Pre-procedure steps

General survey

The patient appears to be aware and alert of his surroundings and he seems impartially in good health. The patient is complaining of experiencing different symptoms such as chest pain that was sharp and intense, shortness of breath and difficulty ambulating for the past one week. The patient also stated that he had noticed a smelly discharge during urination and experienced sharp abdominal pain. Another symptom as stated by the patient was strange sensations in their feet throughout the day.

Vital signs

Temp.100.3, P 122, RR 26, BP 174/102, O2 sats 91% on room air

 HEENT

Head: No headaches. The distribution of hair is even. Involuntary facial movements are not evident. The scalp is normal.

Eyes: EOM untouched; optic disks are of proper size and look. No norm or discharge variations in the vessel. The eyelids are normal and the conjunctivae are pale. Discharge, ptosis or edema are not evident. Pupils are round and symmetrical, reacting to light immediately and consensually. Fields of vision are normal.

Ears, Nose, Throat: The outside ears and nose appear to be of ordinary and symmetrical shape and size. No evident scars, masses or sores. No sensitivity to ear, nose or sinuses palpations.

The auditory external canals seem like pink, with trivial cerumen. Clear and in place are tympanic layers. Rinne and Webber tests were regular and the patient could bilaterally comprehend whispered syllables. Regular and symmetrical septum and turbinates. Without discharge, nasal mucosa is moist and pink. No dehydration evidences.

Neck: The neck is symmetrical, without evident masses, wounds, external bodies or variations from normal. There is no palpability tenderness. The trachea is midline. No obvious crepitus. The symmetric thyroid is fitting in size. Under the ligament of the cricoid is the middle line of the isthmus. No evident masses, injuries or differences outside the body or the norm. No significant lymph node.

Thorax, Lung, and Back assessment: Shape and chest size are normal. No evidence of cough and sputum.  Severe and sharp chest pain evident. No wheezes, or crackles were heard on auscultation of right lung. The back is normal in shape and size and no evidence of masses or outside bodies.

Heart and Central vessels

The chest is symmetrical with no scars. There is no cardiac heaves or lifts. There were no wall motions except for the symmetrical expansion resulting from respiration. The point of maximal impulse is noted at mid-clavicle line, in the 5^th intercostal space. The patient has a normal S1 and S2 with regular rate and rhythm. There is no splitting of the heart sounds. There is no murmur.

Gastrointestinal & genitourinary:

Smelly discharge, Urine slightly cloudy. Sharp abdominal pain.

Musculoskeletal, neurologic & peripheral vascular assessment:

No full range of motion in all extremities. However, there is a strange feeling in the feet throughout the day. No deformities or bone fracture. Cannot counter act gravity and resistance on ROM. Patient’s extremities are bilaterally equal in size and length.

Post procedure steps

The nursing care plan for the patient involves educating them on the causes of bacterial infections and how to avoid them. Many of the symptoms that the patient is experiencing could be influenced by hygiene practices. I would also recommend that the patient see a pulmonologist to get to the bottom of his respiratory problems. The patient will also need some pharmacological solutions to their problems. Once a formal diagnosis is reached, various types of antibiotics can be administered to the patient

 

Potential risk factors

Abdomen pain may indicate intestinal obstruction. Unusual finding in the urine such as pain when urinating may indicate compromised urinary function. This requires a focused assessment on genitourinary and gastrointestinal areas. The strange feet sensation may indicate variations in perfusion. Another potential risk factor is enhanced by the infections and is indicated by the chest pain which means that the patient may be suffering from cardiac illness in nature.