UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Melissa Lopez

Assignment Date: 11/4/2016
.
Agency: Sarasota Memorial Hospital
 1 PATIENT INFORMATION
Patient Initials: FF Age: 71 Admission Date: 10/30/2016
Gender: Male Marital Status: Divorced Primary Medical Diagnosis: GI bleeding
Primary Language: English
Level of Education: Four-year college degree Other Medical Diagnoses: (new on this admission)
None
Occupation (if retired, what from?): Retired engineer
Number/ages children/siblings:
Children: 3; 48 y/o son, 46 y/o daughter, 44 y/o son
Siblings: 6; patient cannot remember all their ages
Served/Veteran: Yes (National Guard) Code Status: Full code
If yes: Ever deployed? Yes
Living Arrangements: Lives by himself in a rented condo; has Advanced Directives: No
stairs, but able to walk them well; autonomous in ADL’s If no, do they want to fill them out? No
Surgery Date: 10/30/2016 Procedure: Upper GI
endoscopy
Surgery Date: 10/31/2016 Procedure: Upper GI
endoscopy
Culture/ Ethnicity /Nationality: Italian/American Type of Insurance: Aetna, Self-pay
Religion: Contemporary Christian

 1 CHIEF COMPLAINT:
Patient stated: “I fell and was very dizzy, and I was bleeding.” Patient also reported diarrhea with blood.

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient reported the GI bleeding began last Thursday. He started to feel light-headed, began to fall, braced himself
and landed on his buttocks. He fell twice like this in the kitchen, and one more time in the dining room. Then he decided
to go to the hospital.
As assessed by Dr. Bradd Kaplan, the patient has a past medical history of diverticulitis, and sigmoid colonic resection
about 6 years ago, who presented with acute GI bleeding. The patient noted onset of bright red blood and melanotic stool,
starting Thursday. The patient’s hemoglobin was 7.6 on admission and was transfused with 2 units of packed red blood
cells. The patient was seen in the emergency room, and his hemoglobin was around 10. The patient had a CAT scan,
which showed cecal diverticulitis. The patient had no abdominal pain. The patient had progressive nausea and vomiting
with no hematemesis noted. The patient also had diarrhea. The patient takes baby aspirin and occasional ibuprofen, but no
other blood thinners. He has had recurrent bouts of diverticulitis, which required a bowel resection 6 years ago. The
patient did not report fevers, but did report chills, diaphoresis, dizziness, headache, chronic pain syndrome with multiple
spinal issues.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
Date Operation or Illness
1990’s 2 laminectomies
6 stomach surgeries; large intestine, appendix, and gallbladder removed; colostomy bag until fissure
healed
1998/99 Neck surgery
July 2016 Cancerous cyst removed from kidney

2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause Alcoholism
MEDICAL

Glaucoma

Problems

Problems
Allergies
of

Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY

Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
MI; lung
Father 68
cancer
Mother 84 Natural
Sister 74 Dementia
Sister 73
Brother 69
Brother 66

Comments
Father was diagnosed with lung cancer at 64 y/o; MI was sudden
Brother (69 y/o) had an MI at 67 y/o
Brother (66 y/o) has had diabetes, gout, and hypertension for 10 yrs
Onset of family arthritis later in life. Patient could not report the onset of the rest of his family’s diseases.

 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 (1966)
Adult Diphtheria
Adult Tetanus (2012)
Influenza (flu)
Pneumococcal (pneumonia) (2014)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Not allergic to any
Medications N/A
medications
Not allergic to food, tape,
Other (food, tape,
latex, dye, or anything in N/A
latex, dye, etc.)
the environment

