UNIVERSITY

OF SOUTH FLORIDA
COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Rachael Lewkowiez

Assignment Date: 6/30/16
.
Agency: SJH
1 PATIENT INFORMATION
Patient Initials: ACE Age: 74 Admission Date: 6/29/16

Gender: Male Marital Status: Primary Medical Diagnosis CELLULITIS

Primary Language: English

Level of Education: Masters degree educational psychology Other Medical Diagnoses: (new on this
admission)
Occupation (if retired, what from?): retired teacher Diabetes, HTN

Number/ages children/siblings:


Male child: 43, male child: 40 4 Siblings
Served/Veteran: NO Code Status: Full Code
If yes: Ever deployed? Yes or No
Living Arrangements: with his wife whom he takes care of Advanced Directives:
If no, do they want to fill them out? Has one but
did not bring it to the hospital.
Surgery Date: N/A Procedure: N/A

Culture/ Ethnicity /Nationality: black, non hispanic

Religion: Baptist Type of Insurance:

1 CHIEF COMPLAINT: Monday when I was golfing I noticed blisters on my legs. I went to urgent care
and they told me to go to the ER if the swelling didnt go down, and here I am.



3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) Swelling in the legs started on Monday and pain began when the swelling caused the skin on the lower
legs to tear. Being treated with IV vancomycin and skin tears are being cared for by the WOCN. Patient has
also had trouble sleeping in the hospital and is taking 5mg zolpidem PO, PRN daily.

University of South Florida College of Nursing Revision September 2014 1




2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
45 years ago Knee operation on right knee
February 2016 Routine colonoscopy











2

Stomach Ulcers
Environmental

(angina, MI, DVT etc.)

Heart Trouble

Mental Health
Age (in years)

Hypertension
FAMILY
Bleeds Easily

Cause
Alcoholism

MEDICAL

Glaucoma

Problems

Problems
Allergies

of Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY
Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father MI
Mother Diabetes
Brother
Brother
Brother
Brother
relationship

Mother had diabetes from a young age not sure when his brothers were diagnosed because they didnt talk about it, and he
didnt know they had it until he was diagnosed years later.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U
Adult Tetanus (Date) Is within 10 years? U
Influenza (flu) (Date) Is within 1 years? U
Pneumococcal (pneumonia) (Date) Is within 5 years? U
Have you had any other vaccines given for international travel or
occupational purposes? Please List

