UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Renee Dabydeen

FUNDAMENTAL PATIENT ASSESSMENT TOOL

. Assignment Date: November 7 2014

1 PATIENT INFORMATION

Agency: Bayfront Medical Center

Patient Initials: JL

Age: 56

Admission Date: October 21 2014

Gender: Male

Marital Status: Single

Primary Medical Diagnosis: Fracture of tibial,

Primary Language: English

open wound infection

Level of Education: First Year of Doctoral degree

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Currently unemployed

No new medical Diagnoses on this admission

Number/ages children/siblings: None

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

Code Status: Full Code

Living Arrangements: Two roommates

Advanced Directives: None

If no, do they want to fill them out? No
Surgery Date: October 23 2012

Culture/ Ethnicity /Nationality: Caucasian

Procedure: Removal/replacement two tibial rods

Religion: None

Type of Insurance: Neighborhood

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1 CHIEF COMPLAINT:
Patient describes a throbbing, aching and constant pain in right leg

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course
of stay)

Onset: Two weeks after surgery in which the rods were originally placed in tibial
Location: Right Leg
Duration: Constant pain that does not go away
Charaterisitics: Throbbing and aching pain
Aggravating factors: Any type of activity and movement that involves pressure on right leg
Relieving factors: When right leg is at rest and when he falls asleep

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Treatment: Patient takes aspirin and tramadol as needed, never completely alleviated the pain.
Level of pain: On a scale from 0-10, with 0 being no pain at all and 10 being the most pain that they have ever had the
patient rated level of pain seven
The patient was admitted to the hospital on October 6 2014 after being hit by a car and had hardware place in the right
tibial. The patient was admitted back to the hospital on October 21 2014 due to infection in the right tibial resulting in
removal of hardware and replacement of hardware with an antibiotic rod.

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

Operation or Illness

Unknown

Diagnosed with Asthma: Patient uses inhaler as needed if experiencing difficult breathing

October 6 2014

Open reduction and internal fixation

October 23 2014

Replacement of hardware with antibiotic rod and subsequent removal

2
FAMILY
MEDICA
L
HISTOR
Y

Ag
e
(in
ye
ars
)

Cause
of
Death
(if
applicable
)

Father

Unknown

Mother

67

Heath:
Heat
Attack

Brother

N/
A

Sister

N/
A

relationship

N/
A

relationship

N/
A

Al
co
hol
is
m

Env
iron
men
tal
Alle
rgie
s

A
ne Art As
m hri th
ia tis ma

Bl
ee
ds
Ea
sil
y

Ca
nc
er

Di
ab
ete
s

Hea
rt
H
Tro
yp
Gl
G
uble
er
au
ou
(angi
te
co
t
na,
ns
ma
MI,
io
DVT
n
etc.)

X
X

Kid
ney
Pro
ble
ms

Me
nta
l
Sto
He
ma
alt Sei ch Stro Tu
zur Ul ke
h
mor
Pr es cer
obl
s
em
s

Comments: Include age of onset

Patient did not have a close relationship with father as a result was not sure of this medical history. Also does not know the age and
cause of death for father.
Mother: Patient states that After mom hit age 65 she always had some sort of medical problem

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IMMUNIZATION HISTORY

(May state U for unknown, except for Tetanus, Flu, and Pna)

YES

Routine childhood vaccinations

Routine adult vaccinations for military or federal service

Adult Diphtheria (Date) : UNKNOWN

Adult Tetanus (Date) Is within 10 years? Yes, date unknown

Influenza (flu) (Date) Is within 1 years? Yes, October 22 2014

Pneumococcal (pneumonia) (Date) Is within 5 years? Yes, date

unknown

NO

Have you had any other vaccines given for international travel or
occupational purposes? Please List: According to patient none
If yes: give date, can state U for the patient not knowing date received

1 ALLERGIES

OR ADVERSE
REACTIONS

NAME of
Causative Agent
Penicillin

Type of Reaction (describe explicitly)

According to patient, he looses consciousness, patient states that the last
time penicillin was take was at the age of seventeen years old and has
not taken it since. (As a nurse, I would be able to know that this is

Medications

not a allergic reaction to a medicine however, I would still take note

of the patients symptoms when taking penicillin)

Cats
Other (food, tape,
latex, dye, etc.)