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  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)
Gastrointestinal (GI) bleeding is categorized as either upper or lower gastrointestinal bleeding. Upper GI bleeds
originate in the esophagus, stomach, or duodenum. Lower GI bleeds originate in the jejunum, ileum, colon, or rectum,
which can be caused by polyps, inflammatory disease, cancer, or hemorrhoids. Severe blood loss along with any
comorbidities can be life-threatening. With significant blood loss, blood accumulates in the GI tract, causing increased
peristalsis leading to diarrhea, digestion of blood proteins, and increased blood urea nitrogen (BUN). As blood volume
depletes, heart rate and therefore cardiac output decrease, causing systolic blood pressure to decrease and pulse to
increase. Peripheral arteries then constrict to compensate, which decreases blood flow to the skin, causing skin pallor.
With continued blood loss, there is decreased blood flow to the kidneys causing decreased urine output, tubular necrosis,
and eventually renal failure as evidenced by anuria or oliguria. Decreased blood flow to GI structures causes mesenteric
insufficiency which causes abdominal pain, and eventually bowel infarction and liver necrosis. Once the compensatory
vasoconstriction fails to increase blood pressure and cardiac output due to continued blood loss, there will be decreased
blood flow to the brain, causing anxiety, confusion, stupor, and eventually a coma. Decreased coronary blood flow causes
angina, and may lead to myocardial infarction, causing pulmonary edema, and heart failure may lead to dysrhythmias.
Metabolic acidosis occurs with continued blood loss as well, leading to lactic acidosis and anoxia. The end stage of these
combined processes eventually lead to death if no interventions are made. Presentations of GI bleeding include
hematemesis, melena, and hematochezia which the patient reports or is observed in the hospital in the case of acute
bleeding, and can be used for diagnosis, as well as a colonoscopy to identify where the bleed is located. Occult blood can
also occur and can be used for diagnosis, and can only be detected by a guaiac test (Huether & McCance, 2008).
Treatment includes finding the location and cause of the bleed, and performing surgery when applicable, as well as
evaluating and limiting nonsteroidal anti-inflammatory drug use.

 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 metropolol (Lopressor) Concentration Patient does not know Dosage Amount 100 mg
Route PO Frequency Daily
Pharmaceutical class Beta Blocker Home Hospital or Both

Indication Ventricular arrhythmias/tachycardia

Adverse/ Side effects
CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares
EENT: blurred vision, stuffy nose
Resp: bronchospasm, wheezing
CV: BRADYCARDIA, HF, PULMONARY EDEMA, hypotension, peripheral vasoconstriction
GI: constipation, diarrhea, drug-induced hepatitis, dry mouth, flatulence, gastric pain, heartburn, ↑ liver enzymes, nausea, vomiting
GU: erectile dysfunction, ↓ libido, urinary frequency
Derm: rash
Endo: hyperglycemia, hypoglycemia
MS: arthralgia, back pain, joint pain
Misc: drug-induced lupus syndrome
* CAPITALS indicate life-threatening.
Italics indicate most frequent.
(Davis’sDrugGuide.com)
Nursing considerations/ Patient Teaching
 Instruct patient to take medication as directed, at the same time each day, even if feeling well; do not skip or double up on missed doses.
Take missed doses as soon as possible up to 8 hr before next dose. Abrupt withdrawal may precipitate life-threatening arrhythmias,
hypertension, or myocardial ischemia.
 Teach patient and family how to check pulse daily and BP biweekly and to report significant changes to health care professional.
 May cause drowsiness. Caution patient to avoid driving or other activities that require alertness until response to the drug is known.
 Advise patient to change positions slowly to minimize orthostatic hypotension.
 Caution patient that this medication may increase sensitivity to cold.

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  Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health
care professional before taking any Rx, OTC, or herbal products, especially cold preparations, concurrently with this medication. Patients on
antihypertensive therapy should also avoid excessive amounts of coffee, tea, and cola.
 Diabetics should closely monitor blood glucose, especially if weakness, malaise, irritability, or fatigue occurs. Medication does not block
sweating as a sign of hypoglycemia.
 Advise patient to notify health care professional if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, light-
headedness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occurs.
 Instruct patient to inform health care professional of medication regimen before treatment or surgery.
 Advise patient to carry identification describing disease process and medication regimen at all times.
 Hypertension: Reinforce the need to continue additional therapies for hypertension (weight loss, sodium restriction, stress reduction, regular
exercise, moderation of alcohol consumption, and smoking cessation). Medication controls but does not cure hypertension.
(Davis’sDrugGuide.com)

