UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Anjouli Marie Gerez

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION

Assignment Date: June 30, 2015

Agency: Bayfront Medical Center

Patient Initials: D.F.

Age: 76 years old

Admission Date: June 28, 2015

Gender: Male

Marital Status: Married

Primary Medical Diagnosis: Urinary Retention

(ICD-10 code: R33.8)

Primary Language: English

Level of Education: Associates Degree in Agrobusiness

Other Medical Diagnoses:

1. Generalized Weakness
(ICD-10 code: M62.81)
2. Urinary Tract Infection (UTI)
(ICD-10 code: N39.0)
3. Acute Renal Failure
(ICD-10 code: N17.9)

Occupation (if retired, what from?): Retired from Metal Quality Control
Number/ages children/siblings: Two daughters: Cathy (49 years
old) and Amy (45 years old)
Two brothers: older brother died at 73 years old and younger
brother is 65 years old
Served/Veteran: Served in the army for two years
If yes: Ever deployed? Yes or No
Living Arrangements: a one story house in St. Petersburg with
second wife and two cats

Code Status: Full Code

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Procedure and Date: No surgery done
during this admission.

Culture/ Ethnicity /Nationality: White Caucasian

Religion: Agnostic

Type of Insurance: Care Plus / HMO Insurance

1 CHIEF COMPLAINT:
I went to the movies with my wife. When we went back to the car, I felt weak. I could not get myself up inside the car
and my wife helped me get inside the car. I went home and rested. When I used the toilet, I just felt more weak and I
could not get up out of the toilet. I called my wife and she called 911.

3 HISTORY OF PRESENT ILLNESS:

Patient was brought in by the ambulance to the emergency room at Bayfront Medical Center on Sunday, 06/28/2015.
Patient stated that he developed generalized weakness around 1530 on 06/28/2015 while he was in the toilet at his home.
Patient further stated that he has not been able to urinate and has been feeling a little weak for the last two days prior to his
admission on 06/28/2015. Patient also stated that he vomited once at home on 06/27/2015 and he stated that the urinary
problem is probably what is making the weakness worse and nothing relieves the weakness. He also stated that he has not
used any treatments to improve the weakness. While in the emergency room, a chest x-ray was ordered for his generalized
weakness and the results showed no evidence of acute cardiopulmonary abnormality but the patient was found to have
urinary retention with almost 1000 mL residual and he had an abnormal urinalysis with mildly elevated creatinine. An

University of South Florida College of Nursing Revision September 2014

indwelling catheter was inserted on him in the emergency room. He was started on antibiotics and he was admitted to the
medical surgical floor at Bayfront Medical Center on Sunday, 06/28/2015, for further care. On Monday (June 29, 2015),
an ultrasound for the retroperitoneal was ordered due to his urinary retentions and the results showed no abnormalities and
no presence of calculi on both kidneys. On Tuesday (06/30/2015), the antibiotics are still continued, the patient has an
improving creatinine level, and the urologist ordered for the indwelling catheter to be taken home with him and be
inserted for one to two weeks. Patient complains about his lower back pain that has been going on for years that has a pain
level of 5/10. He states that it is worst when he is lying in bed and it only feels better when he moves around to reposition
himself. He states that he is hoping that he will be getting a medication for his back pain. Although the provider ordered
home health care for the patients indwelling catheter care, patient further states that he is worried about going home with
the indwelling catheter. However, he states that he is feeling well and he is ready to go home.

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

Father

86

Mother

93

Brother

73

Brother

65

Maternal
Grandmother
Maternal
Grandfather
Paternal
Grandmother
Paternal
Grandfather

92

Cancer

90

Old age

94

Old age

92

Old age

University of South Florida College of Nursing Revision September 2014

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Cause
of
Death
(if
applicable
)
Patient
states that
his heart
just
stopped
working.
Old age
Liver
failure
Not
Applicabl
e

Arthritis

2
FAMILY
MEDICAL
HISTORY

Age (in years)

2009
2013

Anemia

1998
2000
2002

Environmental
Allergies

Operation or Illness
Benign Prostate Hyperplasia (BPH): tamsulosin 0.4 mg, one capsule by mouth daily
Depression: citalopram 40 mg, one tablet by mouth daily; primidone 50 mg, one table by mouth
two times daily (treats the tremors due to the side effect of citalopram)
Hyperlipidemia: gemfibrozil 600 mg, one tablet by mouth two times daily
Artherosclerosis: propranolol 80 mg, one tabled by mouth two times daily
Peripheral Vascular Disease: amlodipine 5 mg, one tablet by mouth daily; nitroglycerin 2.5 mg,
one capsule by mouth daily
Triple Bypass Heart Surgery- stented coronary artery: aspirin 81 mg, one tablet by mouth daily
Left Below Knee Amputation Surgery: baclofen 10 mg, one tablet by mouth three times daily;
physical therapy after surgery

Alcoholism

Date
1990
1995

Comments: Patient states that his brother started drinking during his teenage years and he just started having kidney and liver issues as
he became older.

1 IMMUNIZATION HISTORY
YES

NO

Routine childhood vaccinations

Routine adult vaccinations for military or federal service
Adult Diphtheria (Date: Not Applicable)
Adult Tetanus (Date: Patient states probably ten years ago)
Influenza (flu) (Date: Patient states that the last one was three years ago.
Doctor recommended him not to get one anymore due to his reaction of
bulging lips after the immunization)
Pneumococcal (pneumonia) (Date: Not Applicable)
Have you had any other vaccines given for international travel or
occupational purposes? (Please List: Not Applicable)
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

No Known Drug Allergies

Not Applicable

Environmental: Pollen

Patient states that it is seasonal and he gets very bad runny

nose.

