UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Michael Sandin

Assignment Date: 10/18/2016
.
Agency: TGH
1 PATIENT INFORMATION
Patient Initials: LW Age: 57 Admission Date: 10/14/2016
Gender: Female Marital Status: Divorced Primary Medical Diagnosis: Urethral Erosion, and
paraplegia.
Primary Language: English
Level of Education: Some college (Currently working towards Other Medical Diagnoses:
Engineering Degree) Pressure Ulcers (Stage IV)
Occupation (if retired, what from?): Former Saleswomen
Number/ages children/siblings: Daughter 25
Sister 52, Brother - 44

Served/Veteran: No Code Status: Full

If yes: Ever deployed? N/A
Living Arrangements: Nursing Home Advanced Directives: No
If no, do they want to fill them out?: No
Surgery Date: (1st)10/14/2016 Procedure:
Right Flank Nephrostomy Tube
Culture/ Ethnicity /Nationality: White
Religion: Spiritual Type of Insurance: Medicare and Medicate

1 CHIEF COMPLAINT: The chief complaint was the urethral erosion. Having this disease process was
causing problems with urination. The patient stated that getting the nephrostomy was the best of the two options she had
to fix the urethral erosion. The patient went on to explain that the nephrostomy was described to her as the least invasive
surgery compared to her other option of a cystostomy.
3 HISTORY OF PRESENT ILLNESS: The patients main complaint was the urethral erosion, saying its
been almost a year now. Since last October I think it was. The urethral erosion was said to be caused by the
long-term use of a Foley catheter, and the removal and replacements that came along with it. She described, that over
time, the Foley catheter kept rubbing against her urethra, and degraded the wall. She was told by doctors that it caused a
hole in her urethra. The location all these current issues is related to the genitourinary system. She has two nephrostomies
to both of her kidneys to bypass the urine flow. The main injury is to her urethra. She also has a urinary catheter to collect
any excess urine. Dark bloody urine was seen coming from both nephrostomy tubes, tough she described it as being
clearer than before. The patient stated that she has been drinking a lot of clear fluids to help clear up the urine, and she
she believes thats what caused the urine to be clearer than before. The purpose of the nephrostomy was to bypass
the urethra to allow the urethra time to heal. The urinary catheter hasnt been collecting any urine, just blood.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
1/30/2012 Dental surgery Alveoloplasty excision of the exostoses
8/11/2016 Cystoscopy with Retrogrades- Bilateral Retrograde pyelogram
10/14/2016 - 0940 Right Flank Nephrostomy Tube
10/17/201 1226 Left Flank Nephrostomy Tube
8/19/2016 Urinary Tract Infection
Back Surgery after T4 Spinal fracture caused by MVA. Incident led too paraplegia.
Autonomic dysreflexia
Diabetes Miletus
Constipation
Hysterectomy
Pressure Ulcers (Stage IV)
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma

of
Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
MEDICAL

Gout
Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Cerebral
Father 62
Aneurysm
Mother 81
Brother 44
Sister 52
relationship

relationship

relationship

Comments: Her sister has Multiple Sclerosis. She doesnt know when her family members were first diagnosed with diabetes.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations Unknown date, all except Mumps.
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? Not within the last 10 years.
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

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 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Aspirin Breaks out in hives.
Penicillin Breaks out in hives.
Codeine Sensitive to stomach.
Medications
Sulfamide Breaks out in hives.
Tramadol Break out in hives.

Iodine Went into antiphallic shock and almost died.