Name zolpidem (Ambien) Concentration patient does not know Dosage Amount patient does not know
Route PO Frequency daily
Pharmaceutical class Nonbenzodiazepine Hypnotic Home Hospital or Both
Indication insomnia
Adverse/ Side effects lethargy,
drowsiness, dizziness, headache, hot flashes, hangover (residual sedation), irritability, ataxia, visual
disturbances, anxiety, mental depression, nausea and vomiting, erectile dysfunction; tolerance, psychological or physical dependence;
sleep-related behaviors, hypotension, angioedema, dysrhythmias, suicidal ideation
Nursing considerations/ Patient Teaching
 Teach patient to use nonpharmacological ways to induce sleep (taking a warm bath, listening to music, drinking warm fluids
such as milk, avoiding drinks with caffeine after dinner).
 Encourage patients to avoid alcohol, antidepressant, antipsychotic, and narcotic drugs; severe respiratory depression may occur
 Advise patient to take before bedtime
 Suggest that the patient urinate before taking zolpidem to prevent sleep disruption

Name baby aspirin Concentration 0.75 Dosage Amount 81 mg

Route PO Frequency daily
Pharmaceutical class Salicylates Home Hospital or Both
Indication lower risk of heart attack and stroke
Adverse/ Side effects allergic
reaction: itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest
tightness, trouble breathing; bloody or black stools, bloody vomit or vomit that looks like coffee grounds; chest tightness, wheezing;
ringing in the ears; severe stomach pain; unusual bleeding, bruising, or weakness
Nursing considerations/ Patient Teaching
 Advise patient to not take aspirin with alcohol or with drugs that are highly protein-bound, such as warfarin (Coumadin).
 Suggest that patient inform the dentist before a dental visit if taking high doses of aspirin
 Instruct patient to discontinue 3-7 days before surgery to reduce risk of bleeding (with the health care provider’s approval)
 Inform patient that aspirin tablets can cause GI distress

Name ciprofloxacin (Cipro) Concentration 500 mg Dosage Amount 1 tablet

Route PO Frequency every 12 hours
Pharmaceutical class Fluoroquinolones Home Hospital or Both
Indication UTI
Adverse/ Side effects headaches, dizziness, syncope, peripheral neuritis, visual disturbances, rash, photosensitivity
Nursing considerations/ Patient Teaching
 Teach patient to not crush tablets
 Encourage patient to avoid antacids because they interfere with drug absorption
 Teach patient to avoid sunlight

Name metronidazole (Flagyl) Concentration 500 mg Dosage Amount 1 tablet

Route PO Frequency every 6 hours
Pharmaceutical class Antibiotic Home Hospital or Both

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Indication IBS
Adverse/ Side effects CNS:
SEIZURES, dizziness, headache, aseptic meningitis (IV), encephalopathy (IV). EENT: optic neuropathy,
tearing (topical only). GI:abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant taste, vomiting.
Derm: STEVENS-JOHNSON SYNDROME, rash, urticariatopical only, burning, mild dryness, skin irritation, transient redness. Hemat:
leukopenia. Local: phlebitis at IV site. Neuro: peripheral neuropathy.Misc:superinfection.
Nursing considerations/ Patient Teaching
● Instruct patient to take medication as directed with evenly spaced times between doses, even if feeling better. Do not skip doses or
double up on missed doses. Take missed doses as soon as remembered if not almost time for next dose.
● Advise patients treated for trichomoniasis that sexual partners may be asymptomatic sources of reinfection and should be treated
concurrently. Patient should also refrain from intercourse or use a condom to prevent reinfection.
● Caution patient to avoid intake of alcoholic beverages or preparations containing alcohol during and for at least 3 days after treatment
with metronidazole, including vaginal gel. May cause a disulfiram-like reaction (flushing, nausea, vomiting, headache, abdominal
cramps).
● May cause dizziness or light-headedness. Caution patient to avoid driving or other activities requiring alertness until response to
medication is known.
● Instruct patient to notify health care professional promptly if rash occurs. ● Inform patient that medication may cause an unpleasant
metallic taste.
● Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to
consult with health care professional before taking other medications.
● Advise patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may minimize dry mouth. Notify health
care professional if dry mouth persists for more than 2 wk.
● Inform patient that medication may cause urine to turn dark.
● Advise patient to consult health care professional if no improvement in a few days or if signs and symptoms of superinfection (black,
furry overgrowth

