruding
  • Edematous
  • Firm

Peristomal Skin:

  • Intact with mild erythema
  • Slight leakage noted at base; barrier ring in place

Output/Effluent Description:

  • Thick, pasty, brown stool
  • Moderate amount – documented in I&O flowsheet

Appliance Change/Treatment:

  • Appliance changed during shift due to leakage
  • New wafer applied with barrier paste and convex ring
  • Teaching reinforced for self-care at discharge

Ostomy Comments:
Stoma viable. Skin protected with barrier wipe. Monitor for increased swelling or leakage.

  • Mode: Assist Control (AC)
  • Resp. Rate – Vent Setting (BPM): 16
  • Resp. Rate – Spontaneous (BPM): 4
  • Tidal Volume Setting (mL): 450 mL
  • FiO₂ Setting (%): 50%
  • PEEP (cm H₂O): 5 cm H₂O
  • CPAP (cm H₂O): 0 cm H₂O (not in use; patient not on CPAP mode)
  • Audible Alarm On

Comments:
Patient is intubated via tracheostomy and on ventilator for post-op respiratory support. Minimal spontaneous effort noted. Breath sounds diminished bilaterally. Secretions thick; suctioning performed PRN. Oxygenation stable on current settings. Monitor for weaning readiness once peritoneal status stabilizes.

Temperature: 98.4°F

Temperature Source: Tympanic

Pulse: 94 bpm

Pulse Source: Radial

Blood Pressure: 142/86 mmHg

Position: Supine

MAP (Mean Arterial Pressure): 105 mmHg

Respirations: 20/min

SpO₂: 94%

Oxygen Source: Trach collar with humidified O₂

Oxygen Flow Rate: 2 L/min

Faces Pain Rating: 😐 (Mild discomfort)

Numeric Pain Rating: 3/10 (reports mild abdominal ache from PD distension)

Glucose Monitoring Results: 182 mg/dL (pre-transfusion)

Vital Signs Comments:
Patient tolerating transfusion well. No distress noted. Mild abdominal discomfort ongoing, unrelated to transfusion.

Start Time: 04/01/2025 – 1500

Stop Time: 04/01/2025 – 1700

Transfusion Complete? Yes

If not completed, explain why: N/A

Volume Infused: 250 mL packed RBCs (documented in I&O)

Transfusion Reaction? No

If a reaction occurred, explain signs and interventions:
N/A – No signs of fever, chills, rash, dyspnea, or back pain. Vital signs remained stable throughout. Patient monitored q15min during first hour and q30min thereafter.

Action:

  • Initiated soft bilateral wrist restraints (non-locking, padded)

Order in Chart:

  • Yes – Restraint order in chart, MD notified and approved

Face to Face:

  • Completed within 1 hour per policy

Reason for Restraint Explained To:

  • Patient
  • Family member
  • Guardian
  • Other Person Explained to, Comment: N/A
  • Provided diversional activity (stuffed pillow, calming playlist)
  • Reduced environmental stimuli (TV off, curtain closed)
  • Encouraged patient to stay in bed
  • Quietly sat with patient to reorient
  • Other Comments: Used reassurance techniques and verbal redirection before restraint was applied

Explained Discontinuation Criteria to Patient:

  • Yes – Patient was told restraints will be removed when she can follow commands and no longer attempts to remove medical devices

Patient Response:

  • Calm initially, intermittently confused and agitated when suctioning or IV accessed
  • Injuries: None
  • Emotional Status: Anxious but cooperative after redirection
  • Restraint Released: Released and ROM provided every 2 hours
  • Fluids Offered: Sips of thickened liquid (aspiration precautions)
  • Nutrition Offered: Soft diet offered but refused
  • Toileting Offered: Assisted to bedside commode with 1-person assist
  • Range of Movement: Passive ROM provided during restraint check
  • Hygiene Offered/Performed: Pericare and oral care performed

Assessment and Monitoring Comments:
Patient intermittently attempts to reach trach collar and IV. Continues to need wrist restraints to ensure airway and line safety. No signs of distress or circulation issues noted during 2-hour check.