Medications

Other (food, tape,

latex, dye, etc.)

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)
Benign Prostatic Hyperplasia (BPH) is the enlargement of the prostate gland. The prostate in men is pea-sized at birth and it gradually
increased in puberty. Furthermore, there is a period of rapid development until a man reaches around the age of 30 when the prostate
reaches adult size. Benign hyperplasia begins at the around the age of 40 to 45 and continues slowly until death. However, this
condition becomes a problem when the prostate compresses the urethra that passes through the prostate (Huether & McCance, 2012).
The bladder wall thickens and eventually weakens. Therefore, it loses the ability to empty completely and some urine is left in the
bladder. BPH is more common with men who are 40 years and older (NIH, 2014). It also common to black men than white men and a
family history of BPH increases the risk as well. In addition obesity with fat distribution around the abdomen, heart and circulatory
disease, and type II diabetes also increases the risk of BPH (Huether & McCance, 2012).
BPH can be diagnosed from medical history, physical examination, and laboratory tests including a urinalysis. A digital rectal
examination (DRE) and measurement of prostate-specific antigen (PSA) are also conducted to determine hyperplasia (Huether &
McCance, 2012). BPH can be treated through lifestyle changes such as reducing intake of caffeinated beverages and alcohol and
medications such as Alpha Blockers like tamsulosin (Flomax). It can also be treated through minimally invasive procedures such as
prostatic stent insertion and surgery such as transurethral resection of the prostate (TURP) (NIH, 2014). The patient was admitted with
a urinary retention possibly due to BPH and it was diagnosed through a urinalysis and a prostate examination. In addition, the patient

University of South Florida College of Nursing Revision September 2014

has been treated with tamsulosin (Flomax), an Alpha Blocker.

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 amlodipine (Norvasc)

Concentration

Dosage Amount 5 mg

Route Oral

Frequency One time daily

Pharmaceutical class Calcium channel blocker

Home

Hospital

or

Both

Indication Decreases total peripheral vascular resistance and blood pressure by vasodilation
Side effects: Headache, flushing, dizziness, nausea, chest pain, orhostatic hypotension
Adverse effects: Excessive peripheral hypotension marked by hypotension
Nursing considerations: Assess blood pressure, if systolic blood pressure is less than 90 mm Hg then hold medication and contact physician
Patient Teaching: Do not abruptly discontinue medication, slowly stand up because it can cause dizziness and orthostatic hypotension
Name aspirin (Bayer)

Concentration

Dosage Amount 81 mg

Route Oral

Frequency One time daily

Pharmaceutical class Non-steroidal salicylate

Home

Hospital

or

Both

Indication Inhibits platelet aggregation

Side effects: GI distress including abdominal distention, mild nausea, and cramping
Adverse effects: GI bleeding, tinnitus, tachycardia, abnormal breathing patterns
Nursing considerations: Watch out for signs of bleeding, abdominal GI pain, and tinnitus
Patient Teaching: Report to provider signs of bleeding, abdominal GI pain, and tinnitus
Name baclofen (Lioresal)

Concentration

Dosage Amount 10 mg

Route Oral

Frequency Hospital: PRN (as needed)

Home: three times daily

Pharmaceutical class Skeletal muscle relaxant

Home

Hospital

or

Both

Indication Treats any cerebral spasms or bladder spasms

Side effects: Transient drowsiness, dizziness, light-headedness, nausea, vomiting, tremors, dry mouth
Adverse effects: Severe muscle weakness, vomiting, respiratory depression
Nursing considerations: Monitor hepatic and renal function tests as well as blood counts; Observe patient for drowsiness, dizziness, and ataxia
Patient Teaching: Take with food or milk and do not abruptly withdraw medication
Name citalopram (Celexa)

Concentration

Dosage Amount 40 mg

Route Oral

Frequency Hospital: two tablets daily

Home: one tablet daily

Pharmaceutical class Serotonin reuptake inhibitor

Home

Hospital

or

Both

Indication Treatment of depression

Side effects: Nausea, dry mouth, drowsiness, insomnia, tremor, diarrhea, sexual dysfunction
Adverse effects: Dizziness, tachycardia, confusion, hepatic impairment
Nursing considerations: Assess sleep pattern, renal and liver tests as well as blood count
Patient Teaching: Avoid alcohol, do not stop taking medication or increase dosage, and report suicidal ideation and worsening depression. The worsening of depression
and suicidal ideation may take effect if the drug is not working after one to four weeks of therapy.
Name hydralazine (Apresoline)

Concentration

Dosage Amount 10 mg

Route Intravenous push

Frequency Every six hours interval, PRN (as needed)

Pharmaceutical class Vasodilator

Home

Hospital

or

Both

Indication management of moderate to severe hypertension

Side effects: headache, anorexia, nausea, vomiting, diarrhea, muscle cramps, tachycardia
Adverse effects: severe orthostatic hypotension, skin flushing, severe headache
Nursing considerations: Obtain blood pressure and pulse before each dose and monitor blood pressure
Patient Teaching: Rise slowly from lying to sitting position
Name primidone (Mysoline)

Concentration

Dosage Amount 50 mg

Route Oral

Frequency One tablet two times daily

Pharmaceutical class Barbiturate

Home

Hospital

or

Both

Indication Treatment of essential tremor

University of South Florida College of Nursing Revision September 2014

Side effects: Ataxia, dizziness, nausea, vomiting, altered mental status

Adverse effects: Tremor, seizures, blood dyscrasias
Nursing considerations: Monitor complete blood count and monitor for changes in behavior and suicidal ideation
Patient Teaching: Take with food to minimize GI effects, if dizziness occurs, change positions slowly.
Name propranolol (Inderal)

