UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Morgan Butts

Assignment Date: 10/28/16
.
Agency: FHT
1 PATIENT INFORMATION
Patient Initials: EG Age: 81 Admission Date: 10/26/16
Gender: Female Marital Status: Widow Primary Medical Diagnosis Rotary Cuff
Replacement
Primary Language: English
Level of Education: 11th Grade Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired waitress and factory worker None
Number/ages children/siblings: 2 children, a 66 year old daughter
and 50 year old son

Served/Veteran: No Code Status: Full Resuscitation

If yes: Ever deployed? Yes or No
Living Arrangements: Lives alone in a mobile home in a retirement Advanced Directives: Yes; living will
facility. Daughter states that there are no steps If no, do they want to fill them out?
Surgery Date: 10/26 Procedure: Left
shoulder acromioplasty
Culture/ Ethnicity /Nationality: White American
Religion: Lutheran Type of Insurance: Medicare and Tricare for Life

1 CHIEF COMPLAINT:
I came in two days ago for shoulder surgery.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Since January of 2016, the patient has had discomfort in her left shoulder. My shoulder has been hurting me since
January, so I had tests, MRIs, CAT scans and decided to get the whole thing replaced. The patient had an MRI in
February, the CT scan in July, and an x-ray in August, revealing acromioclavicular joint osteoarthritis. She states that the
pain is sharp sometimes, like a jabbing feeling but that it usually feels like a dull, toothache pain. It hurt most when the
patient tried to ambulate her shoulder and when she got up in the morning. To relieve the numbness in her arm and
tingling in her fingers, the patient used arthritis cream. The patient was admitted to Florida Hospital of Tampa on
10/26/2016 for a left shoulder acromioplasty. She now states that her pain is very slight and rates her pain at a two on a
scale of zero to ten. The patient has been taking Percocet PO and Aspirin PO to relieve the post-operation pain, wearing a
sling, and consulting with physical therapy. The patient will be discharged two days post-op.

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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
September 2015 Left knee arthroplasty for osteoarthritis; uses walker and takes aspirin
May 2013 Cataract surgery
2005 Excisional breast biopsy; returns to her primary care giver every 6 months for check up
2001 Cholecystectomy- gallstones found
Diagnosed with asthma and COPD simultaneously; prescribed Revatio, Advair, and Nebulizer with
Albuterol for asthma flairs, incentive spirometer, and CPAP prescribed PRN for sleeping
1994 Transient ischemic attack; takes aspirin daily
1975 Diagnosed with chronic hypertension; prescribed Colonidine and metoprolol
1940 Tonsillectomy

(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)
Father
Mother 70 Cancer
Brother
Sister
relationship

relationship

relationship

Comments: Mother was diagnosed with cancer in 1986, admitted into Moffitt, and died 6 months later. She never knew her father and
had no siblings.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations U
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U
Adult Tetanus (Date) Is within 10 years? 2007
Influenza (flu) (Date) Is within 1 years? 9/16/2016
Pneumococcal (pneumonia) (Date) Is within 5 years? 2011
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 Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Norvask Break out in rash
Celebrex Interferes with kidneys
Medications

