UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Joshua Jenkins

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION
Patient Initials:
Gender:

JH

Female

Assignment Date: 6/23/2015

Agency: Bayfront Medical Center

Age: 19

Admission Date: 6/22/2015

Marital Status: Single

Primary Medical Diagnosis Nausea, Vomiting

Primary Language: English

Level of Education: Graduated High School, Currently in college

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Student, Patient Care Assistant at

Tampa General Hospital
Number/ages children/siblings: 5 brothers: 22, 17, 14, 14, 7.

Tachycardia, Dysuria, Flank pain, Constipation.

Served/Veteran: No
If yes: Ever deployed? Yes or No

Code Status: Full Code

Living Arrangements: Mom and two brothers. No ambulatory risk

in the home. No stairs.

Advanced Directives: No
If no, do they want to fill them out? No.
Surgery Date:
NA Procedure: NA

Culture/ Ethnicity /Nationality: White/Caucasian

Religion: Christian, nonspecific.

Type of Insurance: Blue Cross HMA

1 CHIEF COMPLAINT:
Patient states I had nausea and vomiting for over 24 hours and flank pain after being treated for a kidney infection a few
days ago.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Onset: Patient states she was treated by her primary physician on Thursday (6/18/2015) presenting symptoms of urination
that the patient described as burning, frequent. She also described symptoms of nausea, back pain, dark urine, and foul
odor lasting for almost a week before seeking treatment. Was placed on antiemetic medications, over-the-counter pain
medications, and an antibiotic. The patient states that she works nights at Tampa General Hospital as a patient care
technician, and had worked Saturday night. She woke up around 1700 hours Sunday (6/21/2015) to get ready for work.
She was nauseous and vomited at work and was sent home. At 0630 hours Monday (6/22/2015) the patient was admitted
to Bayfront Medical Center (BMC).
Location: Lower middle back pain.
Duration: Since Tuesday (6/16/2015)
Characteristics: Throbbing, achey
Aggravating Factors: Movement, ambulation.
Relieving Factors: Some positioning, but not much helped the pain.
Treatments: Zophran, Bactrim, Ibuprofen

University of South Florida College of Nursing Revision September 2014

Severity: 3/10 at the time of seeing her primary care physician. 8/10 on Saturday morning when she woke up. 7/10 upon
admission to the hospital. 0/10 at time of assessment.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease

Mother

42

Brother

22

Brother
Brother

17

Brother

14

Tumor

Stroke

Stomach Ulcers

Seizures

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma
x

Mental
Problems
Health

43

Kidney Problems

Father

Cause
of
Death
(if
applicable
)

Arthritis

2
FAMILY
MEDICAL
HISTORY

Age (in years)

2011

Anemia

2011

Environmental
Allergies

Operation or Illness
Paroxysmal Supraventricular Tachycardia. Admitted to St. Andrews Hospital. Patient was treated
with fluids and monitored for a few hours and then discharged. Patient states the episode was
determined to be self-limiting.
Suicide attempt. Patient record indicates that she was treated at BMC for suicide attempt. Record was
sealed and patient made no note of this event.
Methicillin Resistant Staphylococcus aureus (MRSA) infection in right anterior antecubital region.
Treated with Bactrim and with surgical removal.
Asymptomatic Infectious Mononucleosis. Patient states she was tested after being exposed by
boyfriend. Tested positive for the viral infection but was not treated.

Alcoholism

Date
Late January,
early February,
2015
February 2, 2014

14

Brother

7
Comments: Include age of onset
Patient reports her father has been diagnosed as bipolar since he was in his twenties. Father also has kidney problem related to
medications, but patient is unknowledgeable about the details of the condition.
Patient reports her 17 year old brother was diagnosed with asthma when he was two years old, but has been asymptomatic since
childhood. He was also diagnosed at age two with bipolar disorder.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) : August 2014

YES

NO

x
x
x

University of South Florida College of Nursing Revision September 2014

Adult Tetanus (Date) Is within 10 years? August 2014

Influenza (flu) (Date) Is within 1 years? Date Unknown, approximately 2
years
Pneumococcal (pneumonia) (Date) Is within 5 years? August 2014
Have you had any other vaccines given for international travel or
occupational purposes? Please List
Hepatitis B given 2006.
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Eletriptan
hydrobromide
(Relpax)

x
x
x

Type of Reaction (describe explicitly)

Patient describes getting a flushed face, pines and needles feeling on my
face, and it feels like my nose is bleeding.