University of South Florida College of Nursing Revision September 2014 2

 If yes: give date, can state U for the patient not knowing date received

1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
NKA


Medications



Seasonal Sinus congestion, rhinorrhea, itchy eyes,
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)
(Huether, McCance 2012)
The patient presented to the ER with swelling of the lower extremities and skin tears that were diagnosed as symptoms of
cellulitis. Cellulitis is when Staphylococcus aureus bacteria infects the dermis and subcutaneous tissue (Huether, McCance
2012, 1058). It may or may not stem from an infected wound, so openings in the skin from cuts, insect bites, etc will increase
the risk of acquiring the infection. (Huether, McCance 2012, 1058). A cellulitis infection responds well to systemic antibiotics
but needs to be treated or the infection can spread to the blood stream and lymph nodes and can become life threatening
(Huether, McCance 2012, 1058).
The patient is also living with Type 2 Diabetes Mellitus. Diabetes mellitus is characterized by insulin resistance, which is a
suboptimal response of insulin sensitive tissues such as the liver, muscle, and adipose tissue to insulin (Huether, McCance
2012, 462). There seem to genetic and environmental factors that affect type 2 DM, and the most widely recognized risk
factors include age, obesity, hypertension, inactivity, and family history (Huether, McCance 2012, 462). Diagnosis requires
meeting one of the following four criteria: HbA1c >6.5% , OR FPG >126 mg/dl, OR 2 hr plasma glucose >200 mg/dl, OR classic
symptoms of hyperglycemia with a random plasma glucose >200mg/dl (Huether, McCance 2012, 460). Diet and exercise are
extremely important in treatment, where the goal is to maintain a controlled normal blood glucose level. While dietary and
exercise modifications are the first approach treatment, they may not be enough to maintain glucose levels. In that case, the
next step would be oral hypoglycemic, and possibly insulin therapy (Huether, McCance 2012, 462-468).
The last comorbidity for this patient was hypertension, or elevated systemic arterial blood pressure (Huether, McCance
2012, 587). The older a patient gets they have a higher chance of developing hypertension, and blacks and diabetics also have
a higher prevalence. It is diagnosed by a sustained systolic over 140 and sustained diastolic over 90 (Huether, McCance 2012,
587). The cause is unidentified but is likely a combination of genetic and environmental factors. People with high dietary
sodium have increased hypertension. The sodium causes water retention, which causes increased blood volume, which
increases blood pressure. Increased blood pressure causes renal injury and vasoconstriction, and ultimately can lead to tissue
ischemia (Huether, McCance 2012, 589). Hypertension can be treated in a few ways, but lifestyle changes such as healthy diet,
exercise, weight loss, and smoking cessation are the first line attempt to control blood pressure. Diuretics are a safe and
effective way to treat hypertension, and can be given with or separate from other antihypertensives such as ACE inhibitors,
ARBs, beta blockers, calcium channel blockers, etc (Huether, McCance 2012, 591).
5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
enoxaparin (lovenox) Concentration 100mg/mL Dosage Amount 0.4 mL

Route subcutaneous injection Frequency daily

Pharmaceutical class antithrombolytic Home Hospital or Both
Indication to prevent DVT after hip or knee replacement or prophylaxis after hospitalization
Adverse/ Side effects confusion, spinal hematoma, fever, headache, paralysis, atrial fibrillation, CHF, hyperlipidemia, edema, thrombosis, epistaxis, hematuria,
menstrual irregularities, anemia, hemorrhaging, purpura, thrombocytopenia, thrombocytosis, osteoporosis, dyspnea, pneumonia, pulmonary edema, pulmonary
embolism, anaphylaxis, injection site erythema, hematoma, oozing from wounds.
Nursing considerations/ Patient Teaching: use with caution in patients with a history of heparin induced thrombocytopenia, use caution inpatients with an
increased risk of hemorrhage. Use caution in those with bleeding diathesis, diabetic retinopathy, hepatic or renal impairment, recent GI ulceration, expect
delayed elimination in elderly patients. Not recommended for patients with prosthetic heart valves, especially pregnant women. Use multidose vials cautiously.

University of South Florida College of Nursing Revision September 2014 3

Do not give by IM injection. If patient is receiving with spinal anesthesia, watch closely for spinal hematoma.

Name Insulin Aspart (novolog) Concentration 100units/mL Dosage Amount: sliding scale

Route subcutaneous injection Frequency 3x daily AC

Pharmaceutical class insulins Home Hospital or Both
Indication type 2 diabetes mellitus in adults
Adverse/ Side effects hypoglycemia, hypokalemia, hypersensitivity reaction, anaphylaxis, injection site reaction, myalgia, pruritis, rash, URI, weight gain,
headache, edema, influenze
Nursing considerations/ Patient Teaching use caution in patients who have infection, illness, or stress, or patients with renal or hepatic impairment. Monitor
blood glucose closely. Monitor CR baseline levels.