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
The acromioclavicular (AC) joint is commonly referred to as the rotator cuff. A series of ligaments, capsules, and intra-
articular discs keep the joint stable yet able to ambulate with flexibility. Because of its flexibility and extensive range of
motion, the AC joint is susceptible to overuse and age-related degeneration. This degeneration can be due to mechanical
stresses, the immune system, and even microRNAs that effect gene expression in chondrocytes (Heuther, 2017). Because
these affect the joint space and cartilage loss, osteoarthritis develops in the AC joint (Mall, 2013). According to the
research completed at Rush University Medical Center, the intra-articular disks degenerate by fraying, tearing, and
forming holes, macerated by defects in the chondral surface, (Docimo, 2008). The space is terrorized by inflammation as
the bone and cartilage change shape and density. The discrepancies of the AC joint and diagnosis of osteoarthritis can be
detected through x-rays; physical examination and patient history are also crucial to the diagnostic process. The risk
factors of osteoarthritis include repetitive physical tasks, trauma, obesity, diabetic neuropathy, inflammation, hemophilia,
hyperparathyroidism, and collagen-digesting drug use (Heuther, 2017). These diminish the joint either mechanically or
chemically. To treat this degeneration, there are non-invasive and invasive methods depending upon grade of degeneration
and the patients tolerance of the pain and treatments. The non-invasive methods include physical therapy, non-steroidal
anti-inflammatory drugs (NSAIDs) and corticosteroid injections. The physical therapy will increase the patients strength,
flexibility, and range of motion if performed consistently. The NSAIDs and injections will temporarily decrease
inflammation and alleviate the pain while the medication lasts. If the patient is sustaining significant amounts of pain and
experiencing a continued decrease in shoulder function, the invasive treatments should also be considered. Surgical
approaches include open and arthroscopic clavicular excision of the intra-articular disks of the AC joint. While both
approaches are widely used and approved, the patients condition and potentiated recovery should be evaluated before the
approach is chosen (Mall, 2013). Without any medical intervention, an individual with degenerative osteoarthritis of the
AC joint will worsen with time. The intra-articular disks will continue to tear and cause inflammation, pain, and
instability. Physical therapy will provide the patient a much more positive prognosis, for the strength and flexibility of the
joint will increase. For the most ideal prognosis, the patient should consider using both invasive and non-invasive methods
of treatment. Once surgery is performed, patients are immobilized in a simple sling initially and allowed to perform
pendulums immediately, as noted by the American Journal of Sports Medicine (Mall, 2013). Physical therapy will
increase from passive to active exercise as time and strength increase. This helps keep the joint strong and flexible while
NSAID drug use will help keep the post-operative pain subsided. On this regimen, the patients prognosis is most positive.
One genetic factor to consider before treating the osteoarthritis is the presence of microRNAs that effect gene expression
in the chondrocytes. If this is the case with the particular patient, a total AC joint replacement may need to be considered
(Heuther, 2017).

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 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: Aspirin (Bayer) Concentration Dosage Amount: 325 mg

Route: EC Tablet Po Frequency: Daily for 10 days

Pharmaceutical class: Salicylate Home Hospital or (Both)
Indication: Prophylaxis of transient ischemic attacks and MI, produce analgesia and reduce inflammation and fever by inhibiting the production of
prostaglandins, decrease platelet aggregation
Adverse/ Side effects: GI bleeding, nausea, anemia, hemolysis, increased bleeding time, tinnitus, salicylism
Nursing considerations/ Patient Teaching: Patients who have asthma or allergies have an increased risk for developing hypersensitivity reactions. Assess for
rash, pain, bleeding and fever. Monitor hepatic functions, serum salicylate levels, and signs of toxicity. Take with water, avoid alcohol and acetaminophen, and
restrict sodium in diet.

Name: Colonidine Concentration Dosage Amount: 0.1 mg

Route: Tab PO Frequency: 2 times a day

Pharmaceutical class: centrally acting adrenergics Home (Hospital) or Both
Indication: mild to moderate hypertension
Adverse/ Side effects: drowsiness, dizziness, dry mouth, dry eyes, withdrawal phenomenon
Nursing considerations/ Patient Teaching: Monitor intake and output ratios, blood pressure, and opiate withdrawals. Assess pain location and intensity, skin for
edema, and weight gain. Take at the same time every day for as long as prescribed, avoid sudden changes in position, avoid alcohol, and monitor blood pressure.

Name: Ezetimibe (Zetia) Concentration Dosage Amount: 10 mg

Route: Tab PO Frequency: Daily

Pharmaceutical class: cholesterol absorption inhibitors Home Hospital or (Both)
Indication: management of dyslipidemias including primary hypercholesterolemia, give with simvastatin
Adverse/ Side effects: cholecystitis, cholelithiasis, increased liver enzymes, nausea, pancreatitis, rash, angioedema
Nursing considerations/ Patient Teaching: Obtain a diet history, especially in regard to fat consumption, and evaluate serum cholesterol and triglyceride levels.
Take as directed at the same time each day, follow the proper diet restrictions, exercise, and cease smoking if necessary.

Name: Simvastatin (Zocor) Concentration Dosage Amount: 40 mg

Route: Tab PO Frequency: Daily

Pharmaceutical class: HMG-CoA reductase inhibitors Home Hospital or (Both)
Indication: Secondary prevention of cardiovascular events, given with Ezetimibe
Adverse/ Side effects: dizziness, headache, abdominal cramps, constipation, diarrhea, heartburn, rashes, myopathy
Nursing considerations/ Patient Teaching: Obtain a dietary history, evaluate serum cholesterol and triglyceride levels, monitory liver function, and monitor CK
levels. Avoid grapefruit juice, take as prescribed, follow restriction diet, and notify the healthcare provider of signs of liver injury and muscle pain.