Medications

Bee Sting
Other (food, tape,
latex, dye, etc.)

Fluctuating Food
Allergies

Hives, shortness of breath.

Intermittent and unpredictable allergies to certain foods. Has had episodes
with sweet and sour sauce at Chinese restaurant at age 3, grapefruit juice
at age 12, and watermelon at age 15. Patient described symptoms as
anaphylaxis. Patient states she always carries an epinephrine pen
because she is unsure when a food will trigger a response.

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Urinary tract infections (UTI) are caused by the translocation of normal flora of the gastrointestinal tract into the urinary
epithelium (Huether and McCance, 2012. p.747). Huether and McCance (2012) explain the most common infecting
microorganisms are uropathic strains of Escherichia coli and the second most common is Staphylococcus saprophyticus
(Huether et al, 2012). Urination typically prevents bacteria from being able to move up the urethra and into the bladder;
therefore the anatomical difference between the lengths of the urethra in men and women helps to explain the skew
toward more frequent infections in female patients (Huether et al, 2012). The Mayo Clinic (2015) lists the following as
risk factors for urinary tract infections: being femalebeing sexually activeusing certain types of birth control
completing menopausehaving urinary tract abnormalitieshaving blockages in the urinary tracthaving a suppressed
immune systemusing a catheter to urinate (Mayo Clinic Staff, 2015, Urinary tract infection, Risk factors).
Huether and McCance (2012) explain urine dipstick tests are done for uncomplicated UTI, and culture and sensitivity
testing may be done to determine which pathogen specific antibiotic to use to treat the infection. Typically, UTI are treated
with antibiotics for three to seven days, although in complicated cases the regimen may be extended as long as 14 days
(Huether et al, 2012). Complications of UTI treatment occur in individuals with abnormal urinary tracts that do not allow
normal excretion of urine, immunocompromised patients, or patients with neurological disorders that inhibit their ability
to control their own urination (Mayo Clinic Staff, 2015, Urinary tract infection, Risk factors).

University of South Florida College of Nursing Revision September 2014

 5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name Trimethoprim-sulfamethoxazole (Bactrim)

Concentration

Dosage Amount Unknown

Route Oral

Frequency Twice Daily

Pharmaceutical class Antiinfective

Home

Hospital

or

Both - HOME

Indication Treatment of Urinary Tract Infections

Adverse/ Side effects hypotension, headache, insomnia, hyperkalemia, hyponatremia, crystalluria, Steven Johnson Syndrome, photosensitivity, nausea, vomiting,
diarrhea, stomatitis, hypoglycemia, agranulocytosis.
Nursing considerations/ Patient Teaching Take as directed, complete the full regimen, notify health care provider if sore throat, unusual bleeding, diarrhea containing
blood or mucus.
Name Ondansetron (Zolfran)

Concentration

Dosage Amount Unknown

Route Oral

Frequency Twice daily

Pharmaceutical class Antiemetic

Home

Hospital

or

Both - HOME

Indication Treatment of nausea and vomiting

Adverse/ Side effects headache, dizziness, drowsiness, fatigue, weakness, constipation, diarrhea, abdominal pain, dry mouth, increased liver enzymes, Extrapyramidal
symptoms (EPS).
Nursing considerations/ Patient Teaching Take as directed, notify health care provider if irregular heart beat presents or involuntary movement of eyes, face, or limbs.
Name Ibuprofen (Advil)

Concentration

Dosage Amount 200mg

Route Oral

Frequency PRN for pain

Pharmaceutical class NSAID

Home

Hospital

or

Both - HOME

Indication Mild to moderate pain, fever.