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)
All of the patients illnesses has been, in a sense, caused by the initial issue of the T4 spinal fracture. It resulted in
autonomic dysreflexia, aided in the development of stage IV pressure ulcers, and caused the need of a urinary catheter,
which over time caused urethral erosion. A spinal fracture essentially compresses the spinal tissues, either damaging or
applying just pressure to the spinal cord itself (Huether and McCance, 2012, p. 482). There are four classifications of
vertebral injuries: simple fractures, compressed fractures, commented fractures, and dislocation. (Huether and McCance,
2012, p. 482). The exact fracture for the patient wasnt charted, and the patient didnt know which type the fracture was.
Normal activity of the spinal cord cells at and below the level of injury ceases because of loss of the continuous tonic
discharge from the brain or brain stem and inhibition of suprasegmental impulses immediately after cord injury, thus
causing spinal shock. (Huether and McCance, 2012, p. 482). This explains the inability for the patient to move either leg
(paraplegia), as the normal activity of the spinal cord cells at the T4 region of the patients spine has been permanently
altered. This trauma also explains why the patient lost control of bowels and urination, and has decreased sensation to her
waist down. Diagnosis of spinal cord injury, is usually done through examination and tests, mainly: physical examination,
X-ray, CT, MRI, and myelography. (Huether and McCance, 2012, p. 482). The treatment, at least initially, is
immobilization of the spine, and control of inflammation. In the case of the patient, there is no current treatment that will
allow her to have complete control over her legs again. The current treatment is focused on preventing further issues
caused by her immobilization (pressure ulcers), and treating the current issues like the urethral erosion.

5 MEDICATIONS: (DAILYMED)
Name: baclofen (LIORESAL) Concentration Dosage Amount: 20mg

Route: Oral Frequency: 3x daily

Pharmaceutical class: Skeletal Muscle Relaxants Home Hospital or Both
Indication: Used as a muscle relaxer and antispastic agent.
Adverse/ Side effects: Most common is transient drowsiness. Other side effects include dizziness, weakness, fatigue, headache, hypotension, constipation, and
urinary frequency.
Adverse Reactions: Hallucinations and seizures.
Nursing considerations/ Patient Teaching: Need to maintain respiratory exchange, and monitor for signs of overdose (respiratory depression, vomiting, coma.)

Name: bisacodyl (DULEOLAX) Concentration Dosage Amount: 20mg

Route: Suppository Frequency: 3x weekly (1 a day Monday, Wednesday, and Friday.)

Pharmaceutical class: Laxative Home Hospital or Both
Indication: Duleolax is a stimulant laxative which stimulates bowel muscles to provide relief for constipation.

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Adverse/ Side effects: Abdominal cramping, abdominal distention, vomiting, and diarrhea.
Adverse Reactions: Chronic diarrhea, severe hypernatremia, hypophosphatemia, and hypocalcemia.
Nursing considerations/ Patient Teaching

Name: docusate sodium (COLAGE) Concentration Dosage Amount: 100mg

Route: Oral Frequency: 2x daily

Pharmaceutical class: Laxative Home Hospital or Both
Indication: Laxative intended to produce a bowel movement within 12 to 72 hours. Helps to relieve constipation.
Adverse/ Side effects: Abdominal cramping, and a rash.
Nursing considerations/ Patient Teaching: Teach about side effects and adverse reactions, and when to call the provider.

Name: fentanyl (DURAGESIC) Concentration Dosage Amount: 1 patch (25mcg/hr)

Route: Transdermal Frequency: Every 72 hours

Pharmaceutical class: Narcotic analgesic Home Hospital or Both
Indication: Duragesic is used for around-the-clock, long-term pain treatment.
Adverse/ Side effects: Constipation, headache, nausea, vomiting, dizziness, somnolence, sedation, tachycardia, anxiety, fatigue, irritability, confusion, malaise,
dry mouth, gastritis, dysphagia, dyspepsia, GERD, anorexia, and erythema at site of application.
Adverse Reactions: Anemia, neutropenia, lymphadenopathy, thrombocytopenia, leukopenia, hypoalbuminemia, anaphylaxis, respiratory depression.
Nursing considerations/ Patient Teaching: Monitor for respiratory depression, signs of adverse reactions, and the patient may be at risk of a fall.

Name: insulin aspart (NOVOLOG) Concentration Dosage Amount: 2 units

Route: Injection Subcutaneous Frequency: 3x daily with food and bedtime

Pharmaceutical class: Insulin Home Hospital or Both
Indication: Novolog is a rapid-actin insulin medication used to help with glycemic control in patients with Diabetes Mellitus.
Adverse/ Side effects: Depression, chest pain, rash, lipodystrophy, pruritus, headache, nausea, diarrhea, and abdominal pain.
Adverse Reaction: Hypoglycemia, allergic reaction,
Nursing considerations/ Patient Teaching: Monitor for drugs that affect glucose metabolism.