Name omeprazole (Losec) Concentration 20 mg delayed release Dosage Amount 1 capsule

Route PO Frequency twice per day
Pharmaceutical class proton-pump inhibitors Home Hospital or Both
Indication Reduction of risk of GI bleeding
Adverse/ Side effects CNS:
dizziness, drowsiness, fatigue, headache, weakness. CV:chest pain. GI: PSEUDOMEMBRANOUS COLITIS,
abdominal pain, acid regurgitation, constipation, diarrhea, flatulence, nausea, vomiting. F and E: hypomagnesemia (especially if
treatment duration 3 mo).Derm: itching, rash.MS: bone fracture.Misc:allergic reactions.
Nursing considerations/ Patient Teaching
● Instruct patient to take medication as directed for the full course of therapy, even if feeling better. Take missed doses as soon as
remembered but not if almost time for next dose. Do not double doses.
● May cause occasional drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to
medication is known.
● Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult
health care professional before taking any new medications.
● Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation.
● Advise patient to report onset of black, tarry stools; diarrhea; abdominal pain; or persistent headache to health care professional
promptly.
● Instruct patient to notify health care professional of onset of black, tarry stools; diarrhea; abdominal pain; or persistent headache or if
fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting
health care professional.

Name Acetaminophen / Oxycodone (Percocet) Concentration 5/325 Dosage Amount 1 tablet

Route PO Frequency every 6 hours PRN
Opioid agonists nonopioid analgesic
Pharmaceutical class
Home Hospital or Both
combinations
Indication Moderate to severe pain
Adverse/ Side effects CNS:confusion,
sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams.
EENT: blurred vision, diplopia, miosis. Resp: RESPIRATORY DEPRESSION. CV: orthostatic hypotension. GI:constipation, dry
mouth, choking, GI obstruction, nausea, vomiting. GU: urinary retention. Derm: flushing, sweating.Misc: physical dependence,
psychological dependence, tolerance.
Nursing considerations/ Patient Teaching
●Instruct patient on how and when to ask for and take pain medication.
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● Advise patient that oxycodone is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the
individual for whom it was prescribed.
● Medication may cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to
avoid driving and other activities requiring alertness until response to medication is known.
● Advise patients taking Oxycontin tablets that empty matrix tablets may appear in stool.
● Advise patient to make position changes slowly to minimize orthostatic hypotension.
● Advise patient to avoid concurrent use of alcohol or other CNS depressants with this medication.

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? NPO
Diet patient follows at home? Regular, self-monitored
24 HR average home diet:
Breakfast: Quaker oatmeal prepared with water, or a plain
bagel with butter, or a mushroom omelet
Analysis of home diet (Compare to “My Plate” and
Consider co-morbidities and cultural considerations):
Patient eats less than the USDA’s suggestion on everything,
amounting to 999 calories in a given day out of a 2,000-
calorie diet, but this may be due to the patient’s age. As a
71 year-old retired man, his body needs less nutritional
requirements, though it would still appear that he may need
to increase his whole grains and proteins to maintain his
highest level of functioning. In addition, the patient reports
no consumption of fruits, which means that his soluble and
insoluble fiber intake is dramatically low. This may have
contributed to the irritation of GI tract possibly causing his
diverticulitis overtime, which may have led to his GI bleed.