Adverse/ Side effects - headache, dizziness, drowsiness, blurred vision, hypertension, edema, hepatitis, constipation, dyspepsia, nausea, renal failure,
Nursing considerations/ Patient Teaching Take with full glass of water. Take as directed. Avoid use of other NSAIDS.
Name metoclopramide (Reglan)

Concentration 10mg/2mL

Route IV Push

Dosage Amount 10mg

Frequency Q6H

Pharmaceutical class - antiemetic

Home

Hospital

or

Both - HOSPITAL

Indication Prevention and treatment of emesis

Adverse/ Side effects Drowsiness, EPS, neuroleptic malignant syndrome (NMS), anxiety depression, irritability, arrhythmias, hypertension, hypotension, constipation,
diarrhea, dry mouth, nausea, leukopenia, agranulocytosis
Nursing considerations/ Patient Teaching Take as directed. May cause drowsiness so avoid driving until response is known. Avoid alcohol. Notify health care provider
if symptoms of EPS or NMS or involuntary movement of face, eyes, or limbs.
Name polyethylene glycol 3350 (MiraLax)

Concentration

Dosage Amount 17g Packet

Route Oral

Frequency Daily

Pharmaceutical class laxative

Home

Hospital

or

Both - Hospital

Indication Constipation
Adverse/ Side effects Abdominal fullness, diarrhea, bloating, cramps, nausea, vomiting, fluid and electrolyte imbalances.
Nursing considerations/ Patient Teaching Drink 240mL every 10 minutes until 4L have been consumed or fecal discharge is clear and free of solid matter. Avoid alcohol
during prep.
Name Hydromorphone (Dilaudid)

Concentration 1mg=.5mL

Route IV Push

Dosage Amount 1mg

Frequency x1

Pharmaceutical class opioid analgesic

Home

Hospital

or

Both - HOSPITAL

Indication moderate to severe pain

Adverse/ Side effects Confusion, sedation, dizziness, euphoria, dysphoria, headache, hallucination, blurred vision, respiratory depression, hypotension, bradycardia,
constipation, dry mouth, nausea, vomiting, urinary retention, flushing, sweating
Nursing considerations/ Patient Teaching Discuss with PT about when to treat pain. Advise about abuse potential. Avoid driving. Notify if pain control is not sufficient.
Change positions slowly to avoid orthostatic hypotension. Turn, cough, and deep breathe every 2 hours to prevent atelectasis.
Name phenazopyridine (Pyridium)

Concentration

Dosage 100mg

University of South Florida College of Nursing Revision September 2014

Route oral tablet

Frequency TID (3x daily)

Pharmaceutical class nonopioid analgesic

Home

Hospital

or

Both - HOSPITAL

Indication Provides relief from urinary tract symptoms of pain, itching, burning, urgency, and frequency.
Adverse/ Side effects headache, vertigo, hepatotoxicity, nausea, bright-range urine, renal failure, rash, hemolytic anemia, methemoglobinemia
Nursing considerations/ Patient Teaching Take as directed, stop once symptoms subside, reddish-orange colored urine may stain clothes, may stain contact lenses,
notify healthcare provider if rash, skin discoloration, or unusual fatigue occurs.
Name morphine

Concentration 1mg = 0.5mL

Route IV push

Dosage Amount 1mg

Frequency Q4H, PRN, for pain scale 7-10

Pharmaceutical class opioid analgesic

Home

Hospital

or

Both - HOSPITAL

Indication severe pain

Adverse/ Side effects Confusion, sedation, dizziness, euphoria, dysphoria, headache, hallucination, blurred vision, respiratory depression, hypotension, bradycardia,
constipation, dry mouth, nausea, vomiting, urinary retention, flushing, sweating
Nursing considerations/ Patient Teaching Discuss with PT about when to treat pain. Advise about abuse potential. Avoid driving. Notify if pain control is not sufficient.
Change positions slowly to avoid orthostatic hypotension. Turn, cough, and deep breathe every 2 hours to prevent atelectasis. Avoid alcohol.
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Clear Liquids
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Nonspecific. Normal adult
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: skips breakfast, but has coffee. Sometimes
Usually only eats one real meal per day. Works nights, so
banana or bagel.
her schedule is atypical. Tries to incorporate as many food
groups as she can during her meal. Tries to do a meat, a
starch, and a vegetable. Patient recognizes that this is not an
ideal diet but knows that with her schedule as it is, that she
feels it is sufficient. Does not drink milk.
Lunch: Turkey, potatoes, and greens. Usually
Dinner: Usually skips dinner.
Snacks: Graham crackers, peanut butter, things the hospital
has. Usually 2-3 servings of snacks throughout night shift.
Liquids (include alcohol): 1-2L of water per day, drinks
water bottle at work. Reports that she does not drink
alcohol. Monster energy drinks at night to help get her
through the night shift.