According to patient. he experiences shortness of breath and flares

up [his] asthma. Patient states that he uses is inhaler to relieve this
reaction.

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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)
Based on the information that was presented the patient has osteomyelitis exogenous, which is an infection of bone,
bone marrow, and the soft tissue that surrounds the bone (Sommers 2013). The mechanics of this disease is a indirect
organism into the bone or the surrounding tissue. For this patient the rods that were placed in the patients tibial may

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have been a carrier of an organism that was introduced to the host. Osteomyelitis usually occurs to patients with
previous trauma to a bone as well as, any delay in treatment of a fracture. This demonstrates that the patient was more
susceptible to this illness due to the fracture that occurred in their tibial after the car accident. The way to diagnose this
illness is based on the history of the patient, if the patient suffered from any bone trauma, open injuries, or surgical
procedures they are more susceptible to this illness. Furthermore, during the physical exam if the patient has any areas
of redness, swelling or increased warmth this is a sign of osteomyelitis. In addition, if the patient has a high level of
of anxiety and acute pain theses are signs of the illness. The signs of anxiety and pain were both present in the patient
during the assessment.
Moreover, the most critical factor in eliminating osteomyelitis is prevention (Sommers 2013). Early diagnoses of the
illness can play a critical role controlling the illness efficiently. Also early debridement of the open fracture can remove
necrotic tissue which limits bacterial growth. The patient can also take antibiotics however, this should not be a go to
technique due to the emergence of smart bugs. Also a diet high in calories, protein, calcium, and vitamin C should be
started soon as possible in order to promote bone healing. Furthermore, a surgeons may place catheters in the wound for
irrigation or for direct antibiotic instillation.
In addition, the prognosis of osteomyelitis usually includes a prolonged hospital stay and the patient may need
help within their home. Also during the healing process of the infection the patient will be on prolonged bed rest, so
it is important to watch for the skin integrity of the patient.
Furthermore, genetic factors that influence osteomyelitis include heritable immune reposes (Unbound). Actue
osteomyelitis is found mostly in children while, chronic osteomyelitis is found in adults. Furthermore,
osteomyelitis is much higher in developing countries compared to developed countries.

5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.] Vallerand H. A. Sanoski A. C. & Deglin H. J. (2014)
Name Ascorbic Acid/ Cetane

Concentration: N/A

Route: Oral

Dosage Amount: 500MG

Frequency: Twice daily

Pharmaceutical class: Water soluble Vitamins

Home

Hospital

or

Both

Indication: Treatment and prevention of vitamin C deficiency (scurvy) with dietary supplementation.
Supplemental therapy in some GI diseases during long term parental nutrition or chronic hemodialysis
States of increased requirements such as: pregnancy, lactations, stress, hyperthyrodism, Trauma, Burns, Infancy
Unlabeled Use: Prevention of the common cold
Adverse/ Side effects: Drowsiness, fatigue, headache, insomnia, cramps, diarrhea, heartburn, nausea, vomiting , kidney stones, flushing, deep vein thrombosis,
hemolysis, sickle cell crisis
Nursing considerations/ Patient Teaching: Advise patient to take medication as directed and not to exceed prescribed. Excess doses may lead to diarrhea and
urinary stone formation. If missed dose, skip does and return to dose schedule.Vitamin C Deficiency: Encourage patient to comply with diet recommendations of
health care professional. Explain that the best source of vitamins is well balanced diet. Foods high in ascorbic acid include citrus fruits, tomatoes, strawberries,
cantaloupe, and raw peppers. Rapid loss is caused by drying, salting and cooking