Name: Docusate (Docusate sodium) Concentration Dosage Amount: 100 mg

Route: Cap PO Frequency: Every 12 hours

Pharmaceutical class: stool softener Home (Hospital) or Both
Indication: Prevention of constipation in patients who should avoid straining
Adverse/ Side effects: mild cramps, diarrhea, rashes
Nursing considerations/ Patient Teaching: Assess for abdominal distention, presence of bowel sounds, and color, consistency, and amount of stool. Not a
stimulant laxative, administer with full glass of water, increase bulk of diet, increase fluid intake, and avoid straining.

Name: Furosemide (Lasix) Concentration Dosage Amount: 40 mg

Route: Tab Po Frequency: Daily

Pharmaceutical class: Loop diuretics Home Hospital or (Both)
Indication: Edema due to heart failure, impairment or renal disease. Hypertension
Adverse/ Side effects: dizziness, headache, nausea, vomiting, diarrhea, dehydration, hypocalcemia, hypochloremia, hypokalcemia, hypomagnesemia,
hyponatremia, hypovolemia, metabolic alkalosis
Nursing considerations/ Patient Teaching: Assess fall risk and fluid status, monitor daily weight, blood pressure and pulse, edema, lung sounds, skin turgor,
rash, hearing, and intake and output ratios

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Name: valsartan (Diovan) Concentration Dosage Amount: 160 mg

Route: Tab PO Frequency: Daily

Pharmaceutical class: Angiotensin II receptor antagonist Home Hospital or (Both)
Indication: Reduction of risk of death from cardiovascular causes in patients with left ventricular systolic dysfunction after MI
Adverse/ Side effects: dizziness, anxiety, headache, hypotension, tachycardia, abdominal pain, impaired renal function, hyperkalemia, angioedema
Nursing considerations/ Patient Teaching: Assess blood pressure lying, sitting, and standing, monitor daily weight, fluid overload, and renal function. Continue
taking as directed even if feeling well, avoid salt substitutes or food high in potassium, avoid sudden changes in position, and monitor blood pressure.

Name: metoprolol (Metoprolol Tartrate) Concentration Dosage Amount: 50 mg

Route: Tab Po Frequency: 2 times a day

Pharmaceutical class: Beta Blocker Home Hospital or (Both)
Indication: hypertension, prevention of MI and decreased mortality in patients with recent MI
Adverse/ Side effects: Fatigue, weakness, dizziness, bronchospasm, bradycardia, pulmonary edema, hypotension, peripheral vasoconstriction, erectile
dysfunction, urinary frequency
Nursing considerations/ Patient Teaching: Monitor input and outtake rations, ECG, pulse, and blood pressure frequently. Take as directed and at the same time
each day even if feeling well, check pulse and blood pressure regularly, may cause drowsiness, change positions slowly, and monitor blood glucose (diabetics).

Name: Potassium Chloride (Klor-Con) Concentration Dosage Amount: 20 mEg

Route: REC Powder Po Frequency: 2 times a day

Pharmaceutical class: Replacement supplements Home (Hospital) or Both
Indication: Treatment of potassium depletion
Adverse/ Side effects: confusion, restlessness, confusion, arrhythmias, abdominal pain, diarrhea, flatulence, nausea, vomiting
Nursing considerations/ Patient Teaching: Assess for signs and symptoms of hypokalemia and hyperkalemia, monitor blood pressure and ECG frequently,
monitor serum potassium. Avoid salt substitutes and foods high in potassium.

Name: acetaminophen-oxycodone (Percocet) Concentration Dosage Amount: 5 mg oxy, 325 mg ace

Route: Tab Po Frequency: 2 every 4 hours PRN

Pharmaceutical class: opioid analgesics Home Hospital or (Both)
Indication: Moderate to severe pain, administer PRN with increased pain
Adverse/ Side effects: nausea, vomiting, dry mouth, dizziness, constipation, drowsiness
Nursing considerations/ Patient Teaching: Monitor intake and output of fluids, blood pressure, pulse, and respirations, assess alcohol usage, assess other drugs
taking, assess rash, pain, fever, and liver function. Avoid alcohol, discontinue if rash occurs, change position slowly, and call for assistance with ambulating.