Grains Eats about 5 ounces, target should be 6 ounces.

Vegetable Eats about 2.75 cups, should eat about 2.5
cups.
Fruits Eats about 0.75 cups, should eat about 2 cups.
Dairy Eats about cup, should eat about 3 cups.
Protein Foods Eats about 9 ounces, should eat around 5.5
ounces.
Oils Eats around 4 teaspoons. Should eat around 6
teaspoons.
Total calories Averages 1679 kcal. Should be eating
around 2000.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Mother. Mom works days, and some weekends, but is generally able to take care of the
patient when she is ill.
How do you generally cope with stress? or What do you do when you are upset?
Patient feels she generally handles stress well. Most stress in her life is school related, but the patient reports the stress is
acute and generally related to a test or a project. She reports just stressing out about it while she studies, and feels relieved
once the test is finished.
The patient reports running a few times a week, and feels like that is something she enjoys to relieve stress. She runs for
about 45 minutes to an hour three to four times per week.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient reports not having any recent difficulties. Patient did not report the suicide attempt from 2014 that was noted in her
file.

University of South Florida College of Nursing Revision September 2014

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? ______No_________________________________________________
Have you ever been talked down to?____No_________ Have you ever been hit punched or slapped? ___No_______
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
______Yes, father had violent bipolar episodes ____ If yes, have you sought help for this? _Child Protective Services
were called in on several occasions for physical abuse from father. Parents separated when patient was 13 and the patient
now lives with mother. _____
Are you currently in a safe relationship? Not currently in a romantic relationship

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:

In Eric Erickson, author Saul McLeod (2008) explains that in the intimacy versus isolation stage of psychosocial
development theory, the young adult stage is when the child is no longer living at home, or is beginning to create a larger
picture of autonomy and self discovery. The author describes the primary virtue of this stage is love, and being successful
in this stage leads to the development of healthy, satisfying relationships, while failure here leads to loneliness and
possible depression (McLeod, 2008).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is 19 years old, and has had several relationships throughout her teens. She is following in her mothers
footsteps of becoming a nurse, and is currently enrolled in nursing school at Galen Nursing School. I feel that she has
successfully completed the Identity vs. Role Confusion stage that is typical of the teenage years, as she has developed a
sense of self, left behind her childhood activities of cheerleading, and has focused herself into what will be her career. She
now exerts self-confidence, and looks to establish herself and begin a life, casually dating but also conscious of the
limitations that nursing school and working overnight has on her social life. Because I feel like she has successfully
established a sense of self, and started on a trajectory of the life she wants to build for herself, this position of creating
emphasis on finding love and commitment would be the most appropriate psychosocial stage for this patient.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

This hospitalization has not had tremendous effect on her outlook on life. She looks forward to progressing her diet and
being able to handle having more complete foods. She is currently on a break between semesters and her care plan
involved her most likely being discharged later the date that she was interviewed for this assessment. Upon discharge, she
will return home with her mother and begin the healing process toward recovery.

+3 CULTURAL ASSESSMENT:
University of South Florida College of Nursing Revision September 2014

What do you think is the cause of your illness?