Concentration

Dosage Amount 80 mg

Route Oral

Frequency One tablet two times daily

Pharmaceutical class Beta-adrenergic blocker

Home

Hospital

or

Both

Indication Treatment for dysrhythmias, hypertension, and essential tremors

Side effects: Drowsiness, difficulty sleeping, unusual fatigue, bradycardia, diarrhea
Adverse effects: Hypotension
Nursing considerations: Assess blood pressure and apical pulse before administering the drug (if pulse is 60/min or less or systolic BP is 90 mm Hg or less, withhold
medication and contact the physician) and monitor hepatic function
Patient Teaching: Do not abruptly discontinue medication and rise slowly from lying position to avoid hypotensive effect
Name 0.9 % Sodium Chloride

Concentration

Dosage Amount 1000 mL

Route Intravenous

Frequency Continuous

Pharmaceutical class Mineral and electrolyte replacements

Home

Hospital

or

Both

Indication Sodium depletion, extracellular fluid volume deficit with sodium deficit
Side Effects: Facial flushing, irritation, phlebitis
Adverse Effects: Peripheral edema, hypokalemia, hypervolemia, hypernatremia
Nursing considerations: Obtain baseline serum electrolyte and assess fluid balance; Monitor for any pain or redness around the intravenous site
Patient Teaching: Temporary burning irritation may occur upon instillation of eye medication and monitor for any pain or redness around the intravenous site
Name ceftriaxone (Rocephin)

Concentration

Dosage Amount 1 gram

Route Intravenous Piggyback

Frequency Daily

Pharmaceutical class Third-generation cephalosporin

Home

Hospital

or

Both

Indication Treatment of susceptible infection due to urinary tract infection

Side effects: Oral candidiasis (thrush), mild abdominal cramping, diarrhea, nausea
Adverse effects: abdominal cramps, severe watery diarrhea, fever
Nursing considerations: Asses for history of allergies to penicillin, assess oral cavity for white patches on mucous membranes, and monitor bowel activity patterns
Patient Teaching: Continue antibiotic therapy for full length of treatment
Name 0.9 % Sodium Chloride Syringe Flush

Concentration

Dosage Amount 3 mL

Route Intravenous

Frequency Every eight hours

Pharmaceutical class Mineral and electrolyte replacements

Home

Hospital

or

Both

Indication Sodium depletion, extracellular fluid volume deficit with sodium deficit
Side Effects: irritation at the injection site
Nursing considerations: Obtain baseline serum electrolyte and assess fluid balance, do not flush rapidly to the intravenous line, and monitor for any pain or redness
around the intravenous site
Patient Teaching: Temporary burning irritation may occur upon instillation of eye medication; Monitor for any pain or redness around the intravenous site
Name tamsulosin (Flomax)

Concentration

Dosage Amount 0.4 mg

Route Oral

Frequency One capsule daily

Pharmaceutical class Alpha1-adrenergic blocker

Home

Hospital

or

Both

Indication Treatment of bladder dysfunction and symptoms of benign prostate hyperplasia

Side effects: Dizziness, drowsiness, headache, orthostatic hypotension, nausea, anxiety
Adverse effects: Tachycardia
Nursing considerations: Assist with ambulation and monitor renal function, weight changes, and peripheral edema; Monitor blood pressure and decreased respirations
Patient Teaching: Take 30 minutes after meals and use caution when getting up from sitting or lying position
Name gemfibrozil (Lopid)

Concentration

Dosage Amount 600 mg

Route Oral

Frequency one tablet two times daily

Pharmaceutical class Fibric acid derivative

Home

Hospital

or

Both

Indication Treatment for hyperlipidemia

Side effects: Dyspepsia, abdominal pain, diarrhea, vomiting, fatigue, altered taste, headache, vertigo
Adverse effects: Cholelithiasis, cholecystitis, pancreatitis

University of South Florida College of Nursing Revision September 2014

Nursing considerations: Monitor bowel activity pattern and stool consistency and monitor hepatic function
Patient Teaching: Take before meals and notify physician if dizziness, blurred vision, abdominal pain, diarrhea, nausea, and vomiting becomes pronounced
Name nitroglycerin (Nitrostat)

Concentration

Dosage Amount 0.4 mg

Route Oral (sublingual)

Frequency every five minutes, PRN (as needed)

Pharmaceutical class Nitrate

Home

Hospital

or

Both

Indication Used for acute relief of angina pectoris

Side effects: Headache, dizziness, weakness, burning, tingling sensation at oral point of dissolution
Adverse effects: Blurred vision, dry mouth, severe orthostatic hypotension
Nursing consideration: Monitor blood pressure and heart rate before and after administration, hold the medication if the systolic blood pressure (SBP) is less then 90
mmHg, and assess for facial and neck flushing
Patient Teaching: Rise slowly from lying to sitting position, dissolve sublingual tablet under tongue and do not swallow, take at first sign of angina, take up to a total of
three doses and if pain is not relieved contact physician or immediately go to the emergency room, expel from mouth any remaining tablet after pain is relieved
Name finasteride (Proscar)

Concentration

Dosage Amount 5 mg

Route oral

Frequency one tablet twice daily

Pharmaceutical class Androgen hormone inhibitor

Home

Hospital or

Both

Indication Used for urinary hesitancy, feeling of incomplete bladder emptying, difficulty of initiating flow, and interruption of urinary stream; Reduces risk of need for
surgery in symptomatic benign prostatic hyperplasia
Side effects: Gynecomastia, sexual dysfunction
Adverse effects: Hypersensitivity reaction, swelling around the mouth, testicular pain
Nursing considerations: Monitor input and output
Patient Teaching: May not notice improved urinary flow even if prostate gland shrinks and need to take medication longer than six months

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:

Breakfast: 1 cup of cheerios, 1 regular size of white bread,

1 tablespoon of peanut butter

This graph shows that the patient is lacking some of the

food groups. According to USDA (n.d.), the patient has a
daily amount that is under for grains, fruits, and dairy.
However, he has a daily amount that is over for vegetables
and protein. Although he has given up drinking alcohol, he
needs to be more careful of his diet by eating a more
balanced diet of grains, vegetables, fruits, dairy, and protein
because he has a history of peripheral vascular disease, he
had a triple bypass surgery, hyperlipidemia, and other
complications that need a balanced diet for a healthier
living. The patient may also see a dietitian to help with his
diet.