Lunch: salad with ½ a romaine heart, or a can of Progresso

mushroom soup, or Italian wedding soup

Dinner: halibut, with salad, and sometimes potatoes

Snacks: Häagen-Dazs ice cream bars

Liquids (include alcohol): 6-8 glasses of water, 1 glass of

chardonnay in the evening

(https://www.supertracker.usda.gov/foodtracker.aspx#graph)

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Patient states that he is independent and goes to the hospital when ill.

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How do you generally cope with stress? or What do you do when you are upset? Patient responded that he copes “very
well” with stress. Patient states, “I’m not a stressful person, never have been.” Patient says he “cools down and rolls with
the punches.”

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient states he has had recent difficulties “only on the gulf course, but other than that no.”

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? Patient says “no.”

Have you ever been talked down to? Patient says he has been before in his life, but not at home.

Have you ever been hit punched or slapped? Patient says he has been, but never at home.

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? Patient says
he has been emotionally harmed when he got divorced and became depressed.

If yes, have you sought help for this? Patient says, “no.”

Are you currently in a safe relationship? Patient says “yes.” Patient says he has a girlfriend.

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s 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 Erickson’s developmental stage for your
patient’s age group:
Ego Integrity: “As we grow older…we contemplate our accomplishments and are able to develop integrity if we see
ourselves as leading a successful life.” (McLeod, 2008)
Despair: “…if we see our lives as unproductive, feel guilt about our past, or feel that we did not accomplish our life goals,
we become dissatisfied with life and develop despair, often leading to depression and hopelessness.” (McLeod, 2008)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
Due to the patient’s age, he is in the ego integrity vs. despair stage of psychosocial development, according to Erikson.
The patient shows no signs of regret or guilt about his past, and is very positive and talkative. He talks about his
grandchildren, how he enjoys playing golf whenever possible, and shows no signs of dissatisfaction or depression. The
patient also offered advice in conversation about his past, which is key in ego integrity, as wisdom is goal of this stage. He
seems to have accomplished the goals he had set for his life.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
Because the patient appears to be successful in this developmental stage, his disease may give him more wisdom which
he can impart to his children and grandchildren. The suddenness of his condition and hospitalization may also cause him
to think more on his frailty and the inevitability of death, and may advance him further in evaluating his life
accomplishments and the successfulness of his life.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?” Patient says his haitus hernia was involved in causing his illness. Patient
also stated that he “gobbles drinks down” and eats “PB&J until my mouth gets dry and I wash it down with milk.”

What does your illness mean to you? Patient says that he now must “eat smaller bites,” have a smaller glass, take smaller
sips, and “not gobble it down.”

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 +3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)

Have you ever been sexually active? Patient says, “yes.”

Do you prefer women, men or both genders? Patient says, “women.”
Are you aware of ever having a sexually transmitted infection? Patient says, “no.”
Have you or a partner ever had an abnormal pap smear? Patient says, “no.”
Have you or your partner received the Gardasil (HPV) vaccination? Patient says, “no.”

Are you currently sexually active? Patient says, “yes.” If yes, are you in a monogamous relationship? Patient says, yes.”
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? Patient says, “none.” Patient states that because of his and his partner’s ages, he does not take precautions,
and “none of us have anything.”
How long have you been with your current partner? Patient says, “two years.”
Have any medical or surgical conditions changed your ability to have sexual activity? Patient says, “only stays in the
hospital.”
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
Patient says, “no, because of our ages. We both got tested before we started anything.”

±1 SPIRITUALITY ASSESSMENT:
What importance does religion or spirituality have in your life? Patient replied, “very important.”
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition? Patient replied, “yes; I prayed all the way through testing, and every
morning for family and friends.”
______________________________________________________________________________________________________

+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? Cigarettes, a pipe How much? (specify daily amount) For how many years? X years
½ a pack of cigarettes a day (age 17 thru 21 )
Smoked a pipe once a day
If applicable, when did the
Pack Years: 17-21
patient quit? 21/22 y/o

Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? No If yes, what did they use to try to quit? Patient did not say.