The patient reports that she believes she acquired a UTI, which progressed into a kidney infection. She began taking
medications for the UTI and it caused her to have severe nausea and vomiting. She stopped taking the medications but
was still vomiting and unable to keep anything down. She states that she became very dehydrated.
What does your illness mean to you?
The patient states I got a UTI. The patient states that since she is in nursing school, she understands the pathophysiology
of how a UTI occurs and what is happening in her body.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?___Yes__________________________________________
Do you prefer women, men or both genders? ___Men_____________________________________________________
Are you aware of ever having a sexually transmitted infection? ____No_____________________________________
Have you or a partner ever had an abnormal pap smear?__No_____________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? _Yes, either 2011 or 2012. _____________
Are you currently sexually active? ______Yes__________________ If yes, are you in a monogamous relationship?
__Not currently____________ When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? ____Condoms. On Depo-Provera Shot. ______________
How long have you been with your current partner?___N/A_____________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? __N/A__________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
N/A

University of South Florida College of Nursing Revision September 2014

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
______Not much. General Moral guidance but not much involvement. Attends church a few times a year.
________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_____________________________No___________________________________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)

Yes
No
For how many years? 0 years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much?
No

Has the patient ever tried to quit?

If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? On a vacation to Mexico, a day of
drinking with her mom where she was of age. How much? Appx. 6 drinks
Patient states that she is not a regular drinker.
Volume:
Frequency: 1 time.
If applicable, when did the patient quit?

No
For how many years? 0
(age

thru

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient works as a Patient Care Technician at Tampa General Hospital. She does bedside care, and so she is at risk of
hospital acquired infections.
Patient was a cheerleader for 18 years. She did competitive cheerleading throughout middle and high school. She stopped
competing when she graduated high school, and but still teaches occasionally, and therefore is at risk for trauma related
injuries.
5. For Veterans: Have you had any kind of service related exposure?
N/A

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health? Patient states My health is pretty good. I should probably get more active.

Integumentary: Patient occasionally gets eczema on her face. Usually breaks out during winter months. Not
currently exhibiting symptoms.
HEENT: Within normal limits.
Pulmonary: Within normal limits.
Cardiovascular: Within normal limits. Had episode of paroxysmal supraventricular tachycardia a year ago, self limiting. Not
currently exhibiting symptoms.

GI: Mild nausea. Constipated for 2 days.

GU: Recovering from urinary tract infection.
Women/Men Only:
Musculoskeletal: Within normal limits. Was experiencing pain in upper middle back but has since been relieved.
Immunologic: Within normal limits.
Hematologic/Oncologic: Within normal limits.
Metabolic/Endocrine: Within normal limits.
Central Nervous System: Within normal limits.
Mental Illness: Within normal limits. Did not disclose any depression nor any information about suicide attempt
a year prior.
Childhood Diseases:.
In 2010/2011 Patient was treated five times for strep throat and bronchitis. Was treated with antibiotics (patient
believes Azithromycin and Tesselon Perles.)
Onset Sudden. Location throat and lungs. Duration 2-3 weeks. Characteristics coughing, severe phlegm,
sore throat, fever. Aggravating Factors exertion. Relieving factors Rest, medications. Treatments
antibiotics and antitussives.
Patient was treated in 2011-2012 for tunneling MRSA in two sites on her right anterior antecubital region. Onset
Noticed a sore, red area that was spreading. Drew circle around it and noticed it was spreading. Tried
antifungal. Showed biology teacher, who suggested it was MRSA and to go to the hospital for treatment.
Location Right anterior antecubital region. Characteristics sore, red, elevated, spreading. Aggravating factors
popping the blister. Relieving factors none. Treatments tried antifungals, then went to hospital to have it
surgically removed. Only was in epidermal layer, and epidermal layer was removed. Treated with antibiotics.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Suicide attempt. Admitted to Bayfront Medical Center 2/5/2014.