Name: Sildenafil (Revatio) Concentration Dosage Amount: 20 mg

Route: Oral tablet Frequency: 3 times a day

Pharmaceutical class: phosphodiesterase type 5 (Home) Hospital or Both
Indication: Pulmonary arterial hypertension
Adverse/ Side effects: headache, dizziness, myocardial infarction, sudden death, dyspepsia, flushing
Nursing considerations/ Patient Teaching: monitor hemodynamic parameters and exercise tolerance. Take as directed, do not take with alpha-adrenergic
blockers, seek medical attention if chest pain occurs.

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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? General nutritious diet
Diet patient follows at home? None
24 HR average home diet:
Breakfast: 1 cup of cereal and 2 cups of non fat milk
Lunch: Salad (iceberg lettuce, 4 cherry tomatoes, 1
tablespoon of shredded cheddar, 1 tbsp diced purple onion),
1 cup of plain yogurt
Dinner: baked chicken leg, 1 baked potato, dash of salt and
pepper, 1 tsp butter, and side salad (iceberg lettuce, 2
cherry tomatoes, tbsp. shredded cheddar, tbsp. diced
purple union)
Snacks: 1 chocolate chip cookie, 2 cups of plain popcorn
Liquids (include alcohol): 16 oz cocktail, 12 oz Diet Pepsi,
1.5 cups of black coffee, 2 liters of water
Analysis of home diet (Compare to My Plate and
Consider co-morbidities and cultural considerations):
Considering the patients hypertension, decreased physical
ability, osteoarthritis, cancer and recent stroke, the patient
should consider revising her diet. Her lab values also
indicate lowered electrolytes across the board. For the
patients age, height, and weight, My Plate suggests
foods high in potassium, calcium, vitamin D, vitamin B12,
and fiber. Reducing foods high in sodium and fats will also
help the patient with her impending comorbidities. The
patient is currently not taking in any fruits, which will
provide her with most of her potassium, vitamins, and
antioxidants. Increasing her intake to 2.5 cups of fruit will
aid in the healing of her surgical site, keep her heart
pumping effectively, and maintain active cellular transport.
Introducing more fiber through apples or darker, leafy
greens will also help aid in the digestion process and in the
heart health. Reducing the sugars and fats like those in
cookies, butter and Diet Pepsi will help to decrease fats
stored in her body that, in turn, will help her heart and other
muscles move more efficiently. The patient is keeping a
low calorie diet, introduced calcium, grains, proteins, and
varied vegetables in her food choices. Encouraging the
patient to maintain these choices but increasing her dairy
intake to 3 cups will help reinforce these other changes.

1 COPING ASSESSMENT/SUPPORT SYSTEM: Use this link for the nutritional analysis by comparing the patients
(these are prompts designed to help guide your discussion) 24 HR average home diet to the recommended portions, and use
My Plate as a reference.
Who helps you when you are ill?
My daughter
How do you generally cope with stress? or What do you do when you are upset?
When Im upset and stressed, I like to be by myself. To me, its called moodiness.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient denies any difficulty with emotions or activity . This includes depression, anxiety, being overwhelmed,
relationships, friends, or her social life.

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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? Yes_____________________________________________________

Have you ever been talked down to? _Yes__________ Have you ever been hit punched or slapped? Yes____________

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Yes, Ive had black eyes.___________________________ If yes, have you sought help for
this? _Yes_____________________

Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
Because the patient is older than 65, she falls under Stage 8 of Ego Integrity vs. Despair. Ego Integrity indicates the individual is
accepting of his or her current life situation and is thus satisfied with the life he or she has lived. He or she will look back on her life
with happiness and appreciates his or her current situation. An individual in despair is fearful or unaccepting of death and is
unsatisfied with life and aging. The person does not interact or look upon life fondly (Treas, p. 164).

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient has demonstrated acceptance and satisfaction in her current life situation and is therefore showing signs of
Ego Integrity. The patient was happy to be going home and seeing her daughter and son-in-law. The patient is settled into
her home and enjoys her dog. No signs of fear, denying of her condition, or upset with her age where exhibited by the
patient.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The patient has accepted that her age and lifestyle choices have led her to where she is today. The patient is settled and satisfied with
life and her situation. However, with the continued degeneration of her body, the patient may be prone to more hospitalization and
decreased quality of life. With this in mind, the patient is vulnerable to the Despair phase of life.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states that general ware and many years of use may have caused the shoulder pain. I walk my dog, and she is
strong. She pulls me this way and that way. I dont know if she caused it or not.