Name vancomycin Concentration 4mg/mL Dosage Amount 1000mg in 250 ML d5W

Route IV over 1 hr Frequency q12 hr

Pharmaceutical class antibiotics Home Hospital or Both
Indication to treat bacterial septicemia, bone and joint infections, pneumonia, and skin and soft tissue infections caused by staphylococcus, including
methicillin-resistant strains, and life threatening infections.
Adverse/ Side effects chills, depression, dizziness, fatigue, headache, vertigo, hypotension, edema, ototoxicity, abdominal pain, diarrhea, nausea, vomiting,
nephrotoxicity, UTI, anemia, neutropenia, thrombocytopenia, back pain, dyspnea, exfoliative dermatitis, rash, stevens Johnson syndrome, anaphylaxis, red man
syndrome.
Nursing considerations/ Patient Teaching infuse over at least 1 hour, blood concentrations are frequently monitored, higher concentrations are associated
with nephrotoxicity, monitor serum concentrations especially in patients with renal impairment and colitis, monitor renal function while on this drug, observe
IV injection sitemonitor closely for diarrhea as it may indicate pseudomembranous colitis, instruct patient to use a calibrated measuring device for accurate
doses of oral solution. Advise patient to call a provider immediately in improvement does nott occur in a few days. Instruct patient to complete a full dose as
prescribed. Instruct to notify provider if persistent diarrhea occurs.

Name zosyn Concentration 0.0675mg/mL Dosage Amount 3.375g in 50 mL d5w

Route IV infusion over 30 mins Frequency q6hr

Pharmaceutical class extended spectrum, penicillins Home Hospital or Both
Indication for intra abdominal infections, gynecologic infections, skin infections, pneumonia
Adverse/ Side effects : anaphylaxis, hypersensitivity reaction, serum sickness rxn, erythema multiforme, stevens Johnson, superinfection, C diff associated
diarrhea, hemolytic anemia, leukopenia, neutropenia, agranulocytosis, thrombocytopenia, bleeding, hypokalemia, seizures, diarrhea, headache, constipation,
nausea, insomnia, rash, vomiting, dyspepsia, pruritis, fever, agitation,
Nursing considerations/ Patient Teaching: do not use in patients with a penicillin sensitivity, if asthma or history of asthma, in cystic fibrosis, in antibiotic
associated colitis, in seizure disorder, in renal impairment, in sodium restriction, in hypokalemia, in bleeding risk, no known risk of fetal harm.

Name Tylenol (acetaminophen) Concentration 325 mg/tab Dosage Amount 2 tabs

Route PO Frequency PRN q4 hrs for fever>100.4 or mild pain

Pharmaceutical class antipyretic, non-opioid analgesic Home Hospital or Both
Indication to relieve moderate to mild pain from headache, muscle ache, back ache, minor arthritis, common cold, toothache, or menstrual cramps; to reduce
fever.
Adverse/ Side effects abdominal pain, hepatotoxicity, nausea, vomiting, hemolytic anemia, neutropenia, thrombocytopenia, jaundice, pruritis, rash, stevens
Johnson syndrome, anaphylaxis, angioedema, hypersensitivity reaction.
Nursing considerations/ Patient Teaching use cautiously in hepatic disease, alcoholism, chronic malnutrition, or severe renal impairment. Monitor liver
function during long term therapy. Monitor renal function in long term therapy. Store suppositories under 80 degrees F. teach that tablets may be swallowed or
crushed. Instruct to follow dosage guidelines on labels precisely. Caution patients not to exceed recommended dose. Teach about signs of hepatotoxicity.

Name zolpidem Concentration 5mg/tab Dosage Amount 1 tab

Route PO Frequency PRN daily for insomnia

Pharmaceutical class sedative-hypnotic Home Hospital or Both
Indication to provide short term treatment of insomnia.
Adverse/ Side effects abnormal thinking, aggressiveness, amnesia, ataxia, behavioral changes, confusion, decreased inhibition, dizziness, drowsiness,
hallucinations, headache, nightmares, suicidal ideation, worsening of depression, diplopia, throat tightness, visual abnormality, diarrhea, hiccups, nausea,
vomiting, UTI, myalgia, angioedema, withdrawal symptoms.
Nursing considerations/ Patient Teaching might aggravate other conditions, especially those with respiratory symptoms. Administer just before bedtime.
Teach patient they will not receive more than a month supply. Can produce anticonvulsant and muscle relaxant effects at high doses. Reduce dose with other
CNS depressants. Take exactly as prescribed. Take on an empty stomach. Teach patient to notify the provider immediately if they experience abdominal cramps,
discomfort, fatigue, flushing, light headedness, nervousness, panic attacks. Instruct patient to seek emergency care if they have trouble breathing, throat
tightness, nausea, vomiting, or abnormal swelling. . teach patient that the drug may produce unusual behaviors during sleep such as driving a car, or eating, the
patient may experience daytime drowsiness while taking this drug.