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10

Any other questions or comments that your patient would like you to know?
No

10 PHYSICAL EXAMINATION:
General survey _____Patient is pleasant, talkative, cooperative, light hearted, and well humored. Her appearance is clean,
alert, calm, relaxed._____________________________
Height _____53_______Weight_____110_____ BMI _____19.5______ Pain (include rating and
location)_____0/10______________ Pulse___72____ Blood Pressure (include location)__122/65 Left Arm
___Temperature (route taken)____ 98.8 temporal swipe ________
Respirations_____18_______ SpO2 __100_______________ Room Air or O2___Room air________________
Overall Appearance____Clean, hair combed, appropriate dress, maintains eye contact, no obvious handicaps.__
Overall Behavior__ Patient is pleasant, talkative, cooperative, light hearted, and well humored. Her appearance is clean,
alert, calm, relaxed.
Speech____Patient is talkative, with no speech difficulties_____________
Mood and Affect_____Patient is tired and anxious to progress her diet, but otherwise calm and relaxed.__ ___
Integumentary___Warm, dry, intact.___________________________
IV Access______Left hand. Nor redness, discharge, or edema._____________________________________________
HEENT_______Normal.__________________
Pulmonary/Thorax_________Normal__________________________________________
Cardiovascular____Normal____________________________________________________
GI___Normal. Active bowel sounds in all 4 quadrants, although patient has yet to have a bowel movement since being in
the hostpial. ____________
GU_____Not assessed. Patient denies problems. ________________________________
Musculoskeletal____Normal_____________________________________________________
Neurological normal

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11

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
WBC

Dates
7.1

(06/22/2015, 14:08)

4.3 L
Normal (4.5-11)

(6/23/2015, 05:26)

RBC
4.94
4.19 L
Normal (4.20-5.40)

(06/22/2015, 14:08)
(6/23/2015, 05:26)

Monocytes
7.6

(06/22/2015, 14:08)

13.8 H
Normal (1.0-9.0)

(06/22/2015, 14:08)

68 L
Normal (70-105)

Total Protein
7.1

The patient experienced a

significant monocyte
increase.

The patients blood

glucose level decreased
below normal values.

(6/23/2015, 05:26)

(06/22/2015, 14:08)

5.8 L
Normal (6.4-8.3)

The patient experienced a

decrease in her red blood
cell count between her
admission lab work and
her those done the day
she would be discharged.

(6/23/2015, 05:26)

Glucose
101

Trend
Upon admit, the patients
WBC were within normal
limits. The following
morning they had
dropped to below normal
range.

Loss of protein in her

blood during the patients
stay.

Analysis
Patient was admitted
following treatment of a
urinary tract infection.
This downward trend
indicates the infection is
not active and has been
treated.
It is normal to experience
a decrease of RBC with
elevated WBC counts.
Also, this may be
expected because of her
dehydration being treated
with saline, causing an
increase in her blood fluid
volume.
Acute increases in
monocytes can be the
result of stress. The
patient has no other
elevated WBC counts and
therefore infection is not
indicated.
The patient is being kept
on a clear liquid diet and
a drop in glucose is
expected. Her levels are
just barely below normal
levels and therefore do
not cause alarm, but will
be monitored.
Expected result from
being on a clear liquid
diet.

(6/23/2015, 05:26)

Physician ordered a CT scan on the abdomen of the patient due to her complaint of flank pain. The test indicated
no abnormalities to cause alarm. Flank pain was treated with heating pad, and since the pain was relieved with
University of South Florida College of Nursing Revision September 2014

12

heat treatment, and the CT scan was negative, the patients pain was determined to likely be musculoskeletal
related.
The Physician also ordered a urinalysis to be done. Due to the patients report of a urinary tract infection, this test
will give the medical team information about kidney function and sign of infection. The urinalysis showed hazy,
yellow colored urine with a specific gravity of 1.031 (normal range is 1.001-1.025) (Huether and McCance,
2012). The urine test showed mucus present in the patients urine, which is normal and expected following a
urinary tract infection ((Mayo Clinic Staff, 2015, Urinalysis).

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
The patient is currently being kept on a clear liquid diet due to her nausea and vomiting. The hope is also that
with the hydration treatments of liquid diet and normal saline IV drip, the fluids will help the constipation that the
patient is experiencing. The patient reports having decreased nausea, and requested being advanced to a full
liquid diet. The physician approved the advancement of her diet.
Patient has her vitals checked every four hours. No indication of need to increase the frequency.
The patient is not under any limitations to mobility, and is not a fall risk.
The patient is not indicated to undergo any further consults.
The plan is to discharge the patient and have her follow up with her primary care provider.

8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Nausea related to adverse reaction to medication as evidenced by patient reporting neasuea and pharmacologic treatment
of urinary tract infection.
2. Imbalanced nutrition: less than body requirements.
3. Constipation
4.

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5.