What does your illness mean to you?

Patient indicates she does not think it means much to her. I dont ask for help. Ill try and do it on my own, she states.

+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

University of South Florida College of Nursing Revision September 2014 7

Have you ever been sexually active? _Yes. Years ago. Just with my husbands. I had three
_____________________________________________________________
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?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _None_________________________________

How long have you been with your current partner? ___Patient was with previous partner 3 years
_____________________________________________________

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

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

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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?
I pray every night._______________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
Yeah. I thank God every morning, and thank Him for helping me.
_________________________________________________________
______________________________________________________________________________________________________

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

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

If applicable, when did the

Pack Years:
patient quit?

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

2. Does the patient drink alcohol or has he/she ever drank alcohol? (Yes) No
What? Light beer or pina coloda How much? 1 or 2 a month For how many years? 60
Volume: 1 cocktail cup (age 21 thru 81 )
Frequency: Patient drinks when out to
dinner with daughter once a month
If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes (No)
If so, what?
How much? For how many years?
(age thru )

Is the patient currently using these 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
None

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

University of South Florida College of Nursing Revision September 2014 9

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? Patient says her health is good.

Integumentary: Patient has a history of lower leg edema, states mother had similar swelling. Patient denies any
recent skin diseases.
HEENT: Patient was diagnosed with cataracts and had cataract surgery 2 years ago. Patient states she hears
clearly and denies any nose or throat issues.
Pulmonary: Patient admits to COPD and asthma.
Cardiovascular: Patient has hypertension, denies myocardial infarction or heart failure.
GI: Patient states constipation occurs often with pain medication. Patient denies nausea, vomiting, diarrhea, or
any other gastrointestinal issue.
GU: Patient has history of gallstones, no history of UTIs or other urinary issues.
Women/Men Only: Patient has received care from both men and women.
Musculoskeletal: Patient has osteoarthritis of the left knee, had a knee replacement and has a decreased use of
her left leg. Patient states she is having trouble ambulating her left arm due to her surgery and has felt numbness
and tingling along with it.
Immunologic: Patient has no history of adult immune diseases.
Hematologic/Oncologic: Patient has low iron, patient had benign nodules on breast
Metabolic/Endocrine: Patient admits to having type 2 diabetes mellitus.
Central Nervous System: Patient has history of transient ischemic attack
Mental Illness: Patient denies any mental work up or mental illness.
Childhood Diseases: Patient states she had measles, mumps, and chicken pox as a child.

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?
No

University of South Florida College of Nursing Revision September 2014 10

10 PHYSICAL EXAMINATION:
General survey Patient is mildly overweight elderly woman that reacts appropriately to her surroundings.
____________________________________________________________________________________
Height 5 3 Weight 193 lbs BMI 34.2 kg/m2 Pain (include rating and location) 2 in left shoulder Pulse 76
Blood Pressure (include location) 125 in right arm Temperature (route taken) 98.1 orally
Respirations 17 SpO2 96% Room Air or O2 Room air
Overall Appearance Patient appears appropriate for age and status. Patient is well kept.
Overall Behavior Patient is A&O x3 and is acting appropriately.
Speech Patient is articulates clearly and has appropriate vocabulary for age and education.
Mood and Affect Mood and affect are positive and responsive.
Integumentary +1 pitting edema in both lower extremities, edema in left arm due to shoulder sling and elevation, skin is
warm, dry, and intact, liver spots noted on arms and face due to old age
IV Access _IV in right hand, bloody but no erythema is present, skin is remaining intact_
HEENT Scalp is dry, no lesions present, skin of ears, nose and mouth were intact and no lesions were present, would assess
PERRLA here, sclera is a little cloudy but white, conjunctiva were red and moist
Pulmonary/Thorax Patient is breathing comfortably on room air, no use of accessory muscles, lungs were clear, no
adventitious breath sounds were noted, cap < 3 seconds in all four extremities _
Cardiovascular S1 and S2 noted, no adventitious sounds were noted, pulses of radial and carotid were equal bilaterally,
pedal pules were difficult to assess with the edema
GI Bowel is normoactive in all 4 quadrants, bowel is soft, patient states that she has not had a bowel movement since
Wednesday (10/26) before surgery, notes that it was watery
GU Patient is urinating about 500 mL every 3 hours, urine is light yellow and clear, patient states no discomfort when
urinating
Musculoskeletal Patient has diminished use of left arm due to shoulder, diminished use of left leg due to knee surgery, all
other extremities were +5 for muscle strength and range of motion after completing the hand grip and foot pumping
exercise
Neurological Patient was alert and oriented to person, place and time, speech and appearance were appropriate for age and
health status

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.