University of South Florida College of Nursing Revision September 2014 4


Name metformin Concentration 500 mg tab Dosage Amount 1 tab

Route PO Frequency 2x daily

Pharmaceutical class antidiabetic. Home Hospital or Both
Indication to reduce blood glucose levels in type two diabetes mellitus.
Adverse/ Side effects
Nursing considerations/ Patient Teaching give tablets with food. Alter dosage if patient has delayed gastric emptying. Assess BUN and creatinine often during
long term therapy. Monitor patients blood glucose level for hyper glycemia. Withhold drug if patient becomes dehydrated or septic. Instruct patient to take at
breakfast. Instruct to take exactly as prescribed. Emphasize importance of following diet and exercise regimen. Caution patient to avoid alcohol. Teach to report
early signs of lactic acidosis.


Name aspirin Concentration 325 mg tabs Dosage Amount 1 tab

Route PO Frequency 1x daily

Pharmaceutical class anti-inflammatory, antiplatelet, antipyretic,
Home Hospital or Both
non-opioid analgesic.
Indication to relieve mild pain from fever or inflammation. , to reduce the risk of transient ischemic attacks or stroke in men. To prevent acute MI
Adverse/ Side effects confusion, reyes syndrome, tinnitus, diarrhea, GI bleeding, heartburn, hepatotoxicity, stomach pain, shortened life span of RBCs,
ecchymosis, rash, angioedema, reyes syndrome, headache.
Nursing considerations/ Patient Teaching do not take along with ibuprofen, do not take with a tartrazine allergy. Take with food or after meals, teach patient
to notify for signs of bleeding. Teach patient not to use the aspirin if it has a vinegar like smell.


Name hydrochlorothiazide Concentration 25 mg/tab Dosage Amount 1 tab

Route PO Frequency 1x daily

Pharmaceutical class diuretic, antihypertensive Home Hospital or Both
Indication to manage hypertension
Adverse/ Side effects anesthesia, dizzinesss, fever, insomnia, restlessness, vertigo, hypotension, orthostatic hypotension, vasculitis, acute myopia, blurred
vision, dry mouth, hyperglycemia, abdominal cramps, anorexia, decreased libido, impotence, nocturia, polyuria, renal failure, agranulocytosis, anemia, bone
marrow failure, muscle spasms, pulmonary edema, anaphylaxis, dehydration, hypercalcemia, hyperuricemia, hypochloremia, hypokalemia, hyponatremia,
hypovolemia, weight loss.
Nursing considerations/ Patient Teaching give in the morning and early evening, monitor fluid intake and output. Monitor BUN and creatinine, monitor
vision and for ocular pain, instruct to take with food or milk to avoid GI upset. Tell patient to weigh herself at the same time of morning each day. Instruct
patient to eat a diet high in potassium. Teach to report ecreased urination, muscle cramps, weakness, unusual bleeding, or bruising.