Name: iohexol (OMNIPAQUE) Concentration Dosage Amount: 300mL

Route: Injection Frequency: Once

Pharmaceutical class: Non-ionic iodinated contrast media. Home Hospital or Both
Indication: Intrathecal administration for myelography and to enhance contrast for computerized tomography.
Adverse/ Side effects: Diarrhea, nausea, vomiting, pancreatitis, lower abdominal pain, headaches, dizziness, neuralgia, pain, and visual problems.
Adverse Reactions: Hypersensitivity reaction, seizure, hallucinations, transient ischemic attack, cerebral infraction.
Nursing considerations/ Patient Teaching: Teach about side effects and adverse reactions, and when to call the provider.

Name: levetiracetam (KEPPRA) Concentration Dosage Amount: 500mg

Route: Oral (Tablet) Frequency: 2x daily

Pharmaceutical class: Pyrrolidine anticonvulsants Home Hospital or Both
Indication: Keppra is generally used in patients with partial onset of seizures.
Adverse/ Side effects: Drowsiness, weakness, nervousness, headache, fatigue, irritability, mood changes.
Adverse Reactions: Depression, seizure, aggressive behavior, and personality disorder.
Nursing considerations/ Patient Teaching: Keppra can increase the risk of suicidal thoughts and worsen depression.

Name: Oxycodone (ROXICODONE) Concentration Dosage Amount: 20mg

Route: Oral (Tablet) Frequency: Every 6 hours

Pharmaceutical class: Narcotic analgesic Home Hospital or Both
Indication: Opioid pain medication used for moderate to severe pain.
Adverse/ Side effects: Abdominal pan, anorexia, diarrhea, dyspepsia, nausea, vomiting, anxiety, dry mouth, and photosensitivity.
Adverse Reactions: Respirator depression, respiratory arrest, circulatory depression, cardiac arrest, hypotension, and shock.
Nursing considerations/ Patient Teaching: Patient could experience severe respiratory depression, which needs to be monitored. Signs of overdose should also be
monitored.

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Name: Oxybutynin (Ditropan) Concentration Dosage Amount: 5mg

Route: Oral (Tablet) Frequency: 2x Daily

Pharmaceutical class Home Hospital or Both
Indication: Used for symptom relief of bladder instability.
Adverse/ Side effects: Palpitations, dry skin, pruritus, flushing, rash, dry mouth, constipation, nausea, diarrhea, abdominal pain, vomiting, flatulence, GERD,
headache, dizziness, and somnolence.
Nursing considerations/ Patient Teaching: Teach about side effects and adverse reactions, and when to call the provider.

University of South Florida College of Nursing Revision September 2014 5

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Non-restrictive, regular diet.
Diet patient follows at home? Non-restrictive, regular diet.
24 HR average home diet:
Breakfast: Cereal, milk, juice
Lunch: Tuna salad/roast beef/hamburger/pizza, often
With a fruit.
Dinner: Pizza/pork, often with a fruit.
Snacks: Various snacks and some fruit (Apples,
Strawberries, watermelon, bananas.)
Liquids (include alcohol): Juice during breakfast, soda, and
water.
Analysis of home diet (Compare to My Plate and
Consider co-morbidities and cultural considerations):
The patients home diet relies heavily on what the nursing
home can provide. Though her nursing home does change
its meals slightly, she does complain of a lack of variety.
When comparing her home diet to My Plate, she does
Appear to be lacking in both vegetables and grains. The
Doesnt consume vegetables, and doesnt consume much
of any grains (aside from hamburger buns, and the grains
found in the main meals at lunch.) She controls her diabetes
by constant accu checks to make sure her blood glucose is
within acceptable limits, and takes insulin to help manage
blood glucose levels.
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? Nursing home facility is the ones who monitor her when shes ill. She has no family
nearby to help.
How do you generally cope with stress? or What do you do when you are upset?
The patients main ways to deal with stress are videogames, painting, any activity to get her mind of things. She was also
previously prescribed Buspar for some anxiety attacks shes been having, though she is no longer taking that medication.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
She says shes been having some depression and her anxiety for quite some time now. She describes it as
situational anxiety whenever she has a new medical issue, or one of her current medical issues gets worse.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.