Color (Skin Assessment): Intact

Sensation: No complaints of numbness, tingling, or pain

Movement: Able to move fingers and hands freely within restraint limits

Continued or Discontinued: Continued – criteria not yet met

Criteria for Discontinuation: Will reassess once patient is alert, oriented, and no longer pulling at medical devices

Risk Status

  • Suicide Status: Pt denies thoughts, plan, or intent of suicide
  • Suicide Comments: "I'm just overwhelmed. I’m not thinking about hurting myself—I just want to feel normal again."
  • Homicide Comments: None expressed

Agitation, Violence, Assault

  • Verbal Agitation
  • Resists care (during suctioning, line access)
  • Violence Comments:
    "Stop touching me—I’m fine." Patient becomes anxious during invasive care but calms with reassurance. No threats or aggression.

Other Risks

  • Falls
  • Self-injury behavior risk (pulling at trach/lines due to anxiety)
  • Substance abuse history: Long-term tobacco use
  • Other Risk Comments:
    Fall precautions in place. History of anxiety contributes to risk of pulling medical equipment when agitated.

Affect: Labile

Mood: Anxious, fearful

Orientation: Person, place, time, and situation

Alertness: Alert

Memory Impairment: None noted

Insight: Limited insight into condition; deflects when symptoms are discussed

  • Logical and relevant
  • Goal-directed with occasional circumstantial speech
  • Thought Content:
    • Repetitive health complaints
    • Fears and phobias (particularly about dialysis and breathing issues)
    • Self-depreciation: "I’m just a burden to everyone."

Delusions: None present

Delusion Comments: N/A

Perceptual Disturbances: None reported

Perceptual Comments: N/A

Psychomotor agitation (frequent repositioning, tapping fingers)

Motor Comments:
Anxious movements when alone; rubs hands, tugs at linens

Cooperative

Guarded at times

Withdrawn (requires encouragement to participate)

Behavior Comments:
Needs redirection and reassurance. Responds best to calm, soft-spoken staff. Easily overstimulated.

Speech:

  • Soft
  • Tangential when anxious
  • Speech Comments:
    Slightly hoarse due to trach. Speaks quickly and tangentially when anxious; calms with reassurance

Naps during day

Hours Napping: Approx. 2 hours (intermittent)

Comments: Light, disrupted sleep overnight due to hospital environment and discomfort. Dozes off throughout day.

Personal alarm – Chair alarm active when out of bed

Safety Device Comments: Fall risk protocol in place. Chair alarm used due to unsteadiness and limited insight.

Visitors This Shift: Spouse (Jerry Reck)

Visitor Interactions: Supportive; calm presence during visit

Visitor Concerns: Asked for updates on trach care and dialysis progress; concerned about patient’s anxiety and energy level

Patient is emotionally labile post-operatively, with baseline anxiety exacerbated by hospitalization and invasive care. No suicidal or homicidal ideation expressed. Demonstrates limited insight into her condition. Requires frequent emotional support, redirection, and reassurance. Supportive spouse present. Recommend continuation of SSRI and supportive therapy engagement post-discharge.

  • First Identifier: Mrs. NerVous Reck
  • Second Identifier: Date of Birth – 01/01/1970
  • Surgeon Name: Dr. Evelyn Thomas, General Surgery
  • Date of Surgery: 04/01/2025
  • Procedure to Be Performed: Exploratory laparotomy with peritoneal catheter inspection and potential revision
  • Surgical Consent Form Completed: Yes
  • Consent Includes Side: N/A (midline procedure)
  • Consent for Blood Products Completed: Yes
  • Copy of Living Will/Advanced Directives on Chart: Yes – patient has DPOA and Living Will on file
  • Preoperative Instructions Provided to Patient or Legal Representative: Yes – verbal and written instructions reviewed with patient and spouse
  • Preop Medications Given (List):
    • Sertraline 50 mg (routine)
    • Lisinopril held
    • IV cefazolin 1g administered per pre-op protocol
  • Last Oral Intake – Date and Time: 04/01/2025 @ 0200 (NPO after this time)
  • Vital Signs on Chart: Yes – stable
  • Urinary: Patient is anuric (ESRD); no catheter needed
  • Skin Prep: Abdominal chlorhexidine prep performed
  • Valuables: No valuables brought in; documented in belongings sheet
  • Make-up and Nail Polish Removed? Yes
  • Prosthetics Removed?:
    • Glasses
    • Hearing aids – none
    • Dentures – removed and secured in labeled denture cup

Comments:
Patient anxious pre-op but cooperative. Reassurance provided. Pre-op sedation deferred due to trach status and respiratory risk.

