Nursing Assessment

Here is an example of a good, thorough nursing assessment for a patient in the hospital for short gut

syndrome.

General Assessment: C.H is a 10-month-old African American male currently admitted for short gut syndrome, not tolerating feeds and weight loss. Patient appeared awake and alert but fussy and irritable,with minimal signs of distress, due to morning episode of emesis. Pt. is small for age.

Vitals:  P: 1 (FLACC scale); HR: 121 ; RR: 44; T: 36.5 C; BP: 103/59 MAP:71; Wt. 5.2kg

Review of Systems:

Integumentary: color appropriate for race, warm to touch, dry and smooth, turgor good, no lesions. No clubbing, nail beds pink, temperature even bilaterally in extremities. Patient has PICC line in his right AC. Patient has continuous TPN infusing through PICC line at 14ml/hr and lipids infusing at 1.5ml/hr. Both cycle for 24 hours. No redness or infiltration of line noted, flushes well. PICC line labeled with necessary dressing date change. Dressing on PICC line is CDI. HEENT: normocephalic & symmetric head, no tenderness or lesions. PERRL but lacks accommodation. Corneal light reflex symmetric bilaterally. Unable to track objects or sound with eyes. No obvious hearing impairment or visible discharge from ears. Nose symmetric, nares patent, no discharge. Respiratory: Breath sounds clear in all fields bilaterally, no adventitious sounds. No increased WOB, chest expansion symmetric, slight retractions present during morning episode of emesis. No evidence of aspiration post-emesis. Cardiovascular: Regular rate & rhythm, S1/S2 present and not diminished or accentuated, no murmurs noted, no S3/S4. Pulses 2+ and equal bilaterally in all extremities. CRT < 2 seconds all extremities. Apical pulse present 5^th ics at left midclavicular line. No heaves.  GI/GU: abdomen round, soft and slightly distended, hyperactive bowel sounds present all 4 quadrants, no vascular sounds noted. Scars present across entire front of abdomen due to several abdominal surgeries related to the short gut.  Scars are well healed and well approximated. Patient has accessed G-tube in LUQ with enfacare 20 Kcal infusing at 42ml/hr x 20 hours/day. Dressing intact, no redness or drainage around site.  2 episodes of emesis prior to 10AM this shift. Emesis episodes were approximately 30ml of undigested formula. Pt. has good urine output evidenced by several wet diapers this shift. Last BM 0930 was loose, light brown stool. Musculoskeletal System: Full ROM in all extremities, no joint swelling or deformities.  Poor muscle tone noted, weak grasp. Lack of head control in the same plane as body when supported in sitting position. Pt. not able to sit up unassisted.  Neurological: Awake and conscious. Smiles appropriately in response to staff attention.  Lacks rooting and Landau reflex. Weak palmar grasp present bilaterally.

Developmental: Patient has not met appropriate developmental milestones AEB lack of several key milestones for age. Pt. unable sit up or pull himself up to a standing position. Patient has not shown any signs of crawling or rolling over. Patient not able to transfer object from between hands or grasp using fingers and opposing thumb. Pt. has limited amounts of babbling and no words were formed. No use of hand gestures, such as waving “bye.” Pt. not consistent with eye contact and does not turn head towards sound though he does respond to noises. Pt. receiving PT and OT several times a week and is improving his muscle tone and working on tasks such as head control.