Have you ever felt unsafe in a close relationship? __No_____________________________________________

Have you ever been talked down to?__No___________ Have you ever been hit punched or slapped? ___No___________

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_______________No___________________________ If yes, have you sought help for this? ______N/A__________

Are you currently in a safe relationship?

University of South Florida College of Nursing Revision September 2014 6

Patient states she hasnt been in a relationship for about 10 years.

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: Treas and Wilkinson (2014) describes Ericksons developmental stage of generativity as the desire and
motivation to guide the next generation, (Treas, L. S., & Wilkinson, J. M., 2014, pg. 164) and stagnation as the person who fails to
achieve generativity, (Treas, L. S., & Wilkinson, J. M., 2014, pg. 164).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient seems to be in stagnation in stage 7 of Eriksons developmental stage. Shes in this stage because she feels that she hasnt
done enough to raise her biological daughter (whom she had to put up for adoption for issues she didnt wish to discuss.) She also
doesnt feel like she had done enough with her career, and is generally feeling lonely due to the absence of family around her. She
describes her family as distant, with most of her relative in different states. Despite all of this, my patient does appear to be actively
trying to change things in her life. She stated that was contacted by her daughter after posting some of her information on certain
websites, and has been trying to keep up some communication with her. She also is working towards a new career, and is trying to get
an engineering degree to achieve that goal.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The main things my patient discussed was the issues related to depression and a feeling that she hasnt accomplished
much. The diseases/conditions she had throughout the years seems to have caused much of the issues with her progressing
in her career, thus contributes to the stagnation related to her developmental stage.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The patient views the illness in as a strict medical issue. She blames the cause of becoming a paraplegic on the crash,
I was hit by a drunk driver. For the issues to come, she blames her former nursing home regarding the hip fracture.
She stated the cause of the urethral erosion was from the Foley catheters.
What does your illness mean to you?
For her, she essentially stated that this current illness is just another problem for her to overcome. She seemed to focus
more in terms of her goals when thinking about this illness, stating that my number one goal is to get out of the nursing
home, and get home. In general, she expressed trouble with coping with this and other illness she had.
+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record

Have you ever been sexually active?_____________________Yes___________________________________________

Do you prefer women, men or both genders? _Men________________________________________________________
Are you aware of ever having a sexually transmitted infection? __No__________________________________________
Have you or a partner ever had an abnormal pap smear?____No for her, unknown for other partners._____________
Have you or your partner received the Gardasil (HPV) vaccination? No for her, unknown for other partners.
Are you currently sexually active? __________No_______________
If yes, are you in a monogamous relationship? ____No___________ When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? __Not currently sexual active, hasnt been
since the onset of her medical issues (paraplegia)._______________________________

How long have you been with your current partner?________Not currently in a relationship_________________
University of South Florida College of Nursing Revision September 2014 7
Have any medical or surgical conditions changed your ability to have sexual activity? ___T4 Spinal fracture.

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No, not currently sexually active. Claims its highly unlikely if she ever will again.

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
__The patient says shes spiritual, but religion doesnt play a big role in my life.
Do your religious beliefs influence your current condition?
_The patient says that her religious beliefs dont really include her current condition, once again stating religion doesnt play a big
role in my life.__________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes
If so, what? How much?(specify daily amount) For how many years? 4 years
Smoked Tobacco 1 Pack a Day (age 43 thru 47)

If applicable, when did the

Pack Years:
patient quit?

Has the patient ever tried to quit? Yes

Does anyone in the patients household smoke tobacco? If If yes, what did they use to try to quit? Patient has quit
so, what, and how much? No. smoking since 2006. She was an on and off smoker before
that time.

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No X
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/Unknown
If so, what? Patient didnt wish to discuss illicit drug use.
How much? For how many years?
(age thru )

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient denies being exposed to any occupational or environmental Hazards/Risks.