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Red wine, usually white wine How much? 1 glass a day For how many years? 25/30 yrs
Volume: “ (age 21 thru present)
Frequency: “
If applicable, when did the patient quit?
N/A

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what? Marijuana
How much? 3 times in his life For how many years?
(age 19/20 thru 20/21)

Is the patient currently using these drugs? If not, when did he/she quit?
Yes No 21 y/o

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4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks? Patient says, “no.”

5. For Veterans: Have you had any kind of service related exposure? Patient says he probably was exposed to asbestos.

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? Patient reports that he views his overall health as “good.”

Integumentary: Patient reports changes in appearance of skin on scalp (dandruff), rosacea, uses 30 SPF sunblock
for body, 50 SPF for face, bathes daily; patient denies nail problems, psoriasis, skin infections
HEENT: Patient reports difficulty seeing in right eye (near-sighted), post-nasal drip, routinely brushing his teeth
2-3 times a day, routine dentist visits 2 times a year, vision screening every year; patient denies cataracts,
glaucoma, difficulty hearing, ear infections, sinus pain or infections, nose bleeds, oral/pharyngeal infection,
dental problems
Pulmonary: Patient reports dry cough, last CXR 2 months ago (cancerous tumor); patient denies difficulty
breathing, asthma, bronchitis, emphysema, pneumonia, tuberculosis, environmental allergies
Cardiovascular: Patient reports hypertension, arrhythmias (erratic heartbeat), last EKG 2 days ago; patient
denies hyperlipidemia, chest pain/angina, myocardial infarction, CAD/PVD, CHF, murmur, thrombus,
rheumatic fever, myocarditis
GI: Patient reports mild constipation, diverticulitis, recent blood in stool, appendicitis removed, last
colonoscopy 11/3/16; patient denies current nausea, vomiting, diarrhea, GERD, indigestion, hemorrhoids,
yellow jaundice, pancreatitis, colitis, appendicitis, abdominal abscess, irritable bowel, cholecystitis,
gastritis/ulcers, hepatitis
GU: Patient reports nocturia, kidney stones from prostate pill 30 years ago; patient denies dysuria, hematuria,
polyuria, bladder and kidney infections
Women/Men Only: Patient reports no known STD; patient denies urinary retention
Musculoskeletal: Patient reports fractured nose and arm, back and neck pain, gout in right big toe a year ago
which resolved quickly, arthritis in neck and wrist; patient denies muscle weakness, osteomyelitis
Immunologic: Patient reports has had chills, night sweats, fever with the flu in the past, tumor in left kidney;
patient denies HIV and AIDS, lupus, rheumatoid arthritis, sarcoidosis, life-threatening allergic reactions,
enlarged lymph nodes
Hematologic/Oncologic: Patient reports cancer in left kidney, blood type unknown by patient; patient denies
anemia, bleeding easily, bruising easily
Metabolic/Endocrine: Patient reports no known metabolic disorders; patient denies diabetes, hypo/hyperthyroid,
intolerance to hot/cold, osteoporosis
Central Nervous System: Patient reports dizziness a week ago, has had migraines in the past; patient denies
CVA, severe headache, seizures, ticks/tremors, encephalitis, meningitis
Mental Illness: Patient reports that he had depression when he got a divorce
Childhood Diseases: Patient reports he had measles and mumps at 7 or 8 y/o which ran their course (had a house
doctor), and had chicken pox when he was young; patient denies having polio, scarlet

Is there any problem that is not mentioned that your patient sought medical attention for with anyone? Patient did not
report any other problems.

Any other questions or comments that your patient would like you to know? Patient did not add anything further.

