Centennial College Practical Nursing Focused Assessment – Client Admitting Diagnosis: Surgery on R hip, pain. Client Past Medical History: Allergies & Reaction:Code Status:N/ACurrent Diet: Current Medical Issues and Treatments: Isolation Status:☐Contact☐Airborne☐Droplet Interdisciplinary Team Involved in Client Care:☐Wound Care☐SLP☐Social Worker☐OT☐PT☐Recreation Therapist☐PharmacistOther (please specify): Physiotherapist Main Issues from Change of Shift Report/Transfer of Accountability: pain, inability to sleep due to pain, High BP, High pulse SystemAssessmentAssessment Findings (must use proper terminologies)Analysis TMT(P)/TMT(N):Analyze thedata findings usingevidences from PNUR126, PATH122 and PNUR124. Please identify the Need Affected based on the Analysis NeuroBaseline Status:✔Level of Consciousness;Conscious✔Orientation -PPT✔GCS Score:✔Motor Strength (upper and lowerextremity) FOCUSED: Neuro related condition ✔PERRLA Findings:-Patient alert, oriented but restless d/t pain -Motor skill in R hip impaired -Data gap for GCS & PERRLA ☐Normalx☐Abnormal Patient’s hip impairment canaffect his ability to independently perform ADL’s TMT(P):The patient’s inability to perform ADL’s independently will affect his self-esteem and sense of independence TMT(N):The nurse will assess the patient’s ability to perform ADL’s independently and assist her when she needs help. Service of physiotherapist will be needed. Activity & Exercise (Bishop, 2018, pp 30-31). PainBaseline Status:✔Location✔PQRST Findings:P: pain increases without movement and activity. Symptoms are not relieved Q: client didn’t say R: Pain on R hip and radiated all over upper body and to head S: Pt states pain of 8/10 T: pain is constant and intensity increases in the morning before pt. could sleep after being administered Tylenol 3.Pt was admitted to hospital due to hip surgery and is experiencing a lot of pain TMT(P):The patient’s pain can affect his ability to perform ADL’s.
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