Lab Dates Trend Analysis

WBC After surgery, the Number of infection
7.6 (10/27/16) patients WBC was fighting cells. High WBC
within normal range. indicates the presence of
8.4 (10/28/16) Though it remains within an infection or
Normal (4.5-11) normal ranges, the slight inflammation. Monitor
increase warrants a need surgical site for infection.
to monitor infection or
inflammation.
RBC Slight continual decrease Number of oxygen
3.77 L (10/27/16) in hemoglobin levels after transporting cells in
surgery. blood. Indicates probable

University of South Florida College of Nursing Revision September 2014 11

 3.37 L (10/28/16) anemia
Normal 4.2 5.4
million/mm3
HGB Decrease in hemoglobin Protein on RBCs.
11.5 L (10/27/16) levels from slightly below Indicates low oxygen
normal ranges to more levels in blood and
10.4 L (10/28/16) significant. Aligns with probable anemia
Normal 12.0 16 g/dL RBC count
HCT Decreasing in hematocrit Percent of RBCs in
34.5 L (10/27/16) percentages is consistent relation to CBC. Indicates
post-op. Consistent with anemia.
31.0 L (10/28/16) RBC and HGB lab count
Normal 38 47%
Na Slight continual decrease Maintains water balance.
134 L (10/27/16) in sodium levels below Patient is retaining water,
normal ranges. so levels are low.
130 L (10/28/16)
Normal 135- 145 mEq/L
Cl Major decrease in Indicative of blood pH.
196 H (10/27/16) Chloride levels from Dramatic change in levels
abnormally high to indicate patients
91 L (10/28/16) abnormally low. treatment is out of
Normal 95-105 mEq/L therapeutic range and
needs adjustment
Glucose Though there is a 6- Glucose level in blood.
127 (10/27/16) mg/dL increase, the Indicates patients
glucose level remains diabetes is controlled.
133 (10/28/16) within normal ranges. Monitoring the slight
Normal below 140 mg/dL increase is important in
keeping her diabetes
under control.
BUN Slight increase in BUN Nitrogen levels in blood
17 (10/27/16) level. Remains within urea. Kidneys are
normal ranges. working properly post-op.
20 (10/28/16)
Normal 6-20 mg/dL
Creatinine Slight increase in Increased creatinine
1.0 (10/27/16) Creatinine from within levels in the urine show
normal range to above proteins may be present
1.4 H (10/28/16) normal range. in urine.
Normal 0.6-1.3 mg/dL
Ca Slight decease in calcium Calcium levels in the
8.9 (10/27/16) levels from within normal blood. Needed to
range to below normal maintain bone density,
8.3 L (10/28/16) range. especially with
Normal 8.5-10.2 mg/dL osteoarthritis.

University of South Florida College of Nursing Revision September 2014 12

Patient was tested for MRSA on 10/26. The test was negative. The patient also had an x-ray on her left shoulder
on 10/26 to confirm surgical site and procedure. The space of the acromioclavicular joint is visible in the x-ray.
Though a post op x ray was not documented in the chart, I assume the patient had one performed, and the x- ray
showed a well-placed and healing shoulder.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient will have her vitals checked once every 4 hours to assess general function. Patient also recieves an accu
check between meals to assess glucose levels and monitor her diabetes. With the patients diabetes under control,
no special diet will need to be ordered. Before being discharged, the patient will consult with the physical
therapist once a day to assess her shoulder range of motion and to ambulate safely without her walker to prevent
DVT or pressure ulcers. Patient is also wear supportive shoulder sling until healing has taken place. Additionally,
patient will consult with the respiratory therapist once a day to receive a breathing treatment for her COPD. This
will help to raise her oxygen levels as well.

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

1. Impaired physical mobility AEB instability of left leg and left shoulder sling

2. Constipation AEB I have not had a bowel movement since Wednesday before my surgery. Patient also is on opioid
medications

3.

4.

5.