Name: Aspirin/ Acetylsalicylic acid

Route: Oral

Concentration: N/A

Dosage Amount: 81 mg
Frequency: Twice Daily

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Pharmaceutical class: Salicylates

Home

Hospital

or

Both

Indication: Inflammatory disorders including: Rheumatoid arthritis, Osteoarthritis; Mild to Moderate pain; Fever; Prophylaxis of transient ischemic attacks and MI.
Unlabeled uses: Adjunctive treatment of Kawasaki disease
Adverse/ Side effects: GI bleeding, dyspepsia, epigastric distress, nausea, abdominal pain, anorexia, hepatotoxicity, vomiting, anemia, hemolysis, rash, urticaria
ALLERGIC REACTIONS: Anaphylaxis and laryngeal edema
Nursing considerations/ Patient Teaching: Instruct patient to take with full glass of water and to remain in a upright portion for 15-30 min after administration,
advise patient to report tinnitus, unusual bleeding of gums, bruising; black, tarry stools. or fever lasting longer than 3 days. Caution patient to avoid concurrent use of
alcohol with this medication to minimize possible gastric irritation; 3 or more glasses or more glasses of alcohol per day may increase GI bleeding. Caution patient to
avoid taking concurrently with acetaminophen or NSAIDs for more than a few day, unless directed by health care professional to prevent analgesic nephropathy.
Teach patient on a sodium restricted die at to avoid effervescent tablets or buffered-aspirin preparations.

Name: Cyanocobalamin/ Nascobal

Concentration: N/A

Route: Oral

Dosage Amount: 1,000 MCG

Frequency: Daily

Pharmaceutical class: Water soluble vitamins

Home

Hospital

or

Both

Indication: Vitamin B12 deficiency; Pernicious anemia; Part of the schilling test
Adverse/ Side effects: Headache, heart failure, diarrhea, itching, swelling of the body, hypokalemia, thrombocytosis, pulmonary edema
Nursing considerations/ Patient Teaching: Encourage patient to comply with diet recommendations of health care professional. Explain that the best source of
vitamins is a well balanced diet with foods from four basic food groups. Foods high in vitamin B12 include meats, seafood, egg yolk, an fermented cheeses, few
vitamins are lost with ordinary cooking. Inform patient with pernicious anemia of the lifelong need for vitamin B12 replacement

Name: Docusate-senna/ Senokot-S

Concentration: N/A

Route: Oral

Dosage Amount: 1,000 MCG

Frequency: Twice Daily

Pharmaceutical class: Stimulate Laxatives; Stool Softeners

Home

Hospital

or

Both

Indication: PO: treatment of constipation associated with dry, hard stools and decreased intestinal motility
Adverse/ Side effects: electrolytes imbalances, dehydration, abdominal cramps, nausea, vomiting, diarrhea, rashes, urine discoloration
Nursing considerations/ Patient Teaching: Advise patients that laxatives should be used only for short-term therapy. Long term therapy may cause electrolyte
imbalance and dependence. Encourage patients to used other forms of bowel regulation, such as increasing bulk in the diet, increasing fluid intake (6-8 glasses/day)
and increasing mobility. Normal bowel habits are variable and may vary from 3 times ad day to three times a week.

Name: Fluticasone Nasal/ Nystop

Concentration: N/A

Route: Topical

Dosage Amount: 100,000 units/g

Frequency: Twice daily

Pharmaceutical class: Antifungals

Home

Hospital

or

Both

Indication: Treatment of a variety of cutaneous final infections, including cutaneous candidiasis, tines pedis (athletes foot), tines cruris (jock itch), tines corporis
(ringworm) and tine versicolor
Adverse/ Side effects: burning, itching, local hypersensitivity reactions, redness, stinging
Nursing considerations/ Patient Teaching: Instruct patient to apply medications directed as for full course of therapy even if feeling better. Emphasize the
importance of avoid the eyes. Advise patients to report increased skin irritation or lack of respond to therapy to health care professional.