Name lisinopril Concentration 10 mg/tab Dosage Amount 1 tab

Route PO Frequency 1x daily

Pharmaceutical class antihypertensive, vasodilator Home Hospital or Both
Indication to manage uncomplicated essential hypertension. To treat heart failure.
Adverse/ Side effects ataxia, confusion, depression, dizziness, fatigue, memory impairment, somnolence, arrhythmias, chest pain, fluid overload, MI,
hypotension, orthostatic hypotension, peripheral edema, hyperglycemia, SIADH, blurred vision, diplopia, dry mouth, taste disturbances, tinnitus, visual loss,
abdominal pain, acute renal failure, diarrhea, elevated liver enzymes, flatulence, decreased libido, impotence, anemia, neutropenia, thrombocytopenia, arthritis,
bone or joint pain, myalgia, bronchospasms, cough, dyspnea, PND, pulmonary embolism, upper erspiratory tact infection. Anaphylaxis, angioedema,
dehydration, gout, weight gain or loss.
Nursing considerations/ Patient Teaching teach patient signs of angioedema and to report it immediately to provider and stop the med. Take at same time
every day. Teach that it isnt a cure for hypertension and patient may need lifelong treatment. Advise to drink adequate fluids. Patient may develop a persistent
nonproductive cough and to contact the provider if it becomes difficult to tolerate. Caution not to use salt substitutes. Advise patient to change position slowly.
Instruct to report signs of neutropenia, urge to monitor blood glucose closely. Notify provider immediately if patient could be pregnant.

Name cephalexin (Keflex) Concentration 500mg/capsule Dosage Amount 1 cap

Route PO Frequency 2x daily

Pharmaceutical class cephalosporins, 1 generation.
st
Home Hospital or Both
Indication to treat streptococcal tonsillitis, pharyngitis, and skin and soft tissue infections.
Adverse/ Side effects diarrhea, nausea, vomiting, rash, headache, dizziness, ALT, AST, eosinophilia, anaphylaxis, angioedema, erythema multiforme, C diff
associated diarrhea, neutropenia, thrombocytopenia, hemolytic anemia, aplastic anemia, hemorrhage, hepatitis, jaundice, seizures.
Nursing considerations/ Patient Teaching use caution in penicillin sentitivity, if possible obtain C&S before giving drug, monitor BUN and creatinine,, watch
for signs of nephrotioxicity, assess CBC, assess bowel pattern daily, assess for pharyngitis, ecchymosis, bleeding,teach patient to complete prescribed therapy,
instruct to shake oral medicine well, tell patient that yogurt and buttermilk can help maintain flora, teach to report watery bloody stool immediately.

University of South Florida College of Nursing Revision September 2014 5


***Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2011). Davis's drug guide for nurses. Philadelphia: F.A. Davis.

University of South Florida College of Nursing Revision September 2014 6

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with
recommendations.
Diet ordered in hospital? Consistent carbohydrate Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Consider co-morbidities and cultural
considerations):
24 HR average home diet: The diet the patient follows is seemingly very healthy,
Breakfast: oatmeal, egg whites, toast but I have reason to believe that the patient may not
being completely truthful about his home diet. I think he
Lunch: steamed vegetables may have been trying to paint himself in the best light
because he knows that a healthy diet is extremely
Dinner: steamed vegetables with chicken/fish important in the maintenance of diabetes and HTN.
When I asked for more details about his at home diet,
Snacks: fruits the patient refused to give me more information. When I
asked him what types of vegetables he would eat for
Liquids (include alcohol): 4-5 glasses of water a day, lunch, and in what quantities he replied just
occasional lemonade or iced tea vegetables, and quickly changed the subject. Because I
could not get specific information about his at home
diet, it is not possible for me to evaluate what he
normally eats. However, I can recommend a diet that
would be good for him with his current disease
processes. A sample meal plan for the patient would be
BREAKFAST: a glass of skim milk, 1 serving of fruit such
as and orange or banana, a bowl of whole grain cereal or
oatmeal. LUNCH: grilled chicken, brown rice with beans,
1 serving cottage cheese, broccoli. SNACK: carrot
sticks/celery with hummus or peanut butter, kale chips.
DINNER: salmon with quinoa, steamed spinach, half a
sweet potato. The goal is to have half of the plate be
fruits and vegetables, and the other half protein and
grains. The patient should stay away from too myuch
sodium because of his HTN, and eat lots of leafy greens
to avoif hypokalemia from his medications. By choosing
complex carbs like whole grains, this meal plan or a
similar one would be great for the patient with diabetes
and HTN.
Use this link for the nutritional analysis by comparing the
patients 24 HR average home diet to the recommended
portions, and use My Plate as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Patient says he likes to just rest when he isnt feeling well and take it easy.