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±10 PHYSICAL EXAMINATION:
General survey The patient is a 71 year old man who looks very healthy and young for his age, though he is slightly
overweight. Patient is sitting in a chair, talkative, willing to answer questions and can ambulate on his own without
assistance. ____________________________________________________________________________________
Height 5’8” Weight 202 lbs 6 oz BMI 32.97kg/m2 Pain (include rating and location) 9 out of 10 in lower neck & back
Overall Appearance: clean, hair combed, dress appropriate for setting and temp, maintains eye contact, no obvious
handicaps
Overall Behavior: awake, calm, relaxed, interacts, well with others, judgment intact
Speech: clear, crisp diction
Mood and Affect: pleasant, cooperative, cheerful, talkative
Integumentary: skin is warm, dry, and intact; skin turgor elastic; no rashes, lesions, or deformities; nails without clubbing;
capillary refill <3 seconds; hair evenly distributed, clean, without vermin
IV Access: Left arm, inserted yesterday; no redness, edema, or discharge; IV hydromorphone (Dilaudid); 0.9% saline
HEENT: facial features symmetric; no pain in sinus region; no pain/clicking of TMJ; trachea is midline; thyroid not
enlarged; sclera white and conjunctiva clear, without discharge; eyes watery and itchy; eyebrows, eyelids, orbital area,
eyelashes, and lacrimal glands symmetric without edema or tenderness: PERRLA; ears symmetric without lesions or
discharge; nose without lesions or discharge; lips, buccal mucosa, floor of mouth, and tongue pink and moist without
lesions
Pulmonary/Thorax: respirations regular and unlabored; chest expansion symmetric; lung sounds clear with no
adventitious breath sounds; no sputum production
Cardiovascular: no lifts, heaves, or thrills; heart sounds S1, S2 present and regular; no murmurs, clicks, or adventitious
heart sounds; calf pain bilaterally; apical pulse 3+ (normal); carotid, and radial pulses bilaterally equal, 3+ (normal)
GI: bowel sounds active x4 quadrants; no bruits auscultated; no organomegaly; percussion dull over liver and spleen and
tympanic over stomach and intestine; last bowel movement 11/4/16, watery stool
GU: genitalia clean, moist, without discharge, lesions, or odor; urine clear
Musculoskeletal: full ROM intact in all extremities without crepitus; vertebral column without kyphosis or scoliosis;
neurovascular intact: no pallor, paralysis or paresthesia
Neurological: patient awake, alert, oriented to person, place, time, and date; gait smooth, regular with symmetric length of
stride
±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS:

Lab Dates Trend Analysis

Occult blood (10/31/2016) Patient was positive for The patient no longer was
+ occult blood upon blood in his stool, which
- (11/4/2016) admission, but was means his GI bleeding
negative upon discharge has stopped
WBC WBC remained within Decrease in WBC
10.2 (10/30/2016) normal range and indicates that there is no
decreased over the course infection present
5.8 (11/3/2016) of hospitalization
RBC RBC were below Patient is replenishing
2.55 (10/30/2016) expected range, but RBC lost in GI
increased throughout hemorrhage
3.25 (11/3/2016) hospitalization
Hg Hg was low upon Patient is healing from GI
7.6 (10/30/2016) admission, lowest was 6.8 bleed and is not at as
on 10/31, but steadily great of a risk of ischemia
10.3 (11/3/2016) increased throughout
hospitalization
Hematocrit Hematocrit was low upon RBC are increasing in
22.6 (10/30/2016) admission, lowest was blood

University of South Florida College of Nursing – Revision September 2014 10

 20.4 on 10/31, but
31.7 (11/3/2016) increased throughout
hospitalization
Protime Protime was within Patient is not expected to
13.2 (10/30/2016) expected range upon have coagulation
admission, though it did problems
14.2 (10/31/2016) rise before discharge

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

Patient had hematological lab studies every day, specifically to assess his hemoglobin, hematocrit, and blood cell counts to
determine when he could be safely discharged from the hospital because of his recent acute blood loss. The patient also
multiple colonoscopies in order to determine the cause and location of the bleeding. The patient was discharged today and
is scheduled for a follow up appointment with his doctor.