Name: TraMADol/ Conzip

Concentration: N/A

Route: Oral

Dosage Amount: 50mg

Frequency: Twice daily

Pharmaceutical class: Analgesics (Central acting)

Home

Hospital

or

Both

Indication: Moderate to moderately server pain (extended-release formulations indicted for patient who require around the clock pain management )
Adverse/ Side effects: Visual disturbance, vasodilations, constipation, nausea, abdominal pain, anorexia, diarrhea, dry mouth, dyspepsia, flatulence, vomiting,
menopausal symptoms, pruritus, sweating, hypertonia

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Nursing considerations/ Patient Teaching: Instruct patient on how and when to ask for pain medication, may cause dizziness and drowsiness. Caution patient to
avoid driving or other activities requiring alertness until respond to medication is known. Advise patient to change positions slowly to minimize orthostatic
hypotension. Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication. Advise patient to notify health care professional
before taking other RX, OTC, or herbal products concurrently. Advise patient to notify health care professional if seizure or if symptoms of serotonin syndrome
occurs. Encourage patent to turn, cough, and breathe deeply every 2 hours to prevent atelectasis.

Name: Vancomycin/ Vancocin

Concentration: N/A

Route: Intravenous

Dosage Amount: 1,250mg

Frequency: Every 12 hours rate 185.33 infuse over 1.5 hours

Pharmaceutical class: Anti-infectives

Home

Hospital

or

Both

Indication: Treatment of potentially life treating infection when less foci anti-invectives are contraindicated. Particularly useful in staphylococcal infection,
including: endocarditis, meningitis, osteomyelitis, pneumonia, septicemia, soft tissue infections in patients who have allergies to penicillin or its derivatives or when
sensitivity testing demonstrates resistance to methicillin
Adverse/ Side effects: Ototoxicity, hyotension, nausea, vomiting, nephrotoxicity, rashes, eosinophilia, leukopenia, phlebitis, back and neck pain
Nursing considerations/ Patient Teaching: Instruct patient to report sings of hypersensitivity, tinnitus, vertigo, hearing loss. Advise patient to notify health care
provider if no improvement is seen in a few days. Patients with history of rheumatic heart disease or valve replacement need to be taught importance of using
antimicrobial prophylaxis prior to invasive dental or medical procedures.

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5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with
recommendations.

Diet ordered in hospital? Regular Diet

Analysis of home diet (Compare to My Plate and

Diet patient follows at home? Regular Diet

Consider co-morbidities and cultural considerations):

24 HR average home diet:

Compared to my plate the patient consumes too much

Breakfast: One cup of orange juice (tropicana) , bowl of

saturated fat. The patient consumes 38 grams on average

oatmeal with raisins, cup of yogurt, cup of decaffeinated

while the limit on saturated fats based on My Plate is 22

black coffee

grams. In addition the patient consumes a large amount of

Lunch: Deli wrap with lettuce, tomatoes,cucumbers,

sodium with the limit being 2300mg and the patient

grilled chicken and a ranch dressing with a large diet coke

consuming 3280 on average. Moreover the patient does not

Dinner: Grilled salmon with a vegetable medley. Drinks

meet the daily food group targets. This is due to low intake

full cup of whole milk with meal

of grains, fruits, and dairy. Considering the culture in

Snacks: Nachos and cheese and 2 cookies (chocolate chip)

which the patient is adapted to I can see how his diet does

Liquids (include alcohol): Water, milk, Orange Juice,

not match up with My Plate requirements. The patient is

Coffee, Red Wine (Drinks two cups daily)

adapted to the American lifestyle were indulging in food is

a common item. Also the patients intake of a lot of sodium
is common in America due to the amount of processed
food. I can see how the patient culture plays a key role in
their choices of food consumption.
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.