How do you generally cope with stress? or What do you do when you are upset?
Patient says he likes to just relax and have quiet time when he is stressed or dealing with something
difficult, he says that listening to music he enjoys really helps him take his mind off things and relax



Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient says the biggest difficulty in his life is taking care of his wife who has been sick for over three years
University of South Florida College of Nursing Revision September 2014 7
and he is her caregiver, but he doesnt feel stressed or overwhelmed about it. Patient states its a job but
Ive never felt overwhelmed.



+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? ____yes, I used to
get into fights when I was young.__________

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? _N/A_________________

Are you currently in a safe relationship? yes


4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt
Industry vs. Inferiority Identity vs. Role Confusion/Diffusion 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: Ego integrity versus despair: the task of this stage is the acceptance of
ones life, worth, and eventual death. Ego integrity reflects a satisfaction with life and an understanding of ones place in the
life cycle. A sense of loss, discomfort with life and aging, and a fear of death are seen in despair. a (Treas, Wilkinson 2014,
164)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination: My patient is in the Ego integrity stage of ego integrity vs. despair. I believe this because the Ego integrity
stage is characterized by acceptance of ones life, and acceptance of death and ones place in the life cycle (Treas, Wilkinson
2014, 164). I believe my patient is in this stage because he seemed very satisfied with the life he has lived. When he told me he had a
Masters degree in education psychology, I asked him what he did with that degree. He seemed very proud when reflecting on his 40+
years as a school teacher and administrator, and as he was telling anecdotes about students he remembers particularly fondly. He also
seems to have accepted the inevitable eventual death of himself and his wife, when he talked about how sick his wife is and how much
he takes care of her, he seemed at peace with the situation regardless of her deteriorating physical status. I believe he knows their time
will come soon and has accepted it as a part of life.



Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
I think disease and hospitalization of himself and his wife has helped him to accept the place he is in life. He is very
active and stays as healthy as he can but I think his wifes illness and his own comorbidities have helped him accept
that his health wont last forever and face his own mortality, even if it is not coming at him right now.


+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? Patient says if he really thinks about it he has probably
gotten sick because of undetected stress. Even though he doesnt feel stressed out or overwhelmed, he thinks that
the daily stresses of taking care of his wife and just every day trial of life have over time taken their toll on him.

University of South Florida College of Nursing Revision September 2014 8


What does your illness mean to you? The patient says that what his illness means to him is that it is
hereditary. He said when his older brothers were diagnosed as diabetic, they didnt tell anyone and he himself
didnt even know they had diabetes for many years. He thinks they kept it a secret because it was stigmatized to
have something wrong with you. He thinks if his brothers had told him earlier about their diagnoses, he could have
done his research and learned how to prevent himself from developing it, or at least reduced the severity or
delayed it.



+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?_________no____________________________________________ Have you
or your partner received the Gardasil (HPV) vaccination? _______no____________________________________

Are you currently sexually active? ________yes___________________ If yes, are you in a monogamous relationship?
_________yes___________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _____condom_____________________________

How long have you been with your current partner?____50 years
Have any medical or surgical conditions changed your ability to have sexual activity? no_________________________

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 9

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
____very important
Do your religious beliefs influence your current condition?
_____yes___________________________________________________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much?(specify daily amount) For how many years? X years
(age thru )

If applicable, when did the
Pack Years:
patient quit?

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? NO If yes, what did they use to try to quit?


2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years?
Volume: (age thru )
Frequency:
If applicable, when did the patient quit?