Lunch: 1 piece of medium boneless breast chicken, 1 cup of

frozen mixed vegetables

University of South Florida College of Nursing Revision September 2014

Dinner: 1 medium steak, 1 piece of potato, 1 cup of frozen

mixed vegetables
Snacks: 1 chocolate chip cookie
Liquids (include alcohol): , 1 cup of coffee

1 COPING ASSESSMENT/SUPPORT SYSTEM:

Who helps you when you are ill?
Patient states that wife helps him when he is ill.
How do you generally cope with stress? or What do you do when you are upset?
Patient states that, I do not cope with stress very well and I just hold it all in. He further states that, I do not talk about
it with his wife because we end up fighting about the issue and that, I had a very bad temper when I used to work and
this is why I got fired in so many jobs. Patient also stated that, I try to go outside and look around when I am upset or
stressed out and before my leg amputation, I used to walk outside when I am upset or stressed out.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient states that, I suffer from depression and I feel anxious and overwhelmed due to my illness but I take pills for it.
Patient also states that, I get along with my daughters very well but I try my best to get along with my stepdaughters and
stepsons because they have medical problems.

+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? __Yes____ 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? No_If yes,
have you sought help for this? __Not Applicable___
Are you currently in a safe relationship? Yes

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:
Eriksons stage eight of psychosocial development is ego integrity versus despair. This stage is about the acceptance of ones life,
worth, and eventual death. Ego integrity shows a satisfaction with life and an understanding of the place of a person in the life cycle.
Meanwhile, despair is a sense of discomfort with life and aging, loss, and fear of death (Treas & Wilkinson, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient is undergoing Eriksons psychosocial development of despair because patient stated that, I am dying and I do not want to
die but I do not want to live life like how I am living it right now. He also states that, I believe that inside an old person is a young

University of South Florida College of Nursing Revision September 2014

person saying what the hell happened. In addition, he would sometimes look away with a sad face while being asked various
questions during the interview about his condition.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The patient had many health complications; however, the health complications that caused his below the knee amputation surgery on
his left leg is what lead him to his psychosocial development of despair because the patient stated that, I still sometimes dream that I
have my leg and he also stated that, if you can help me grow my leg back then that will make my life better.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states that, my illness is due to biological reasons because I am 76 years old and just old.
What does your illness mean to you?
Patient states that, my illness means that I am old and it is all just biological.

+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?__Women_____________________
Are you aware of ever having a sexually transmitted infection? __No______
Have you or a partner ever had an abnormal pap smear?__None________
Have you or your partner received the Gardasil (HPV) vaccination? ___None___________
Are you currently sexually active? ____No__If yes, are you in a monogamous relationship? __Not Applicable____
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? ____Not Applicable________
How long have you been with your current partner?___25 years_________
Have any medical or surgical conditions changed your ability to have sexual activity? __Yes__
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
_No__

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?
Patient states that, it is hard to say and there is nothing important to say about religion or spirituality because I am agnostic. Patient
further states that, I believe that there is a God but I do not think that going to church is the answer.
____________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
Patient states that, my current condition is because of biological, being 76 years old, and just being old.
______________________________________________________________________________________________________

+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? cigarettes
How much?(specify daily amount)
1 pack/day

Yes
No
For how many years? 55 years
(age 21

thru

present

If applicable, when did the

patient quit? Not Applicable

Pack Years: 69
Does anyone in the patients household smoke tobacco? If
so, what, and how much? Patient states that, my wife
smokes one pack of cigarettes per day.

Has the patient ever tried to quit? Yes

If yes, what did they use to try to quit? Nicotine patches
and Nicotine gum

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? hard liquor
How much? Two to four shots
Volume: 1.5 fluid ounces per shot
Frequency: occasionally
If applicable, when did the patient quit?
60 years old

For how many years?

(age: 18 thru

60

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 denies any exposure to occupational or environmental hazards or risks. However, patient stated that, I worked
with metals and specifically Titanium as a metal quality control worker before I retired.
5. For Veterans: Have you had any kind of service related exposure?
None