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Web: //www.supertracker.usda.gov/foodtracker.aspx

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1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Patient has two roommates that are willing to help him in times of illness

How do you generally cope with stress? or What do you do when you are upset? Patient copes with stress by
internalizing and pondering about the issues. Also the patient explains that he enjoys going to the gym and releasing
frustration and anxiety by running and working out. However, the patient states since the injury to my leg I have
been able to get out to the gym, right now I just cry in order to cope with my health and other issues

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient admits to feeling depresses and overwhelmed due to the loss of his art gallery as well as, his partner after the
accident. Also the patient feels overwhelmed because of all the medical bill that he is dealing with.

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+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?

Patient indicated that he never felt unsafe in a close relationship
Have you ever been talked down to? Yes Have you ever been hit punched or slapped? No

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
No, patient has not been emotionally or physically harmed by a person in close relationship
If yes, have you sought help for this?
N/A

Are you currently in a safe relationship? Patient is currently not in a relationship

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:
The patient developmental stage is generativity vs. stagnation. Erickson refers to the adults ability to look outside of oneself an
an for another, through parenting. This stage refers to ability to create a living legacy. (Learning theories 2014)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

From the assessment the patient is in the generativity vs. stagnation stage in his life. The patient exhibits this by
speaking of this art gallery, which he states that he misses and that this gallery is his mark in the world. The patient

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showed great love and honor for his art gallery. Also the patient brought up the art gallery throughout the assessment,
demonstrating how much it meant to him.

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

Since the patients hospitalization he has lost his art gallery due to financial issues. I feel that this has played a major
in his feeling of depression. The patient also may be stuck in this stage of his life until he is able to redeem his legacy
with the art gallery of find another legacy.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The law that allows people over the age of 75 to drive

What does your illness mean to you?

The loss of my business, livelihood and income This illness has ruined my life

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record

Have you ever been sexually active? Yes

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

Are you currently sexually active?

No
If yes, are you in a monogamous relationship?
N/A
When sexually
active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?
Use of condoms for protection

How long have you been with your current partner?

N/ A

Have any medical or surgical conditions changed your ability to have sexual activity?
for sexual activity

Infection in leg now is an issue

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

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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?
Patient believes in a higher being however, does not believe in organized religion. Patient states that religion is not part of their daily
life style.
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_No, patients religious does not influence their current condition
___________________________________________________________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what? N/A

Yes

No

How much?(specify daily amount)

For how many years? X years

N/A

(age

thru

If applicable, when did the

patient quit? N/A

Pack Years: N/A

Does anyone in the patients household smoke tobacco? If

so, what, and how much? No one in household smokes

Has the patient ever tried to quit? N/A

If yes, what did they use to try to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? Red Wine

Yes

No

How much?

For how many years? 35 years

Volume: 16 oz

(age 21

thru

56

Frequency: Daily
If applicable, when did the patient quit?
Patient quit after car accident due to medication and alcohol interaction.

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?

Yes

No

If so, what? N/A

How much? N/A

For how many years? N/A

(age

Is the patient currently using these drugs?

Yes No
N/A

If not, when did he/she quit?

thru

N/A

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4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No, not that I know of

5. For Veterans: Have you had any kind of service related exposure? N/A

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? I feel that I was an over all healthy person, until this accident occur