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 thru )

Is the patient currently using these
If not, when did he/she quit?
drugs? Yes No


4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
no


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

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health? Overall feels he is healthy even though he has diabetes he manages it well with
diet and medication. He works out at least 5 days a week at the YMCA and plays golf regularly.

Integumentary: Patient has noticed changes in the skin on his legs, has had some dandruff, and has a
skin infection. He denies problems with his nails, psoriasis, hives, or rashes. Patient reports using
sunscreen in the sun, SPF 70 or higher but didnt use sunscreen in his youth. Patient reports bathing 2x daily.
HEENT: patient denies difficulty seeing or hearing, cataracts, glaucoma, ear infections, sinus pain, nose
bleeds, post nasal drip, oral infections, or dental problems. Patient reports brushing his teeth 2-3 times a
day, seeing a dentist 2x a year, and getting his vision tested yearly.
Pulmonary: patient denies dyspnea, cough, asthma, bronchitis, emphysema, TB, and pneumonia. Patient
reports last chest x-ray around a year ago, and admits to having seasonal allergies causing a reaction of
rhinorrhea.
Cardiovascular: Patient denies hyperlipidemia, chest pain, MI, arterial/venous disease, CHF, DVT, and a
murmur. Also denies rheumatic fever, myocarditis, and arrhythmias. Patient reports hypertension and last
EKG 2 years ago.
GI: patient denies nausea, vomiting, diarrhea, constipation, GERD, indigestion, hemorrhoids, jaundice,
pancreatitis, colitis, diverticulitis, appendicitis, IBS, cholesystitis, ulcers, blood in stool, and hepatitis,
GU: patient denies nocturia, dysuria, blood in urine, polyuria, kidney stones, and bladder/kidney
infections. Patient reports voiding around 5 times a day.
Women/Men Only: Patient denies infection of the male genitalia and prostate, urinary retention, and
BPH. Patent reports prostate exam every 4 years and the last one around 3 years ago.
Musculoskeletal: patient denies injuries, fractures, weakness, gout, osteomyelitis, and arthritis. Patient
reports pain only related to cellulitis.

University of South Florida College of Nursing Revision September 2014 11

Immunologic: patient denies chills with shaking, night sweats, fever, HIV/AIDS, and lupus. Also denies
rheumatoid arthritis, tumors, life threatening allergies, and enlarged lymph nodes.
Hematologic/Oncologic: Patient denies anemia, easy bleeding, easy bruising, cancer, and blood
transfusions. Patient reports not knowing his blood type.
Metabolic/Endocrine: Patient denies thyroid problems, intolerance to heat and cold, and osteoporosis.
Patient reports Diabetes type II
Central Nervous System: Patient denies CVA, headaches, migraines, seizures, ticks or tremors,
encephalitis, and meningitis. Patient reports he used to experience vertigo but hasnt in the last 25 years.
Mental Illness: patient denies depression, schizophrenia, anxiety, and bipolar disease.
Childhood Diseases: patient denies scarlet fever and polio. Patient reports getting mumps, measles, and
chicken pox as a child.
















Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
no






Any other questions or comments that your patient would like you to know?
Not that he can think of