  • History and Physical Attached: Yes
  • Physician's Orders Attached: Yes
  • History and Physical Identifies Side: N/A – midline abdominal site
  • Preanesthesia Assessment Completed: Yes – anesthesia aware of trach airway and ESRD
  • Pathology/Laboratory Studies Completed: CBC, BMP, PT/INR – results available in chart
  • Radiologic Studies Completed: KUB and abdominal ultrasound completed
  • EKG Completed: Yes – normal sinus rhythm

Other Tests:

  • COVID-19 rapid test: Negative
  • Hemoglobin: 7.9 → transfusion completed pre-op

Time of Surgery Verified: Yes – scheduled for 0800

Surgical Procedure Verified: Yes – reviewed by RN and surgeon

Surgical Site Verified: Yes – abdomen marked with surgical pen

Surgical Side Verified: N/A (not side-specific)

Patient prepped and ready for transport. All documentation verified. Abdominal prep completed. Emotional support provided due to elevated anxiety. Trach in place; suction set up for OR handoff. All pre-op requirements met.

  • Verified by: K. Morales, RN
  • Social Security Number: 123-45-6789
  • Marital Status: Married
  • Address: Street: 123 Anxious Lane
  • City: Worryville
  • State: CA
  • Zip Code: 90210
  • Home Phone: (555) 123-4567
  • Mobile Phone: (555) 987-6543
  • Email Address: nervous.reck@example.com
  • Receive Appointment Reminders by Email? ✅ Yes
  • Employer Name: Retired – former Admin Assistant
  • Employer Phone Number: N/A
  • Employer Address: Street/City/State/Zip: N/A
  • Primary Care Physician Name: Dr. Asha Mehta
  • Copay Amount: $20

🧾 Guarantor (Same as Patient – section left blank)

  • Guarantor Name: N/A
  • Social Security Number: N/A
  • Relationship to Patient: N/A
  • Date of Birth: N/A
  • Address: N/A
  • Phone Number: N/A
  • Employer Name: N/A
  • Employer Address: N/A
  • Name: Jerry Reck
  • Address: Street: 123 Anxious Lane
  • City: Worryville
  • State: CA
  • Zip Code: 90210
  • Home Phone: (555) 123-4567
  • Work Phone: (555) 765-4321
  • Relationship: Spouse
  • Insurance Company: MediSecure Health
  • Complete Address for Insurer:
    400 Coverage Blvd
    Sacramento, CA 95814
  • I.D. Number: 9876543210
  • Group Number: 44321-MED
  • Effective Date: 01/01/2022
  • Policy Holder's Name: Mrs. NerVous Reck
  • Policy Holder's Date of Birth: 01/01/1970
  • Policy Holder's Sex: Female
  • Patient’s Relationship to Insured: Self

Plan Name: CalCare Supplemental

Complete Address for Insurer:
200 Peaceful Way
Los Angeles, CA 90017

I.D. Number: 2233445566

Group Number: CAL-ESRD22

Effective Date: 03/01/2023

Policy Holder's Name: Mrs. NerVous Reck

Policy Holder's Date of Birth: 01/01/1970

Policy Holder's Sex: Female

Patient’s Relationship to Insured: Self

Scoring Interpretation:

  • High Risk (45 or higher): Implement high fall prevention protocol
  • History of falls (past 3 months):
    Yes – Patient had one fall at home 1 month ago while attempting to get to the bathroom without assistance
    (Score: 25)
  • History of predisposing diagnosis:
    Yes – ESRD, diabetes with neuropathy, impaired vision, post-op fatigue, trach, anxiety with occasional disorientation
    (Score: 10)
  • Ambulatory assistance:
    Yes – Requires walker and one-person assist for all transfers and toileting
    (Score: 10)
  • Equipment issues (oxygen tubing, IV, nasogastric tube, etc.):
    Yes – Has trach collar tubing, IV saline lock, and chair alarm; frequent repositioning needed
    (Score: 5)
  • Elimination status:
    Yes – Uses bedside commode, partial incontinence, wears brief at night
    (Score: 5)
  • Mental status:
    Yes – Alert but intermittently confused and anxious; forgets limitations
    (Score: 10)
  • Medications (affecting balance or awareness):
    Yes – On sertraline, occasional acetaminophen with diphenhydramine for sleep, insulin, and antihypertensives
    (Score: 5)