Integumentary: Patient has changes in appearance of skin and skin infections on site of wound. Patient
denies problems with nails, dandruff, psoriasis, and hives or rashes.Uses of sunscreen with an SPF of 15 on a
daily bases. Bathing routine take place on daily bases.
HEENT: Routine brushing of teeth ranging from 2-3 times daily; yearly routine dentist visits, last vision
screening was last year. Patient denies: difficulty seeing, cataracts or glaucoma, difficulty hearing, ear
infection, sinus pain or infection, nose bleed, post nasal drip, and dental problems.
Pulmonary: Patient has asthma. Patient denies difficulty breathing, cough, bronchitis, emphysema,
pneumonia, tuberculosis and environmental allergies. Last CXR- october 6 (The day of accident)
Cardiovascular: Patient denies hypertension, hyperlipidemia , chest pain/angina, myocardial infarction,
CAD/ PVD, CHF, Murmurs, Thrombus, Rheumatic fever, Myocarditis, and Arrhythmias. Last EKG: 2 years
ago
GI: Patient has constipation. Patient denies nausea, GERD, indigestion, hemorrhoids, yellow jaundice,
pancreatitis, colitis, diverticulitis, appendicitis, abdominal abscess, cholecystitis, gastritis/ulcers, blood in
stool, and hepatitis. Last colonoscopy: Unknown
GU: Normal frequency of urination: 3-4 times daily. Patient denies nocturia, dysuria, hematuria, polyuria,
kidney stones, bladder or kidney infections.
Women/Men Only: Patient denies infection of male genitalia/prostate and urinary retention; frequency of
prostate exam: every year; BPH: yearly
Musculoskeletal: Patient has injury, weakness and pain at site of wound. Patient denies weakness, gout,
osteomyelitis, arthritis
Immunologic: Denies chills with sever shaking, night sweats, fever, HIV or AIDS, lupus, rheumatoid
arthritis, sarcoidosis, tumor, life threatening allergic reactions, enlarged lymph nodes
Hematologic/Oncologic: Denies anemia, bleeds easily, bruises easily, cancer, blood transfusions. Blood type
AB
Metabolic/Endocrine: Denies diabetes, hypothyroid/hyperthyroid, intolerance to hot or cold, osteoporosis
Central Nervous System: Denies CVA, dizziness, severe headaches, migraines, seizures, ticks or tremors,
encephalitis, meningitis
Mental Illness: Patient has depression and anxiety. Denies having schizophrenia and bipolar
Childhood Diseases: Patient had chickenpox at the age of six. Patient denies measles, mumps, polio, scarlet
fever.
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Asthema
Onset: Since the age of seven, however with age has become less severe
Location: Chest areas and breathing
Duration: Last up to 30 minutes however, depends on the severity of the case
Characteristics: SOB and chest pain, feels like weight on chest
Aggravating Factors: Occurs after extraneous activity and allergic reactions to cats
Relieving Factors: Trying to relax and take deep breaths also using inhaler.
Treatment: Use inhaler during episodes
Scale of pain: When they occur pain is at a level of 3

Constipation
Onset: After starting medication after accident
Location: Uncomfortable feeling in stomach
Duration: intermittent
Characteristics: Stomach has sharp pains that come and go
Aggravating Factors: Staying still and not moving around
Relieving Factors: Trying to walk around
Treatment: Taking laxatives.
Scale of Pain: From a scale of 0-10 patient rates pain 2 however, with the laxatives pain has disappeared.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone? None