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 15 CARE PLAN
Nursing Diagnosis: Nausea related to adverse reaction to medication as evidenced by patient reporting nausea and pharmacologic treatment of urinary tract
infection.

Patient Goals/Outcomes
The patient will experience relief
of nausea and vomiting as
evidenced by verbalization of relief
of nausea before discharge.

Nursing Interventions to Achieve

Goal
Determine cause or risk for N&V
(e.g., medication effects, infectious
causes, disorders of the gut and
peritoneum, central nervous system
causes [including anxiety],
endocrine and metabolic causes
[including pregnancy],
postoperative-related status)
(Ackley and Ladwig, 2011).

Evaluate and document the

clients history of N&V, with
attention to onset, duration, timing,
volume of emesis, frequency of
pattern, setting, associated factors,
aggravating factors, and past
medical and social histories
(Ackley and Ladwig, 2011).
Document each episode of nausea
and/or vomiting separately, as well
as effectiveness of interventions.
Consider an assessment tool for

Rationale for Interventions

Provide References
Because most episodes of N&V
are now preventable, it is important
for the cause to be determined and
appropriate plan and interventions
to be developed. Reviewing the
clients medication record and
electrolytes is appropriate for early
identification of cause of nausea
(Makic, 2011). Prophylactic
interventions given before
chemotherapy have proven to be
most successful in preventing
N&V. Client expectancy of nausea
after chemotherapy is predictive of
that treatment-related side effect
(Ryan 2010; Shelke et al, 2008).
The onset and duration of nausea
and vomiting may be distinctly
associated with specific events and
may be treated differently
(Brearley, Clements, &
Molassiotis, 2008).

Evaluation of Goal on Day Care

is Provided
Progressing. The patient states that
the Bactrim she was prescribed is
likely the cause of her nausea and
vomiting. Bactrim was
discontinued at home before
admission. Observation continues.

It is important to recognize that

nausea is a subjective experience
(Brearley, Clements, &
Molassiotis, 2008; Kearney et al,

Progressing. Patient has not had an

episode of vomiting since
admission. Patient will continue to
be assessed for nausea, especially

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Progressing. As stated above, the

patient discontinued the use of the
medications that she feels caused
her nausea and vomiting.

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consistency of evaluation. A
2009; Ryan, 2010; Wood,
systematic approach can provide
Chapman, & Eilers, 2011).
consistency, accuracy, and
measurement needed to direct care
(Ackley and Ladwig, 2011).

as diet progresses.

Identify and eliminate

contributing causative factors. This
may include eliminating unpleasant
odors or medications that may be
contributing to nausea (Ackley
and Ladwig, 2011).

Progressing. Patient is in private

room. Trays from dietary are
removed promptly.

These interventions are theorybased; however, there is no

research evidence to support
outside of expert opinion (Ackley
and Ladwig, 2011).

Implement appropriate dietary

measures such as NPO status as
appropriate; small, frequent meals;
and low-fat meals. It may be
helpful to avoid foods that are
spicy, fatty, or highly salty
(Ackley and Ladwig, 2011).

Reverting to previous practices

when ill in the past and consuming
comfort foods may also be
helpful at this time. Expert opinion
consensus recommends these
interventions, with no research data
available (Eaton & Tipton, 2009;
Tipton et al, 2007).
Recognize and implement
Recognition of complications of
interventions and monitor
N&V is critical to prevent and
complications associated with
manage complications of
N&V. This may include
dehydration and electrolyte
administration of intravenous fluids imbalance (Ackley and Ladwig,
and electrolytes (Ackley and
2011).
Ladwig, 2011).

Progressing. Patient has requested

to advance diet from clear liquids
to full liquids. Physician approved
and patients tolerance will be
assessed.

Administer appropriate
antiemetics, according to emetic
cause, by most effective route,
considering the side effects of the
medication, with attention to and
coverage for the timeframes that
the nausea is anticipated (Ackley

Progressing. Patient has been

prescribed Metoclopramide
(Reglan).

Antiemetic medications are

effective at different receptor sites
and treat different causes of N&V.
A combination of agents may be
more effective than single agents
(Ryan, 2010).