10 PHYSICAL EXAMINATION:
General survey __Patient is alert and orientated X3.
Height ___58_________Weight_____159 lbs_____ BMI 24.3__ Pain (include rating and location)_____5, lower legs____
Pulse_61 __ Blood Pressure (include location)_left upper arm, 115/62_______Temperature (route taken)_98.9
oral____
Respirations_____18_______ SpO2 ___99______________ Room Air or O2___________________________
Overall Appearance_____appropriate____________________________________
Overall Behavior____appropriate______________________________________________________
University of South Florida College of Nursing Revision September 2014 12
Speech__clear and appropriate__________________________________________________________________
Mood and Affect______calm and cooperative_____________________________
Integumentary___pt is warm, dry and appropriate color for his ethnicity. Skin tears on lower legs. __
IV Access: right antecubital______________
HEENT: head is symmetrical, eyes positive for PERRLA, mucous membranes are moist and intact. Sclera is white and
moist. No nasal drainage,
Pulmonary/Thorax: breath sounds clear in upper, middle, and lower lungs bilaterally. No extra effort in breathing.
No nasal flaring, accessory muscles, etc. SpO2 99 on room air.
Cardiovascular_S1+S2 heard. Even rate and rhythm. No tele, radial pulses 2+ bilaterally, dorsalis pedis pulses 1+
bilaterally. _
GI/GU: abdomen is flat and soft, non tender. bowel sounds present in al four quadrants, last void 1 hour before
assessment, last bowel movement the previous day. Patient denies nausea/vomiting.___________________________________
Musculoskeletal: upper extremities strength 5/5, sensation intact, full ROM, bilaterally. Lower extremities strength
4/5, sensation intact, full ROM bilaterally.
Neurological: no numbness/tingling,


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 lab values for this patient would include WBC counts because that would tell about the
progression of the infection and how the antibiotics are working on the cellulitis infection. Another
important lab value would be glucose levels since the patient is diabetic. His glucose would need to be
checked after meals because his insulin is given on a sliding scale and the glucose level will determine the
insulin dose.

Lab Dates Trend Analysis
WBC levels When patient was WBC counts are a
- 9.9 6/29 at 1647 admitted the previous breakdown of the
- 9.4 6/30 at 0247 day the WBC count was number and types of
normal levels (4.5-11) in the normal range, but WBCs in the blood and
began to trend down can help evaluate the
when the patient presence of infection in
started IV antibiotics to the body (Treas, Wilkinson
treat his cellulitis 2014, 613)

GLUCOSE LEVELS Patients blood glucose When blood sugar levels
- 307 6/30 at 0738 was very high, and are not controlled they
normal levels (70-140) patient was dosed with can lead to
insulin at 0800 to bring hyperglycemia, or
levels down diabetic ketoacidosis. If
this goes on for long
term, the uncontrolled
sugar levels can lead to
blood vessel damage in
vessels that supply
blood to vital organs
such as the heart,
kidneys, nerves, and
eyes. This can cause
severe complications for

University of South Florida College of Nursing Revision September 2014 13

 uncontrolled diabetics.

Diabetes Control: Why It's
Important. (n.d.). Retrieved
July 17, 2016, from
http://kidshealth.org/en/tee
ns/diabetes-control.html





Other pertinent lab values: Another lab value that I should have recorded but did not realize at the time
was serum proteins, albumin, and prealbumin. These values would be important for my patient because he
has skin tears on both lower extremities. Low serum protein levels indicate low nutritional stores and
cases delayed wound healing. If the patients serum protein levels were low, he may not be able to heal his
skin tears effectively or efficiently (Treas, Wilkinson 201, 1242).














+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:
- Dressing change 1x daily, this would be to keep the skin tears clean and protected and encourage healing.
- Accuchecks 4xdaily w/meals and at bedtime: this is to monitor blood glucose levels to know how much
insulin the patient needs
-Consistent carbohydrate diet: this diet helps control blood sugar by making sure the patient is eating the
same amount of carbohydrates at each meal.
-up w/ assistance: because of the patients pain and swelling of lower legs bilaterally, he is at a fall risk and
needs assistance to ambulate.



8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. acute pain r/t inflammatory changes in tissues from infection, as evidenced by patient reporting pain at 5/10 in
lower extremities, swelling and skin tears of lower legs.


2. risk for infection r/t high glucose levels and preexisting infection as evidenced by glucose level at 307 and
presence of cellulitis.

University of South Florida College of Nursing Revision September 2014 14


3. risk for decreased cardiac output r/t increased afterload from hypertension.


4.


5.

University of South Florida College of Nursing Revision September 2014 15