Professional Documents
Culture Documents
Pat Semester 1
Pat Semester 1
Pat Semester 1
COLLEGE OF NURSING
± 1 CHIEF COMPLAINT:
“I came here because I had this unbearable pain in my back and left leg.”
± 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
O: Injured back 2 years ago while working, but pain became severe 6 weeks ago.
L: Mostly in the mid to lower back as well as left leg.
D: A constant pain.
C: Stabbing, aching pain.
A: Sleeping on problem areas aggravates the pain.
R: None
T: None
S: 7 on a pain scale of 0 to 10.
±2
Stomach Ulcers
Environmental
FAMILY
Mental Health
Age (in years)
Heart Trouble
Bleeds Easily
Hypertension
Cause
Alcoholism
MEDICAL
Glaucoma
of
Problems
Problems
Allergies
Diabetes
Seizures
Arthritis
Anemia
HISTORY
Asthma
Kidney
Cancer
Tumor
Death
Stroke
Gout
(if
applicable)
Father 86 Stroke
Mother 88 CHF
Brother #1 58
Brother #2 68
Sister 54
Son #1 30
Son #2 Motor
34 vehicle
accident
Comments: Include age of onset
Father: arthritis (76yrs), stroke (3 days prior to death at 86yrs)
Mother: environmental allergies (15yrs), arthritis (80yrs), heart trouble (85yrs)
Brother #1: alcoholism (38yrs)
Brother #2: environmental allergies (22yrs)
Sister: environmental allergies (17yrs), asthma (3yrs)
Son #2: asthma (8yrs), hypertension (28yrs)
± 1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
University of South Florida College of Nursing – Revision September 2014 2
If yes: give date, can state “U” for the patient not knowing date received
± 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Iodinated
Burning sensation all over body.
radiocontrast dyes
Cardizem Hives, difficulty breathing
Medications
± 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)
Chronic pain is defined as pain lasting longer than 3 to 6 months, or pain that lasts longer than expected after injury. Not
much is truly understood about chronic pain and it is usually out of scope of any visual tissue damage. Dysregulation of
Nociception caused by changes in the peripheral and central nervous systems is thought to be the cause of chronic pain.
Brain atrophy, often found in patients with chronic pain, can lead to deficits in coping with pain. These issues arise with
the constant burden of dealing with chronic pain, but can be reversed by controlling the pain. Early treatment of acute pain
is encouraged in order to prevent the onset of chronic pain. With chronic pain, the body has the ability to adapt, which
causes a misleading representation of the condition when patients do not actually appear to be in pain. Patients with
chronic pain often struggle with the desire for relief and the desire to hide their pain, so as to not be labeled as simple
complainers (Huether et al, 2012).
± 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 Concentration: 325 mg = 1 tab Dosage Amount: 1 tab
Adverse/ Side effects: Hearing loss, tinnitus, GI bleeding, heartburn, abdominal pain, hepatotoxicity, anemia, allergic reactions
Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
“My Plate” as a reference.
±1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
“My son means the world to me and always takes care of me.”
How do you generally cope with stress? or What do you do when you are upset?
“Whenever I’m stressed or have problems I pray.”
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“No, I haven’t had any issues like that.”
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 been talked down to?___No____________ Have you ever been hit punched or slapped?
__No____________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_________No_________________________________ If yes, have you sought help for this? ______________________
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:
“The task of this stage is the acceptance of one’s life, worth, and eventual death. Ego integrity reflects a satisfaction with life and an
understanding of one’s place in the life cycle. A sense of loss, discomfort with life and aging, and a fear of death are seen in despair
(Treas et al, 2014).”
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient is at a stage in which they reflect on their lives and ponder their accomplishments and failures. This is a stage
that if someone feels that their lives were unproductive and full of regret, then they will feel guilt about their past and not
accomplishing the goals that they once had in place. This can lead to feelings of despair, depression, and hopelessness.
The patient exhibited signs of regret in regard to the loss of his son, stating, “I wish I had done things differently. If I had,
he might still be here. I never got the chance to be a real father to him.”
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The patient’s current hospitalization has caused him to think back on his life more than ever before. He’s has multiple
hospitalizations up to this point, and is becoming increasingly more exhausted and frustrated with the process.
+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“I don’t really think much about what’s wrong with me except why it’s happening.”
+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”
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? __________________________________
How long have you been with your current partner? No current
partner______________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity?
___No________________________
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years? 50 years
Beer Volume: 10 pints (age 16 thru present)
Frequency: 3x/wk
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?
Cocaine, meth, marijuana, acid How much? For how many years? 15 years
N/A (age 20 thru 35)
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No, currently unemployed.
5. For Veterans: Have you had any kind of service related exposure?
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
±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.
RBC – 2.5 million/mcL (07/21/2016) This is the only lab value. RBC count is low due to
anemia. Normal range
within 4.7-6.1
million/mcL.
WBC – 7.6 k/mcL (07/21/2016) This is the only lab value. WBC count within
normal range of 4.5-11
k/mcL.
PT – 138.2 seconds (07/21/2016) This is the only lab value. PT is high due to anemia.
Normal range within 9.4-
12.5 seconds.
Creatinine – 1.2 mg/dL (07/21/2016) This is the only lab value. Creatinine within normal
range of 0.8-1.3 mg/dL.
University of South Florida College of Nursing – Revision September 2014 11
BUN – 41 mg/dL (07/21/2016) This is the only lab value. BUN level high due to
diet high in protein.
Normal range within 7-18
mg/dL.
Glucose – 145 mg/dL (07/21/2016) This is the only lab value. Glucose level high due to
intake of added sugars.
Normal levels within 70-
100 mg/dL
Diet: balanced diet with appropriate intake of calories (2,000 calories) and adequate servings of each food group.
Reducing refined grain and protein intake to appropriate levels to attain a balanced diet. Removing added sugar
from diet as well as processed grains to help manage diabetes.
Vitals: taken ever 4 hours based on hospital protocol.
Activity: physical therapy to help treat back pain
Scheduled Diagnostic Tests: none
2. Impaired mobility related to chronic pain as evidenced patient statement of pain when they rise up from bed.
3. Imbalanced nutrition related to inadequate dietary intake as evidenced by high intake of refined grain and protein.
5. Ineffective self-health management related to poor diabetes control as evidenced by high blood glucose levels.
• Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology (Fifth ed.). St.
• Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing: Concepts, skills, & reasoning