Any other questions or comments that your patient would like you to know? None

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University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:
General survey Patient is well developed 56 year old. Patient has visible signs of distress and anxiety. The patient is
alert and oriented to person, place and location.
Height 72 inches Weight150.7 Ibs BMI 20.4 Pain (include rating and location) Level 7 located tibial Pulse 97
Blood Pressure 132/89 (include location) Brachial artery Temperature (route taken)
97.7: oral
Respirations 16 SpO2 98% Room Air or O2 Room air
Overall Appearance Clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, is
physically handicap due to tibial infection
Overall Behavior: Awake, demonstrates some anxiety, interact well with others, judgement intact
Speech: Clear, crisp diction
Mood and Affect: Pleasant, cooperative, talkative, anxious, apathetic, and tearful at times
Integumentary: Skin is warm, dry and intact, skin turgor elastic, no rashes, open wound on right left, nails without
clubbing, capillary refill < 3 seconds, hair evenly distributed, clean, without vermin
IV Access Size 22 gauge in upper left arm; inserted 10/23/2014, no redness,edema, or discharge. Fluid infusing:
Vancomycin; no central access device
HEENT: Facial features symmetric, no pain in sinus region, no pain, clicking of TMJ, trachea midline, thyroid not
enlarged, no palpable lymph nodes, sclera white and conjunctiva clear; without discharge; eyebrows, eyelids, orbital
area, eyelashes, and lacrimal glands symmetric without edema or tenderness; PERRLA pupil size left/right, peripheral
vision intact; EOM intact through 6 cardinal fields without nystagmus; Ear symmetric without lesions or discharge;
whisper test hear right and left ear; Nose without lesions or discharge; lips, buccal mucosa, floor of mouth and tongue
pink and moist without lesions.
Pulmonary/Thorax: Respiration regular and unlabored; transverse to AP ration 2:1; chest expansion symmetric;
percussion resonant throughout all lung fields, dull towards posterior bases; Sputum production: thin; Amount:
moderate; Color: white; Lung sounds clear throughout lung fields.
Cardiovascular No lifts, heaves, or thrills, heart sounds S1 and S2 audible and regular; No murmurs, clicks, or
adventitious heart sounds, no JVD; Calf pain bilaterally negative; pulses bilaterally equal; Apical pulse: 95; Carotid: 94;
Brachial: 97; Radial: 95; Femoral: 96; Popliteal: 94; No temporal or carotid brutus; +1 Edema around wound;
Extremities warm with capillary refill less than 3 second refill
GI: Bowel sounds active times 4 quadrants; no brutus auscultated; no organomegaly; Percussion dull over liver and
spleen and tympanic over stomach and intestine; abdomen non-tender to palpation; last BM 10/24/2014; formed; color:
Medium brown; no nausea; no emesis; Genitalia: not assessed patient oriented denies problems
GU Urine output: clear; color: yellow; no foley catheter; bathroom privileges with assistance; CVA punch without
rebound tenderness
Musculoskeletal Full ROM intact in all extremities without crepitus; strength bilaterally equal at 5 RUE; 5LUE; 3
RLE; 5 in LLE; vertebral column without kyphosis or scoliosis; neuromuscular status intact: peripheral pulses palpable;
no pain, pallor, paralysis, or paresthesia.
Neurological Patient awake, alert, oriented to place, time and date; CN 2-12 grossly intact; sensation intact to touch,
pain, and vibration, stereognosis, graphesthesia, and proprioception intact; DTR: Triceps:+2; Biceps: +2; Brachioradial:
+2; Patellar: +2; Achilles: +2; Ankle clonus: negative; babinski: negative

Patient unable to stand as a result could not conduct the Romberg test also could not complete the gait test on patient

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

WBC 12.6 (High) 10/21/2014
RBC 4.18 (Low) 10/23/2014
Platelet 169 (WNR) 10/21/2014
MCV 88.3 (WNR) 10/23/2014

High number of white blood cells indicates an infection.

This may be due large amount of blood loss after car accident
Within defined limits
Within defined limits

A lab that would help with patient diagnoses is a CT scan would be appropriate for this patient in order to see
infection around sight and look at the positioning of the rod to make sure that it is placed appropriately and is
not going to cause issues to the patient later in life.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient on regular diet however, patient taking vitamin C and vitamin B12 supplement so it is important to
teach patient about eating foods with these vitamins in moderations. Furthermore, the patient blood pressure is
hight and also has a higher pulse this indicates signs of pain as a result vitals should be monitored continually
and if the patient has critical vitals and show critical symptoms nurse should contact a provider. Patient has
physical therapy and occupational therapy twice daily in order to gain back strength within his legs so that he
can walk alone. Continue to monitor wound and note color, odor, consistency and amount of drainage within
wound. Also length and width of wound to see if improving over time.