University of South Florida College of Nursing Revision September 2014 13

 15 CARE PLAN
Patient Goals/Outcomes
Patient will have a bowel
movement
Patient will increase fluid intake
Patient will maintain regularly
scheduled bowel movements
University of South Florida College of Nursing Revision September 2014
Nursing Diagnosis: Constipation
Nursing Interventions to Achieve
Goal
1. Help patient ambulate in
and out of bed, around
hospital, and to the
bathroom. Support the left
side, for the patient has had
a left knee and left shoulder
replacement.
2. Encourage patient to
continue taking laxatives.
1. Assess the amount of fluid
patient currently takes in.
2. Increase fluid intake to 2.5
liter instead of her standard
2 liters
3. Monitor intake and output
during the duration of her
stay
1. Assess diet and nutrition
patient already has in place,
Rationale for Interventions
Provide References
1. The patient normally uses a
walker but cannot support
her own weight due to her
shoulder replacement.
Patient needs proper
assistance in order to
ambulate enough to
stimulate the bowels and
create a movement.
2. The patient is on opioids for
the post-op pain. Though
laxatives should not be
taken long term, the patient
should take them until she
has a proper bowel
movement.
Increasing the fluid intake will aid
in the movement of the bowel. It
softens the stool and creates a
balance in the electrolytes. Though
she claims to be drinking 2 liters of
water, her actual intake needs to be
assessed. Regulating her input at
2.5 liters will encourage her to
drink her more water regardless.
Monitoring the fluid intake and
output will allow for continued
assessment.
1. If the patient is not taking
in enough fiber in her diet
Evaluation of Goal on Day Care
is Provided
The patient was able to ambulate
out of bed and into a chair with the
help of two nurses. She then
proceeded to walk to the restroom
with the help of one aid and
urinated an adequate amount. The
patient never walked around the
hospital. Though she continued
taking her laxatives as prescribed,
the patient did not have a bowel
movement within the shift. Upon
further evaluation, patient will need
to be educated on the importance
ambulation.
The patient continued drinking
Diet Pepsi. Her fluid intake
remained around 1 liter for the
entire shift because patient claimed
to be tired of drinking. The goal
of increasing the fluid intake was
not met, and the patient needs to
reassess her fluid intake methods.
Patient understood the need to
create a regularly scheduled bowel
14
 taking into consideration
the amount of fiber in her
diet while at home.
2. Include the patient in
creating a diet and fluid
intake plan. Choose foods
high in fiber and a water
schedule that works with
the patients tastes and
daily living.
3. Create a voiding schedule
with the patient. Allow the
patient to choose times that
fit her life and schedule.
University of South Florida College of Nursing Revision September 2014
at home, the patient will activity throughout her life. The
need to adjust her eating patient states, I understand how
habits in order to have a important that is. I really do need
continued bowel movement to change my bowel habits.
schedule.
2. To promote the movement
of her bowels, the patient
will need to include more
fiber in her diet and an
increased fluid intake.
Including the patient in the
nutrition of her life at home
will allow her to have
control and take part in her
continued, long-term
health.
3. Maintaining a regular
voiding schedule regardless
if a bowel movement
actually occurred will allow
the body to become
accustomed to a consistent
bowel schedule. Including
the patient in her
scheduling allows her to
have continued control over
her long-term health.
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

University of South Florida College of Nursing Revision September 2014 16

 References

Docimo, S., Kornitsky, D., Futterman, B., & Elkowitz, D. E. (2008). Surgical treatment for

acromioclavicular joint osteoarthritis: patient selection, surgical options, complications,

and outcome. Current Reviews in Musculoskeletal Medicine, 1(2), 154160.

Huether, S. E., & McCance, K.L. (2017). Understanding Pathophysiology (6th edition). St.

Louis, MO: Elsevier

Mall, N. A., Foley, E., Chalmers, P. N., Cole, B. J., Romeo, A. A., & Bach, B. R. (2013).

Degenerative Joint Disease of the Acromioclavicular Joint A Review. The American

Journal of Sports Medicine.

Treas, L. S., & Wilkinson, J.M. (2014). Basic Nursing: Concepts, Skills, and Reasoning.

Philadelphia, PA: F.A. Davis Company

United States Department of Agriculture. Older Adults. (2016). Retrieved from

http://www.choosemyplate.gov/older-adults.

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University of South Florida College of Nursing Revision September 2014 18