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 that he views his overall health as deteriorating and going downhill due to his age of 75 years old. Patient also states that
he is at an age that indicates that he is very old.
Integumentary:
The patient has liver spots on his legs, arms, and face. The patient also has gray colored hair and hair distribution appropriate for his
age. The patient has dandruff that has constant itching and patient stated it is possibly due to his surgeries. The patient stated he has
skin lupus that never itches but it is relieved with prednisone. The patient has a bathing routine of two times a week since his
amputation. The patient denies nail problems, psoriasis, hives, rashes, other skin infections, and the use of sunscreen.
HEENT:
The patient has difficulty seeing and for this reason he wears glasses. The patient also has difficulty hearing and he uses hearing aids to
correct this problem. The patient has dental problems in which his teeth are falling out but he does not use dentures to correct this
problem. The patient has routine brushing of teeth twice per day because it helps him from worrying about his dental problems. The
patient denies a history of cataracts or glaucoma. The patient denies ear infections, sinus pain, sinus infections, nosebleeds, post-nasal
drip, oral infection, pharyngeal infection, routine dentist visits, and vision screenings.
Pulmonary:
The patient has difficult breathing due to shortness of breath from his murmur. The patient stated that he has a history of bronchitis that
happened two years ago due to his chronic coughing. The patient had chest x-ray performed on Sunday, 06/28/2015, due to his
generalized weakness on admission. The patient has environmental allergies to pollen in which he gets a runny nose and he relieves it
through allergy medications and avoiding pollen. Patient denies cough, asthma, current bronchitis, emphysema, pneumonia, and
tuberculosis.
Cardiovascular:
The patient has hypertension due to high blood pressure and high cholesterol that he relieves with medications. The patient has
hyperlipidemia that he relieves with medications. The patient has a murmur due to his poor valves. Patient denies chest pain, angina,
myocardial infarction, Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), thrombus, rheumatic fever, myocarditis,
arrhythmias, and electrocardiogram screening.
GI:
The patient had vomiting two days prior to his admission on Sunday, 06/28/2015, and patient stated he did not know what caused it.
The patient had a colonoscopy three years ago possibly due to his age. Patient denies nausea, diarrhea, constipation, gastroesophageal
reflux disease (GERD), indigestion, hemorrhoids, yellow jaundice, pancreatitis, colitis, diverticulitis, appendicitis, and abnormal
abscess.
GU:
The patient has urinary tract infection that caused his urinary retention. The patient has normal urination frequency of 800 mL per day.
The patient denies nocturia, dysuria, hematuria, polyuria, and kidney stones.
Women/Men Only:
The patient had a prostate exam on Monday, 06/29/2015, possible due to his urinary retention. The patient has urinary retention
possibly due to his BPH. Patient has BPH and he stated it is due to his age. The patient denies infection of male genitalia or prostate.
Musculoskeletal:
The patient has weakness possibly due to his urinary retention. The patient stated that he has arthritis, which comes and goes. Patient
denies injuries or fractures, pain, gout, and osteomyelitis.

University of South Florida College of Nursing Revision September 2014

10

Immunologic:
The patient stated he has skin lupus that never itches but it is relieved with prednisone. The patient denies chills with severe shaking,
night sweats, fever, Human Immunodeficiency Virus (HIV), rheumatoid arthritis, sarcoidosis, tumor, life threatening allergic reaction,
and enlarged lymph nodes.
Hematologic/Oncologic:
Patient stated that he had a blood transfusion during his leg amputation surgery. Patient states that he has a blood type of A plus.
Patient denies anemia, bleeding easily, bruises easily, and cancer.
Metabolic/Endocrine:
Patient denies diabetes, hypothyroidism or hyperthyroidism, intolerance to hot or cold, and osteoporosis.
Central Nervous System:
Patient denies cerebrovascular accident (CVA), dizziness, severe headaches, migraines, seizures, ticks or tremors, encephalitis, and
meningitis.
Mental Illness:
Patient has depression that started when he started having health complication but it is treated with medications. Patient has anxiety
possibly due to his depression that is treated with medications. Patient denies schizophrenia and bipolar.
Childhood Diseases:
Patient had measles, mumps, and chicken pox. Patient denies polio and scarlet fever.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
The patient denies any other medical problem in which he sought medical attention for with anyone.
Any other questions or comments that your patient would like you to know?
The patient does not have any questions or comments that he wanted me to know.

10 PHYSICAL EXAMINATION:
General survey: The patient is a 76 years old, male, who is awake, alert, and oriented times three (AAOx3) and not
overweight.
Height _70 inches Weight_72.75 kg__ BMI _24.3 _
Pain (include rating and location) 5/10 in his lower back_ Pulse__92_____
Blood Pressure (include location)_121/62 on upper left arm_Temperature (route taken)_97.4 F Oral___________
Respirations___20_________ SpO2 ____96%______Room Air or O2____Room Air________________________
Overall Appearance The patient has gray hair that is evenly distributed and according to his age. The patient is clean; hair
is combed, and maintains eye contact. He is dress appropriately for the setting and temperature. The patient has left below
the knee amputation. _______________________________________________________________________________
Overall Behavior The patient is awake, calm, relaxed, interacts well with others, and judgment is intact._____________
Speech The patient has clear and crisp diction.___________________
Mood and Affect The patient is cooperative, quiet, flat, and apathetic.__________
Integumentary_The patient has a skin that is warm, dry, and intact, skin turgor is elastic, and capillary refill is under three
seconds. He has hair that is evenly distributed and according to his age. He has clean hair without vermin. The patient has
old age spots or solar lentigines on his arms and legs that is normal to his age.
IV Access_ The patient has an IV line that is size 22 gauge on his right antecubital (AC). The IV line was inserted on
Sunday, 06/28/2015. The IV site does no have any redness, edema, or discharge. The IV is infusing fluid of 0.9% Sodium
Chloride (0.9% Normal Saline).____________________
HEENT_The patient has facial features that are symmetric. Patient has no pain in sinus region and in clicking of
temporomandibular joint (TMJ). Patient has no enlarged thyroid and no palpable lymph nodes. Patient has a trachea that is
midline. Patient has sclera that is white and clear conjunctiva without any discharges or lesions. Patient has eyebrows,
eyelids, orbital area, eyelashes, and lacrimal glands that are symmetric and without edema or tenderness. Patient has pupils
that are equal, round, and reactive to light and accommodation with a pupil size of 3mm in light on both eyes. The
peripheral vision is intact and extraocular movements (EOM) are intact through six cardinal fields without nystagmus.