Total Score: 70

→ High Fall Risk

Bed in lowest position, locked wheels

Chair alarm in use

Gait belt and assist x1 for all mobility

Call light in reach; reinforced use

Fall risk armband applied

Patient and spouse educated on safety plan

Medical illness: End-stage renal disease (ESRD), diabetes, tracheostomy, post-op pain

Mental health history: Generalized Anxiety Disorder (diagnosed at age 38)

Medication changes: Stress from recent hospitalization and invasive care

Social/emotional stressors: Feeling like a burden to family, missed dialysis session, reduced independence

Past behavioral health history: Prior inpatient admission for anxiety at age 42

Limited coping mechanisms under stress

Supportive spouse and children

Regular therapy and medication compliance (sertraline)

Strong religious/spiritual identity

Insight and willingness to engage in care

No access to weapons or means

Motivated to recover for family’s sake

Ideation: Denies current or recent suicidal thoughts

Plan: No plan disclosed

Intent: No intent

Means: No access or stated method

Patient Statement:
"I’m not thinking about suicide. I just feel worn out and scared sometimes. I want to get better."

Risk Behavior Noted: Verbal self-depreciation and emotional withdrawal, but no active self-harm behavior

Risk Level: Low

Clinical Judgment: Emotional distress and verbalized hopelessness present but no suicidal ideation, plan, or behaviors

Intervention Plan:

  • Continue antidepressant (sertraline)
  • Daily emotional check-ins during hospitalization
  • Involve social work and psych consult if mood worsens
  • Encourage use of spiritual and family support systems
  • Document and monitor for changes

SAFE-T completed by RN on 04/01/2025 @ 1803

Patient assessed as low suicide risk with emotional strain due to chronic illness and post-surgical stress

Verbalizes commitment to recovery and identifies her children as her primary motivation

Will continue observation and reassess if behavior or affect changes

Yes

  • How many years have you smoked?
    ➤ 35 years
1a. Do you smoke cigarettes?

Yes – approximately 1 pack/day

1b. Do you smoke cigars?

No

1c. Do you smoke a pipe?

No

No

Yes

  • How many times have you tried to quit?
    ➤ 4 times over the last 10 years
  • What methods have you used to try and quit?
    ➤ Nicotine gum, cold turkey, prescription patches, brief counseling
  • What factors do you feel made these previous attempts unsuccessful?
    ➤ "Stress, anxiety, and being around people who smoke. I always picked it back up when I got overwhelmed."

➤ 7/10
Patient states: “Now that I have this trach, I know I need to quit for good.”

Spouse (Jerry Reck)

Children (supportive, especially the oldest child)

Primary care provider and dialysis nurse

Yes

  • Quit Date Set: 04/08/2025
    Patient agrees to begin nicotine tapering and schedule a follow-up counseling session.

Location:

  • Sacral region (central over coccyx)

Comments:

Chronic pressure injury noted upon admission. Stage 3 with undermining and moderate slough. Wound appears stable but requires frequent dressing changes due to moisture.

Shape:

  • Oval

Measurement:

  • Length: 4.2 cm
  • Width: 3.8 cm
  • Depth: 1.5 cm
  • Undermining: Present at 6 o'clock – depth: 1.0 cm
  • Undermining Comment: Wound tunnels slightly toward gluteal cleft; requires packing

Edges:

  • Indistinct, diffuse:
  • Distinct, attached:
  • Well-defined, not attached: (Base deeper than edges; visible walls present)
  • Well-defined, rolled under, thickened:
  • Well-defined, hyperkeratosis:
  • Fibrotic, scarring:

Exudate:

  • Amount: Moderate
  • Type: Serosanguineous
  • Odor (after cleaning): Mild, musty
  • Comment: Odor present prior to cleaning but reduced after irrigation

Necrotic Tissue:

  • Loosely adherent, yellow slough
    • Wound involvement: ~60% of wound bed
  • Non-adherent, yellow slough
    • Wound involvement: ~10%
  • Black eschar (soft or hard): Not present

Wound Bed Composition:

  • Granulation: 30%
  • Epithelialization: 0% (none observed)
  • Pale pink: 10%
  • Blanched:
  • Dusky:

Peri-Wound Skin (within 4 cm):

  • Color: Erythematous
  • Edema: Mild, non-pitting
  • Induration: Present
  • Pain: Yes
    • Pain Rating: 4/10
    • Description/Quality: Dull, sore, localized
    • Radiating: No radiation
  • Comments: Moisture barrier applied to reduce breakdown. Patient verbalizes pain during cleaning but tolerates dressing change with pre-medication.