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Progressing. Patient is prescribed

normal saline IV to assist with risk
of dehydration and electrolyte
imbalance.

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and Ladwig, 2011).

Provide oral care after the client
vomits (Ackley and Ladwig,
2011).

Oral care helps remove the taste

and smell of vomitus, thus
reducing the stimulus for further
vomiting (Ackley and Ladwig,
2011).
*The patient will explain methods
Consider nonpharmacological
Nonpharmacological interventions
they can use to decrease nausea and interventions such as acupressure,
are often low cost, relatively easy
vomiting. (Long term).
acupuncture, music therapy,
to use, and have few adverse
distraction, and slow, deliberate
events. CEB: A review of
movements. Nonpharmacological
acupressure studies suggest
interventions can augment
effectiveness in reducing
pharmacological interventions
chemotherapy-induced nausea and
because they predominantly affect
vomiting (CINV) when combined
the higher cortical centers that
with antiemetics (Lee et al, 2008).
trigger N&V (Ackley and Ladwig, There is early support for massage
2011).
and yoga as interventions to reduce
nausea in clients receiving
chemotherapy, as complements to
conventional antiemetics (Billhult,
Bergbom, & Stener-Victorin, 2007;
Raghavendra et al, 2007).

Complete. Patient has not vomited

since prior to admission.
Continuing observation for
vomiting.
Progressing. Need to discuss with
patient about how to avoid and
treat nausea without
pharmacological interference.

Include a minimum of one

Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
xDietary Consult
PT/ OT
Pastoral Care
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Durable Medical Needs

x F/U appointments
x Med Instruction/Prescription
x are any of the patients medications available at a discount pharmacy? xYes No
Rehab/ HH
Palliative Care

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References

1. Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.
2. Billhult A., Bergbom I., Stener-Victorin E. (2007). Massage relieves nausea in women with breast
cancer who are undergoing chemotherapy, J Altern Complement Med 13(1):53-57.
3. Brearley S.G., Clements C.V., Molassiotis A. (2008). A review of patient self-report tools for
chemotherapy-induced nausea and vomiting, Support Care Cancer 16(11):1213-1229.
4. Eaton L.H., Tipton J.M. (2009). Putting evidence into practice: improving oncology patient outcomes,
Pittsburgh, PA, Oncology Nursing Society.
5. Heuther, S.E. & McCance, K.L. (2012). Understanding Pathophysiology. St. Louis, MO: Mosby
Elsevier.
6. Kearney N., et al (2008). Evaluation of a mobile phone-based, advanced symptom management system
(ASyMS) in the management of chemotherapy-related toxicity, Support Care Cancer 17:437-444.
7. Lee J., et al (2008). Review of acupressure studies for chemotherapy-induced nausea and vomiting
control, J Pain Symptom Manage 36(5):529-544.
8. Makic M.B. (2011). Management of nausea, vomiting and diarrhea during critical illness, Adv Crit
Care Nurs 22(3):265-274.
9. McLeod, Saul (2008). Erik Erickson. Retrieved from http://www.simplypsychology.org/ErikErikson.html
10. Raghavendra R.M., et al (2007). Effects of an integrated yoga programme on chemotherapy-induced
nausea and emesis in breast cancer patients, Eur J Cancer Care 16(6):462-474.
11. Ryan J.L. (2008).Treatment of chemotherapy-induced nausea in cancer patients, Eur Oncol 6(2):14-16.
12. Shelke A.R., et al (2008). Effect of a nausea expectancy manipulation on chemotherapy-induced
nausea: a University of Rochester Cancer Center Community Clinical Oncology Program study, J Pain
Symptom Manage 35(4):381-387.
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13. Tipton J.M., et al (2007). Putting evidence into practice: evidence-based interventions to prevent,
manage, and treat chemotherapy-induced nausea and vomiting, Clin J Oncol Nurs 11(1):69-78.
14. Urinalysis. (2014, February 15). Retrieved from http://www.mayoclinic.org/testsprocedures/urinalysis/basics/results/prc-20020390
15. Wood J.M., Chapman K., Eilers J. (2011). Tools for assessing nausea, vomiting, and retching, Cancer
Nurs 34(1):E14-E24.

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