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

1. Acute pain related to abdominal trauma as evidenced by GI bleeding
2. Risk for injury: risk factor: history of accidents

University of South Florida College of Nursing – Revision September 2014 11

± 15 CARE PLAN
Nursing Diagnosis: Acute pain related to abdominal trauma as evidenced by GI bleeding. (Ackley & Ladwig, 2011)
Patient Goals/Outcomes
Patient will report that pain
management regime achieves
comfort-function goal without
adverse effects by discharge today.
Patient will describe
nonpharmacological methods that management approach, including
can be used to help achieve
University of South Florida College of Nursing – Revision September 2014
Nursing Interventions to Rationale for Interventions Evaluation of Goal on Day Care
Achieve Goal Provide References is Provided
1. Asses pain level in patient 1. Pain is a subjective sensory 1. Assess pain level using the 0-10
using a valid and reliable self- experience which only the patient scale.
report pain tool, such as the 0- can accurately report.
10 numerical pain rating scale. 2. Evaluate the patient’s response
2. Obtaining an individualized and apply his individual prior
2. Ask the patient to describe pain history helps to identify experience to current pain
prior experiences with pain, potential factors that may interventions moving forward.
effectiveness of pain influence the patient’s willingness
management interventions, to report pain, as well as, factors 3. Evaluate whether the current
responses to analgesic that may influence pain intensity, drug orders match previously
medications including the patient’s response to pain, ineffective medications to treat the
occurrence of adverse effects, anxiety, and pharmacokinetics of patient’s pain.
and concerns about pain and its analgesics.
treatment.
3. Accurate medication
3. Determine the client’s reconciliation can prevent errors
current medication use. Obtain associated with incorrect
an accurate and complete list medications, dosages, omission of
of medications the patient is components of the home
taking or has taken. medication regime, drug-to-drug
interactions, and toxicity that can
occur when incompatible drugs are
combined or when allergies are
present. This history will provide
the clinician with an understanding
of what medications have been
tried and were or were not
effective in treating the patient’s
pain.
1. Explain to the patient the pain 1. One of the most important steps 1. Ask the client to teach the nurse
toward improved control of pain is the pain management approach,
pharmacological and better patient understanding of the potential adverse effects, and the
12
comfort-function goal by
discharge today.
State ability to obtain sufficient
amounts of rest and sleep by
discharge today.
nonpharmacological interventions,
the assessment and reassessment
process, potential adverse effects,
and the importance of prompt
reporting of unrelieved pain.
2. In addition to administering
analgesics, support the patient’s
use of nonpharmacological
methods to help control pain, such
as distraction, imagery, relaxation,
and application of heat and cold.*
1. Ask the patient to describe
appetite, bowel elimination, and
ability to rest and sleep.
2. Reinforce the importance of
taking pain medications to
maintain the comfort-function
goal.
nature of pain, its treatment, and
the role the patient needs to play in unrelieved pain in order to assess
pain control.
2. Cognitive-behavioral strategies
can restore the patient’s sense of
self-control, personal efficacy, and about managing his own pain
active participation in his care.
1. Opioid-induced constipation is a
common and significant problem
in pain management. Prevention
and early detection are much
easier than management of opioid-
induced constipation.
2. Teaching the client to stay on
top of their pain and prevent it
from getting out of control will
improve the ability to accomplish
the goals of recovery.
importance of prompt reporting of
the patient’s understanding of the
teaching.
2. Ask the patient how he feels
using nonpharmacological
methods in order to determine if
the nurse’s support is successful in
helping him participate in his care.
1. Listen to patient’s response and
determine if there is any
constipation, or inability to rest
and take proactive steps to treat
the patient’s complaints.
2. Ask the patient to repeat the
importance of managing his pain
upon discharge.

±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
□Med Instruction/Prescription
 □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
University of South Florida College of Nursing – Revision September 2014 13
□Palliative Care

University of South Florida College of Nursing – Revision September 2014 14

 References

Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.

Huether, S. E., & McCance, K. L. (2008). Understanding Pathophysiology (4th ed.). St. Louis, MO:
Mosby/Elsevier.

McLeod, S. (2008). Erik Erikson. Retrieved November 18, 2016, from http://www.simplypsychology.org/Erik-
Erikson.html

Metropolol. (n.d.). Retrieved from http://www.drugguide.com/ddo/view/Davis-Drug-

Guide/51497/all/metoprolol#7

University of South Florida College of Nursing – Revision September 2014 15