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Patient has symmetric ears without lesions or discharges. Patient was not able to hear on both ears during the whisper test
because he did not have his hearing aids on. Patient has no lesions or discharges on his nose. Patient has lips, buccal
mucosa, and floor of mouth that does not have any lesions or discharges. Patient has a symmetrical tongue that is pink and
moist without lesions. Patient does not wear dentures but he has teeth that are complete on the front but some are missing in
the back of his mouth.
Pulmonary/Thorax_Patient has regular respirations but he became a little short of breath when he started talking. Patient
has percussion that is resonant through all lung fields and dull towards posterior bases. Patient has a small white sputum
production. Patient has wheezes bilaterally on right lower lobe and left lower lobe. Patient has clear lung sounds bilaterally
on right upper lobe, left upper lobe, and right middle lobe.
Cardiovascular Patient has no lifts, heaves, or thrills. Patient has a murmur. Patient has pulses bilaterally equal on a rating
scale of three(normal) on apical, carotid, brachial, radial, femoral, and popliteal. Patient has pulses bilaterally equal on a
rating scale of three(normal) on left posterior tibial and dorsalis pedis. Patient has no access of pulses on right posterior
tibial and dorsalis pedis due to below the knee amputation. Patient has no carotid bruits and no edema. Patient has
extremities that are warm and have a capillary refill of less than three seconds.______
GI_The patient has active bowel sounds on all four quadrants. Patient has no bruits during auscultation. Patient has no
organomegaly and percussion is dull over liver and spleen but tympanic over stomach and intestine. Patient has abdomen
that is non-tender to palpation. Patient denies nausea. Patient has a genitalia that is clean, moist, without discharges, lesions
or odor. Patient had his last bowel movement on Saturday, 06/27/2015, that was medium brown and soft.______
GU_The patient has an indwelling catheter. The patient has a urine output that is clear with an amber color and 24 hour
output of 850 mL. The patient had no rebound tenderness during costovertebral angle (CVA) punch.
Musculoskeletal_Patient has an intact range of motion (ROM) in all extremities without crepitus. Patient has equal strength
rating of five (against full resistance) bilaterally on right upper extremities, left upper extremities and right lower
extremities. Patient has no access for strength test and ROM on left lower extremities due to below the knee amputation.
Patient has a vertebral column without kyphosis or scoliosis. Patient has peripheral pulses on right lower extremities but
does not have access on left lower extremities due to below the knee amputation. Patient has no pallor. Patient denies pain
and paresthesia. ___________________________________________________________________________________
Neurological Patient is awake, alert, oriented to person, place, and time. Patient has a sensation that is intact to touch, pain,
and vibration. Patient has a stereognosis, graphesthesia, and proprioception that are not intact. Patient is not able to
ambulate because he did not have his left prosthetic leg. Therefore, gait and Romberg tests were not performed. The deep
tendon reflex and Babinski tests were not performed as well because equipment is unavailable.

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):
Lab
White Blood Count (WBC)
Normal (4.5-11)

Dates

13.9 H
(06/28/2015)
10.7
(06/29/2015
)
Red Blood Count (RBC)
Normal (3.81-5.81)
1.79 L

(06/28/2015)

3.73 L

(06/29/2015)

Trend
On admission, the patient
has a high WBC that
shows that his body is
fighting off an infection
or inflammation.
However, the WBC trend
went downwards after
one day indicating that
the infection is starting to
leave the body.
On admission, the patient
has a low RBC that
shows he has a disease
process going through his
body. The RBC trend
remains low after one day
indicating that the disease

Analysis
WBC evaluates viral and
bacterial infections.
Increased WBC shows
presence of infection and
inflammation due to this
patients UTI.

RBC evaluates the

number of circulating
RBC in the blood towards
diagnosing a disease. A
decreased RBC shows a
continuing disease
process due to renal

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12

process continues.

Hemoglobin
Normal (12.6 17.4 g/dL)
11.2 L

(06/28/2015)

11.5 L

(06/29/2015)

33.7 L

(06/28/2015)

33.6 L

(06/29/2015)

Hematocrit
Normal (36-52)

Platelet
Normal (150,000 400,000 microL)
132 L

(06/28/2015)

117 L

(06/29/2015)

Mean Platelet Volume (MPV)

Normal (7.1-10.2)
7.2

(06/28/2015)

7.7

(06/29/2015)

Yellow

(06/28/2015)

UR Color

UR Clarity
Hazy

(06/28/2015)

On admission, the patient

has decreased
hemoglobin that shows he
has a disease process
going through his body.
The hemoglobin trend
remains low after one day
indicating that the disease
process continues.
On admission, the patient
has decreased hematocrit
that shows he has a
disease process going
through his body. The
hematocrit trend remains
low after one day
indicating that the disease
process continues.
On admission, the patient
has decreased platelet that
shows he has a possible
blood disorder going
through his body. The
platelet trend remains low
after one day indicating
that the possible blood
disorder continues.
On admission, the patient
has an MPV within the
normal range. The MPV
trend continues to be
within the normal range
that shows that the patient
does not have any
possible blood disorder.
On admission, the patient
has a urine color of
yellow that shows that he
does not any presence of
unusual substances in his
urine.
On admission, the patient
has a urine clarity of hazy
may indicate a condition

problems that may be

related to decrease
production of
erythropoietin.
Hemoglobin verifies the
conditions involving the
RBC. A low hemoglobin
shows a continuing
disease process possibly
due to renal problems that
may be related to
decrease production of
erythropoietin.
Hematocrit measures the
percentage of the volume
of whole blood. A low
hematocrit shows a
continuing disease
process possibly due to
renal problems that may
be related to decrease
production of
erythropoietin.
Platelet assists in
diagnosing and evaluating
treatment for blood
disorders. A low platelet
shows a possible blood
disorder in his body
process possibly due to
the UTI.
MPV verifies conditions
involving the platelet. An
MPV that is within the
normal range shows that
the patient may only have
an acute blood disorder
problems due to the low
platelet trends.
Urinalysis is used to
screen for multiple
substances such as
infection. A urine color of
yellow shows no presence
of unusual substances in
the urine of the patient.
Urinalysis is used to
screen for multiple
substances such as

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13

going through his body.