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

1. Ineffective protection related to treatments as evidence by +1 edema, redness and pain in the left tibial.

2. Hopelessness related to long term stress as evidence by loosing art gallery, as well as, significant other and
also dealing with medical bills.

3. Constipation related to inactivity as evident by the patient infected wound that causes physical inactivity.

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4.Impaired skin integrity related to physical immobilization as evidence by wound on right leg that patient cannot walk
on due to pain level.

5. Risk for falls related to decreased lower extremity strength as evidence by open wound on right leg that has pain
whenever pressure applied.

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!
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15 CARE PLAN
Nursing Diagnosis: Ineffective protection r/t treatments (Ackley & Ladwig 2011)
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal

Rationale for
Interventions
Provide References

Reduce patients pain

level to a five by end of
shift

-Be an advocate for

patient by telling
physician about patient
pain level
-Find positions that help
patient feel as
comfortable as possible

- The physician can

Reduce patients distress

about mobility by end of
shift.

-Educate patient about the

process of healing an
infection
-Use therapeutic
communication to help
patient reduce distress
about mobility
- Encourage vistors to
come and see patient

- Educating the patient

prescribe medication
that can ease the pain
Positioning the patient
in a better position can
ease the pain and make
sure that no knew
wound occur due to
pressure points

Evaluation of Goal on
Day Care is Provided
-The patient states that
their pain level has been
reduced
-The patients vital sign
are in within normal
range
-The patients facial
expressions

-The patient verbalizes

about the process of
that they feel bester about
healing can help them the situation that they are
understand that healing in
process and feel more - Reading the patients
at ease
facial expressions in
Therapeutic
order to determine that
communication can
they look more at ease
- Talking to family
allow patient to have
more comfort about
members to see how
their position
they feel about the
Visitors can keep the
patients attitude.
patient distracted and
not focus on their
inability to get around

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Give patient more

confidence about about
their ability to move
around by the end of the
shift

- Assist patient into a

- The patient will have

wheelchair

- Demonstrate the ways

in which you want the

patient to move their
arms and legs in the
bed so that they do not
feel alone in the
activity
-Be encouraging of
their movements

Long term: Patient able to - Continue physical and

return to daily activities
occupational therapy
without pain, within a
-Continue to monitor vital
month period.

- Physical and

Long term: Patient no

longer has distress about
ability to get around.

- Group therapy
- Physical/occupational
therapy

some form of mobility

within a wheelchair,
helping them feel more
in control
Having the patient
move in the bed will
make them more
confident and also
allow their blood to
circulate.
Also will reduce risk of
pressure wounds
occupational therapy
will continue to
strengthen the patients
weakened extremities
Monitoring vital signs
in order to catch any
new onsets of
infections or illnesses

-Group therapy can help

patient feel better about
their situation
-Becoming more
physically able will allow
them to have distress
about mobility

- The verbalization of

the patient confirming

that they have gained
more confidence
By paying attention to
the facial expressions
of the patient

- After the month period

if the patient
demonstrates that he is
able to complete daily
activities
Also the verbalization
of the patient

- The patient verbalizes

-

that he has less distress

about mobility
The patients body
language and facial
expressions
demonstrate no distress
and they are more
relaxed.

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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
X Dietary Consult
X 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
X Rehab/ HH
Palliative Care

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!

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References
Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St.Louis, MO:Mosby Elsevier
Learning Theories (2014, Jan 23). Ericksons Stages of Development. Retrieved from
http://www.learning- theroies.com/eriksons-stages-of-development.html
United States Department of Agriculture. (2014). MyPlate. Retrieved from http://choosemyplate.gov
Sommers S. M. (2013). About Diseases and Disorders. New York: Davis Company.
Vallerand H. A. Sanoski A. C. & Deglin H. J. (2014) Daviss Drug Guide for Nurses, 14th edition. New York:
Davis Company

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