5. For Veterans: Have you had any kind of service related exposure?
Patient claims not to have served in the military.

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? Patient claims to be unsatisfied with her overall health. She views her health as one problem
after another.
Integumentary: Patient denies recent problems with nails, dandruff, psoriasis, hives or rashes, and skin
infections. Patient only notes changes in appearances of skin related to pressure ulcers. Patient doesnt use
sunscreen, and bathes only with assistance from either the hospital or nursing homes staff.
HEENT: Patient has some difficulty seeing, and uses glasses to aid with that issue. Patient claims to have minor
issues with cataracts, and claims that she gets early eye exams. The patient stated she has no troubles hearing,
and hasnt had an ear infection since childhood. The patient also says not to have any recent issues with sinus
pain or infections, nose bleeds, post-nasal drip, and oral/pharyngeal infections. Patient has had some issues with
dental problems, stating that she has dentures, and cleans them once a day. She tries to get yearly dental exams.
Pulmonary: Patient claims to have some difficulty breathing related to mild COPD. Patient denies having
emphysema, but claims to have bronchitis. Patient claims to have unproductive cough after surgeries, and had
pneumonia after a surgery in August 2016. Patient denies having asthma, tuberculosis, and environmental
allergies.
Cardiovascular: Patient states she has autonomic dysreflexia, which causes her to have hypertension. She denies
having hyperlipidemia, any history of Myocardial infarction, CAD/PVD, CHF, murmur, thrombus, rheumatic
fever, myocarditis, and arrhythmias. For heart conditions, she stated she had a enlarged bundle branch block on
the left side.
GI: Patient has symptoms of nausea, vomiting, and diarrhea secondary to seizures. Patient also said she had
chronic constipation. Patient denies having GERD, irritable bowel, cholecystitis, indigestion, ulcers, blood in
stool, hepatitis, yellow jaundice, pancreatitis, colitis, diverticulitis, and abdominal abscesses. Patient stated she
had appendicitis, and had her appendix removed in 1979.
GU: Patient stated that she only had problems with nocturia when she was younger. She claims to have no issues
with dysuria, polyuria, or kidney stones. Patient does have hematuria with visible blood coming from both the
urinary catheter and the Nephrostomy tubes.
Women/Men Only: Patient stated to have had an issue with a recent yeast infection, and hasnt been having a
monthly self-breast exam. The patient also denies having any recent pap/pelvic exam. Patient had a
hysterectomy in 1983, and essentially stated that she doesnt recall a menstrual cycle after that.
Musculoskeletal: Patient stated that she had a hip fracture, but no other broken bones in the past. Patient also
claims to have a lack of feeling after her spinal fracture. Patient had T4 spinal fracture, and has been paraplegic
since. Patient also states that she has arthritis.

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Immunologic: Patient denies chills with severe shaking, night sweats, fever, HIV or AIDS, Lupus, rheumatoid
arthritis, sarcoidosis, tumors, and enlarged lymph nodes. Patent claimed that the only time she had a life
threatening allergic reaction is when she was exposed to Iodine.
Hematologic/Oncologic: Patient denies anemia, bleeding easily, bruising easily, cancer, or issues with blood
transfusions.
Metabolic/Endocrine: Patient has type 2 diabetes. Patient denies hypothyroid/hyperthyroidism, osteoporosis, and
intolerance to hot or cold.
Central Nervous System: Patient has had migraines and seizures once and a while. Patient has had trauma to the
T4 spinal cord, and has had trauma to the head on to occasions. Patient denies having a CVA, dizziness, ticks or
tremors, encephalitis, or meningitis.
Mental Illness: Patient has had issues with depression and anxiety. Patient denies schizophrenia and bipolar
disorder.
Childhood Diseases: Patient sated she had measles, polio, scarlet fever, and chicken pox as a child. Patient
denies having mumps.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
The patient was unsure of any other medical issues she had in the past.

Any other questions or comments that your patient would like you to know?
The patient sated that apart from what she came in for, that was all the issues she could remember.