UR Specific Gravity
Normal (1.001-1.029)
1.008

(06/28/2015)

UR pH
Normal (5-9)

On admission, the patient

has a urine specific
gravity within the normal
range that shows that his
kidney is able to dilute or
concentrate his urine.

(06/28/2015)

On admission, the patient

has a urine pH within the
normal range that shows
that his urine does not
have a high level of acid.

UR Protein
Normal (Less than 20 mg/dL)
30 A

(06/28/2015)

On admission, the patient

has a urine protein that is
high that shows albumin
is present in the urine of
the patient.

UR Occult Blood
Small A

(06/28/2015)

UR Leukocyte Esterase
Moderate A

(06/28/2015)

Sodium
Normal (135-145mEq/L)

On admission, the patient

has a small occult blood
in urine possibly due to
kidney problems.
On admission, the patient
has a moderate leukocyte
esterase in his urine
possibly due to bacterial
infection.

On admission, the patient

has a low sodium
possibly due to the

infection. A urine clarity

of hazy indicates a
condition going through
his body possibly due to
UTI.
Urinalysis is used to
screen for multiple
substances such as
infection. A urine specific
gravity within the normal
range indicates that the
kidney is still able to
dilute or concentrate the
solutes in the urine.
Urinalysis is used to
screen for multiple
substances such as
infection. A urine pH
within the normal range
indicates that the patient
does not have a high level
of acid in his urine.
Urinalysis is used to
screen for multiple
substances such as
infection. A urine protein
that is high shows that
albumin is present in the
urine of the patient and
this is possibly due to his
kidney problems.
Urinalysis is used to
screen for multiple
substances such as
infection. A small occult
blood in urine is due to
the UTI.
Urinalysis is used to
screen for multiple
substances such as
infection. A leukocyte
esterase is a urine test to
look for white blood cells
and other signs of
infection. A moderate
leukocyte esterase is due
to the UTI.
Sodium is used to assess
electrolyte balance related
to various disorders. A

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14

127 L

(06/28/2015)

130 L

(06/29/2015)

129L

(06/30/2015)

Potassium
Normal (3.5-5.3mEq/L)
4.1

(06/28/2015)

3.7

(06/29/2015)

3.8

(06/30/2015)

Chloride
Normal(97-107 mEq/L)
96 L
96 L

(06/28/2015)
(06/29/2015
)

98
(06/30/2015)

Blood Urea Nitrogen (BUN)

Normal (8-21 mg/dL)
30 H

(06/28/2015)

24 H

(06/29/2015)

20 H

(06/30/2015)

Creatinine
Normal (0.61-1.21 mg/dL)
1.8 H
1.6 H

(06/28/2015)
(06/29/2015)

urinary retention. The

sodium trend remains low
after two days indicating
that the patient may have
kidney problems or have
excessive fluid.
On admission, the patient
has a potassium within
the normal range. The
potassium trend remains
in the normal range after
two days indicating that
the patient is not having
any chronic disorders or
fluid problems.

On admission, the patient

has a decreased chloride
possible due to the
urinary retention. The
chloride trend remain low
after a day indicating
possibly the urinary
retention or excessive
fluid. The chloride trend
on the third day is within
the normal range possibly
because the urinary
retention has been
corrected.
On admission, the patient
has a high BUN possibly
due to his kidney
problems. The BUN trend
remains low after two
days indicating that the
patient may have kidney
problems.

On admission, the patient

has a high creatinine
possibly due to his renal
problems. The creatinine
trend remains high after
one day indicating that

low sodium is possibly

due to the urinary
retention, the acute renal
failure, or excessive fluid.
Potassium is used to
assess electrolyte balance
related to various
disorders and fluid
balance. A potassium
within normal range
shows that this patient
may not have a chronic
disorder and excessive
fluid. The imbalance may
have been corrected
through the body or the
prescribed medications.
Chloride is used to
evaluate electrolytes and
hydration level. A low
chloride is possibly due to
the urinary retention or
excessive fluid in the
body. The chloride that is
within the normal range
indicates that the urinary
retention or excessive
fluid has been corrected.

BUN is used to assist in

assessing for renal
function toward diagnosis
disorders such as kidney
failure. This is a test to
measure the amount of
urea nitrogen in the
blood. A high BUN
indicates a renal problem
possibly due to the acute
renal failure.
Creatinine is used to
assess kidney function
found in acute renal
failure. A high creatinine
indicates a renal problem
possible due to the acute

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15

1.3

GFR non-African American

Normal (60 or more)
39.19 A

(06/30/2015)

(06/28/2015)

44.89 A

(06/29/2015)

57.04 A

(06/30/2015)

Chest X-ray
No radiographic evidence of acute
cardiopulmonary abnormality

(06/28/2015)

Ultrasound Retroperitoneal
Normal sonographic appearance of the (06/29/2015)
kidneys.

the renal problem

continues. The creatinine
trend on the third day is
within the normal range
possibly because the
kidney problem is being
corrected continuously.
On admission, the patient
has a GFR that is
abnormal possibly due to
his kidney problems. The
GFR trend remains
abnormal after two days
indicating that the patient
may have kidney
problems.
On admission, the chest
x-ray showed no
radiographic evidence of
any cardiac or pulmonary
problems.