Additional Comments/Notes:

Wound irrigated with sterile saline. Packed with damp-to-dry gauze. Hydrocolloid border applied to protect surrounding skin. Dressing reinforced. Patient pre-medicated 30 min prior to procedure. Wound team consult in progress.

Risk Factor - Score/Description

  1. SENSORY PERCEPTION (2 – Very Limited)
    • Responds only to painful stimuli.
    • Somewhat impaired due to sedation, anxiety, and fatigue.
  2. MOISTURE (2 – Often Moist)
    • Wears brief at night due to incontinence.
    • Skin often damp from sweating and peritoneal drainage.
  3. ACTIVITY (1 – Bedfast)
    • Confined to bed with brief periods in chair with assist.
    • No independent ambulation at this time.
  4. MOBILITY (2 – Very Limited)
    • Requires assist x1 to reposition.
    • Cannot make frequent or significant changes in body position without help.
  5. NUTRITION (2 – Probably Inadequate)
    • Poor appetite; consumes ~25% of meals.
    • On renal/diabetic diet; limited protein intake.
  6. FRICTION AND SHEAR (2 – Potential Problem)
    • Requires moderate assistance during movement.
    • Occasionally slides down in bed; uses bed rails and positioning aids.

Total Score: 11 → High Risk

Assessment:

  1. High risk for continued skin breakdown.
  2. Stage 3 pressure injury present on sacrum.
  3. Moisture and nutritional deficits worsening skin integrity.
  4. Pressure-relieving mattress in place; frequent repositioning implemented.

Age: 64 years

Gender Identity: Female

Pronouns: She/Her

Address: 123 Anxious Lane, Worryville, CA 90210

Contact:

Presents with abdominal distension and a low-grade fever.

Missed peritoneal dialysis session two days ago due to nausea and fatigue.

Low-grade fever: 99.8°F

No current BP, HR, RR documented

Appears fatigued and mildly anxious

Complains of abdominal discomfort

Alert and oriented x4

Enjoys reading and gardening

Socially active through a book club and friendships

Light daily exercise (walking)

Alcohol: Occasionally (1–2 glasses of wine/week)

Tobacco: Never

Caffeine: 2 cups coffee/day

Recreational Drugs: Denies use

General malaise reported

Reports increasing abdominal distension

No vomiting, but decreased appetite

Lisinopril 10 mg daily (this morning)

Metformin 500 mg BID (this morning)

Sertraline 50 mg daily (this morning)

Insulin glargine 20 units at bedtime (last night)

Multivitamin daily (this morning)

Calcium carbonate 500 mg with meals (this morning)

Medication: Penicillin (rash)

Food: Shellfish (hives)

Environmental: Pollen (seasonal allergies)

Flu vaccine: Oct 2023

COVID-19 booster: Jan 2024

On peritoneal dialysis x2 years for ESRD

Missed last session due to nausea and fatigue

Increasing abdominal distension and fever over past 24 hours

Hypertension (diagnosed at 40)

Type 2 Diabetes Mellitus (diagnosed at 45)

End-stage Renal Disease (diagnosed at 52)

Cholecystectomy at 50

Hysterectomy at 48 (due to fibroids)

G2P2, no miscarriages or abortions

Generalized Anxiety Disorder (diagnosed at 38)

Hospitalized at 42 for acute anxiety

Ongoing SSRI therapy and counseling

Mammogram: March 2023 (normal)

Colonoscopy: June 2022 (normal)

Mother: Deceased at 78 (heart disease)

Father: Deceased at 80 (stroke)

Brother: Age 60, healthy

Children: Ages 15 and 12, healthy

Married for 25 years, lives with spouse and children

Primary caregiver for her late mother

Reports chronic stress related to illness and caregiving

Follows renal diet

Monitors BP and blood sugar regularly

Attends appointments consistently

Practices relaxation and meditation for anxiety