10 PHYSICAL EXAMINATION:
General survey Patient is 57 year old female who is AOx4, and in no visible signs of distress.
Height 5.7 Feet (172.7 cm) Weight 160 lbs. BMI 25.1 Pain (include rating and location) 8 - Buttocks Pulse 59 bpm
Blood Pressure (include location)103/49 left arm Temperature (route taken) 98.5 F Oral
Respirations 18 respirations/minute SpO2 96% Room Air or O2 Room Air
University of South Florida College of Nursing Revision September 2014 11
Overall Appearance: Patient appears to be a middle-aged woman with well-groomed hair, and a clean appearance.
Overall Behavior: The patient seemed to be relaxed, and very sociable, especially when talking about her medical issues.
Patient was able to discuss her medical issues in detail, and maintained eye contact.
Speech: Patient was able to speak to others with a clear, understandable voice.
Mood and Affect: Patient was initially in a talkative and generally pleasant mood. The patient did seem slightly agitated
with discussing blood tests with a nurse and social worker, but returned to her initial mood once the issue was resolved.
Integumentary: The patient has pressure ulcers (Stage IV) to the sacrum, right ischium, left ischium, and left heel. +1
Edema to right leg. Elastic skin turgor on hand, but the nurse had difficulty pinching the stomach and left thigh when
administering an injection. Capillary refill was under 3 seconds, and there were no signs of clubbing. Skin was warm and
dry. The hair was clean and evenly distributed.
IV Access: IV access on the right arm, just above the wrist. No erythema, edema, or discharge.
HEENT: Patients facial features was symmetrical; conjunctiva were clear and sclera was white. Visual aid of glasses in
order to see. Thyroid and lymph nodes were not felt on palpation. Pupils were equal, round, reactive to light, and
accommodated. Eyes had trouble focusing on a object close to the face. Pupils were 3 mm on both sides.
Pulmonary/Thorax: Lung sounds were clear. No SOB or accessory muscle usage. Chest was symmetrical on inspirations
and expirations. No coughing was present.
Cardiovascular: S1 and S2 heard, no extra heart sounds. Heart was beating at a regular rhythm. Radial pulses were 2+
bilaterally, pedal pulses were 2+ bilaterally.
GI: Bowel sounds were normoactive in all four quadrants. There was no tenderness upon palpation. The abdomen did
appear to be bloated. Last bowel movement was on the 14 th of October.
GU: Nephrostomy tubes in both the left and right kidneys. Discharge is a dark redish/brown from right kidney,
redish/orange from the left. Only blood is being discharged from the urinary catheter.
Musculoskeletal: No movement to lower extremities. 5/5 strength in both arms.
Neurological: Patient was AOx4. Diminished sensation to all lower extremities. Unable to move her legs due to pervious
T4 fracture.

Lab Dates Trend Analysis

Glucose: The patients blood The patient has type 2
167 mg/dL 10/16/2016 1016 glucose levels have been diabetes, in which these
121 mg/dL 10/18/2016 - 0640 higher than normal two elevated glucose
(Normal 70-100 mg/dL) throughout the few days levels are likely
of hospitalization. symptoms of the disease.
BUN: 10/16/2016 - 1016 The result seems to help The patient has a
10 mg/dL indicate proper kidney nephrostomy in both
(Normal 7-20 mg/dL) function. kidneys, so BUN should
be monitored to ensure
proper kidney function.
Creatinine: 10/16/2016 -1016 This result shows a While this is lower than
0.7 mg/dL decreased creatinine 0.84 mg/dL, there doesnt
(Normal 0.84-1.21 level, slightly lower than seem to be a severe
mg/dL) the normal. impairment of renal
function.
RBC: 10/18/2016 - 1106 This result is within Despite the loss of blood
4.00 10^6/uL normal limits. through urine, the patient
(Normal for females: appears to have normal
3.90-5.03 10^6/uL) level of RBCs, this
indicates there isnt a
severe loss of blood
despite the surgery.
WBC: 10/18/2016 - 1106 Patient does seem to have Theres an elevated WBC
University of South Florida College of Nursing Revision September 2014 12
 11.81 billion/L an elevated WBC count count, which could
(Normal: 3.5-10.5 related to the surgery. indicate that the patient is
billion/L) currently fighting an
infection.
Hemoglobin: 10/18/2016 - 1106 The patients hemoglobin This could be indicative
9.9 g/dL levels are slightly lower of blood loss, which was
(Normal for Females: 12- than the normal range for observed coming from the
15.5 g/dL) females. urinary catheter and
nephrostomy tubes.
Hematocrit: 10/18/2016 - 1106 The patients Hematocrit This lab finding is
31.9% levels are slightly lower another sign that the
(Normal for Females: than the normal range for percentage of patients
34.9-44.5%) females. red blood cells compared
to the volume of blood is
slightly less than normal.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Vitals Vitals are being measured, along with assessment of the nephrostomy tubes. The rationale behind this is
the patients preparation for discharge. If the patient remains in a stable condition, and the nephrostomy
tubes cause no further issues, the patient can be discharged to the nursing home.
Accu checks are done with vitals to ensure that the blood glucose levels are within normal ranges. This is
performed because the patient has type 2 diabetes mellitus, and blood glucose levels are effected by the
disease process.