The day after the

admission an ultrasound
was done and it showed
no abnormality of the
kidneys or any presence
of kidney stones.

renal failure. The

creatinine that is within
the normal range
indicates that the acute
renal failure is possible
being corrected through
the medications as well as
the body.
GFR is used to assess
kidney function found in
acute renal failure related
to drug reaction. An
abnormal GFR indicates a
renal problem possibly
due to the acute renal
failure.
Chest x-ray is used to
assist in the evaluation of
cardiac and respiratory
structure within the lung
cavity. The chest x-ray
was performed due to the
generalized weakness of
the patient but it showed
no evidence of any
system problems.
Therefore, the generalized
weakness is not caused by
any cardiac or pulmonary
problems.
Ultrasound
retroperitoneal is used to
visualize and assess the
kidneys in diagnosing
disorders such as stone.
The ultrasound was
performed to check the
size, shape, and position
of the kidney

A urine culture needs to be in the chart to identify the correct antibiotic for the patient and whether the bacterial
infection caused the UTI.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled
diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
The creatinine level of the patient is currently being monitored for his renal function and he has an indwelling
catheter that will be taken home with him and it will remain inserted for two to three weeks per order of the
urologist due to his urinary retention and acute renal failure. A home healthcare team has also been ordered to
oversee his indwelling catheter care. In addition, he is currently in antibiotics due to his urinary tract infection
University of South Florida College of Nursing Revision September 2014
16

and he has a follow up urine culture to make sure he is treated with the correct antibiotics once he is discharged
home.

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

1. Urinary retention related to BPH as evidenced by decreased urinary output of 30 mL per hour
2. Risk for Infection related to indwelling catheter insertion.

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 15 CARE PLAN
Nursing Diagnosis: Risk for Infection related to indwelling catheter insertion (Ackley & Ladwig, 2011).
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Patient will remain free from
1. Assess the insertion site of the
1.The insertion site may create
symptoms of infection by the end
indwelling catheter for any
more risks for infection if it had
of the shift.
discharge, redness, or lesions
discharges, redness, or lesions.
during the start and before the end
2. Redness, warmth, discharge, and
of shift.
increased body temperature are
2. Observe patient for any signs of signs of infection and observing for
infection such as redness, warmth, these signs will reduce the risks for
discharge, and increased body
infection.
temperature during the start and
3. Assessing the vital signs like
before the end of shift.
temperature will help in observing
3. Assess the vital signs of the
signs of infection because a high
patient (blood pressure,
temperature indicate a fever that
temperature, pulse, respiratory rate, may be a sign of infection.
oxygen saturation, pain) during the
start and before the end of shift.
*Patient will state symptoms of
infection of which to be aware
during the shift.

1.Teach the patient the symptoms

of infection.
2. Teach the patient to report back
any symptoms of infection as soon
as noticed.

*Patient will demonstrate

appropriate care of infection-prone
site by the end of shift.

1.Teach patient the importance of

proper care for the insertion site of
the indwelling catheter.
2. Teach patient the steps of proper
care for the insertion site of the
indwelling catheter.

1. Teaching the patient the

symptoms of infection will help
prevent more risk of infection
because the patient can easily
report it when present.
2. Teaching the patient to report the
symptoms as soon as noticed will
help reduce the risk of infection.
1. Teaching the patient the
importance of proper care for the
insertion site will help reduce risk
of infection because the patient will
be more proactive in keeping the
insertion site from infection.
2. Teaching the patient the steps of

University of South Florida College of Nursing Revision September 2014

Evaluation of Goal on Day Care

is Provided
1. An assessment of the insertion
site of the indwelling catheter for
any discharge, redness, or lesion
was complete; Symptoms were not
detected.
2. Patient has been observed for
any signs of infection and no signs
have been noted.
3. Patient has been assessed for
vital signs and no abnormal vitals
signs have been noted.

1. The patient was able to state the

symptoms of infection during the
shift.
2. The patient verbalized that he
will report to the nurse any
symptoms of infection as soon as
possible.
1. The patient verbalized the
importance of proper care for the
insertion site of the indwelling
catheter.
2. The patient demonstrated the
proper care for the insertion site of
the indwelling catheter.
18

* Patient will demonstrate

appropriate hygienic measures such
as handwashing and perineal care
by the end of shift.

1.Teach patient the steps of proper

hand washing.
2. Teach patient the steps of proper
perineal care.

proper care for the insertion site

will help the patient to be more
aware in how to reduce the risk of
infection.
1. Proper hand washing will
promote cleanliness for the patient
and reduce risk of infection.
2. Proper perineal care will
promote cleanliness for the patient
and reduce risk of infection and
perineal abscess that may
contribute to septicemia and death
(Doenges, Moorhouse, & Murr,
2010).

1. The patient demonstrated proper

hand washing.
3. The patient demonstrated proper
perineal care.

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
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
X F/U appointments
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
X Rehab/ HH
Palliative Care

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References
Ackley, B.J., & Ladwig, G.B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care.
St Louis, MO: Mosby Elsevier.
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2010). Nursing care plans: Guidelines for individualizing
client are across the life. Philadelphia, PA: F.A. Davis Company.
Huether, S., & McCance, K. (2012). Understanding Pathophysiology. St. Louis, MO: Mosby Elsevier.
NIH. (2014). Prostate Enlargement: Benign Prostatic Hyperplasia. Retrieved from
http://www.niddk.nih.gov/health-information/health-topics/urologic-disease/benign-prostatichyperplasia-bph/Pages/facts.aspx
Treas, L.S., & Wilkinson, J.M. (2014). Basic Nursing: Concepts, skills, and reasoning. Philadelphia, PA: F.A.
Davis Company.
USDA (n.d.) Supertracker. Retrieved from http://supertracker.usda.gov

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