8 NURSING DIAGNOSES (Ackley, B. J., & Ladwig, G. B.)

1. Impaired skin integrity r/t mechanical factors and physical immobilization.

2. Ineffective Coping r/t inadequate level of confidence in ability to cope, inadequate level of perception of control,
inadequate resources available, and inadequate social support created by characteristics of relationships, AEB verbally
stating issues coping with illnesses, previous history of depression and anxiety.

University of South Florida College of Nursing Revision September 2014 13

3. Constipation r/t decreased mobility and opioid usage.

4.

5.

University of South Florida College of Nursing Revision September 2014 14

 15 CARE PLAN
Nursing Diagnosis: Ineffective coping r/t inadequate level of perception of control, and inadequate social support created by characteristic
relationships, AEB verbally stating issues coping with illnesses, previous history of depression and anxiety. (Ackley, B. J., & Ladwig, G. B.)
Patient Goals/Outcomes
Client will report increased
psychologic comfort.
Patient will use effective coping
strategies, and the patient will
report decreased physical
symptoms of stress.
Patient will seek hep from health
care professionals as appropriate.
University of South Florida College of Nursing Revision September 2014
Nursing Interventions to Achieve
Goal
Use verbal and nonverbal
therapeutic communication
approaches including empathy,
active listening, and confrontation
to encourage the client to express
emotions, verbalize fears and
concerns, and set goals.
1. Encourage the use of social
support resources.
2. Assist the client to set realistic
goals and identify personal skills
and knowledge.
Nurse will teach the client about
available resources (therapists,
ministers, councilors.)
Rationale for Interventions
Provide References
The use communication to helps
contribute to decreased
psychosocial problems in patients.
(Duff E, et al.)
1. It was found that having low
social support could lead to
ineffective coping in patients who
previously had cancer. (Zucca et
al., 2010). Therefore, encoring a
patient to seek social support may
lead to better coping mechanism.
2. Research has found that helping
clients identify stressors and set
goals could help the client reduce
stress. (Alsen, Brink, Persson,
2008).
Essentially, providing additional
resources for a patient aids with
coping with those issues if that
patient is willing to use them.
(Galbraith, Fink, Wilkins, 2011).
Evaluation of Goal on Day Care
is Provided
Patients signs of depression and
anxiety are decreased, and reported
to be decreased by the patient.
1. Patient will verbalize that they
found a good social support
resource.
2. Patient will verbalize
understanding of realistic goals
achievable with her current
illnesses.
Patient will find a resource that the
patient reports helps with issues of
coping and depression.
15
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
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
*Palliative Care Nursing Home

University of South Florida College of Nursing Revision September 2014 16

 References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning
care. Maryland Heights, MO: Elsevier.

Alsen, P., Brink, E., & Persson, L. (2008). Living with incomprehensible fatigue after recent myocardial
infarction. Journal of Advanced Nursing, 64(5), 459-468. doi:10.1111/j.1365-2648.2008.04776.x

ChooseMyPlate. (n.d.). Retrieved October 23, 2016, from https://www.choosemyplate.gov/

DailyMed. (n.d.). Retrieved October 23, 2016, from https://www.dailymed.nlm.nih.gov/dailymed/index.cfm

Duff, E., Firth, M., Barr, K., & Fox, A. (2009). A follow-up study of oncology nurses after communications
skills training. Cancer Nursing Practice, 8(1), 27-31. doi:10.7748/cnp2009.02.8.1.27.c6839

Galbraith, M. E., Fink, R., & Wilkins, G. G. (2011). Couples Surviving Prostate Cancer: Challenges in Their
Lives and Relationships. Seminars in Oncology Nursing, 27(4), 300-308.
doi:10.1016/j.soncn.2011.07.008

Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing: Concepts, skills, & reasoning. Philadelphia, PA: F.A.
Davis Company.

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University of South Florida College of Nursing Revision September 2014 18