UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Chelsea DeLuca

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 02/05/14

Agency: BMC

Patient Initials: CBM

Age: 34

Admission Date: 02/03/14

Gender: F

Marital Status: Single

Primary Medical Diagnosis with ICD-10 code:

G40.0 Epilepsy

Primary Language: English

Level of Education: Some college

Other Medical Diagnoses: (new on this admission)

None

Occupation (if retired, what from?): Unemployed

Number/ages children/siblings: No siblings or children

Served/Veteran: No

Code Status: Full code

Living Arrangements: Lives by herself in a two-story house; her

mother lives nearby

Advanced Directives: No
If no, do they want to fill them out? Yes
Surgery Date:
Procedure:

Culture/ Ethnicity /Nationality: White

Religion: Christian

Type of Insurance: Medicare

1 CHIEF COMPLAINT: I have seizures very frequently and it is interfering with my life.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The patient was admitted to the hospital on 2/3/14 for constant EEG monitoring to try to localize the focus of her seizures
in order for surgery to be performed to remove that section. She can in complaining of having 3-4 seizures per day. Her
seizures are tonic-clonic type and greatly interfere with her life. She is unable to perform normal activities and cannot
keep a job. Since she has been in the hospital, they have lowered her seizure medicine slowly trying to induce a seizure
but avoid her becoming status epilepticus. On 2/4/14, she had a seizure that lasted 27 minutes. Her seizures have been
localized to the left medial occipital region but have not been localized to a small enough region in order to send her to
surgery yet. Patient has an aura that lasts for about 30 seconds before onset of the seizure in which she feels like she is
having an orgasm. She has been instructed to push the call light when she feels a seizure coming on.
Seizure OLDCART
O: Around age 21; 2001
L: brain
D: intermittent, with periods with lots of seizures and periods with only a few
C: tonic-clonic seizures
A: nothing
R: taking prescribed seizure medications
T: Keppra

University of South Florida College of Nursing Revision August 2013

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation

Father

64

Mother

62

Operation or Illness

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable
)

Environmental
Allergies

Brain surgery
Depressive disorder
GERD

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Date
2008, 2010, 2012
2000
2002

Brother
Sister
relationship
relationship
relationship

Comments: Include date of onset

Patient claims that her mother and father have no medical problems that she is aware of, other than her mothers anemia. She is not
sure what the date of onset of her mothers anemia is but she says that her mom has had it for a long time.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or

YES

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NO

occupational purposes? Please List

1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

No known
medication allergies
Medications

Other (food, tape,

latex, dye, etc.)

No known other
allergies

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)
Epilepsy is a brain disorder in which a person has seizures of an unknown or unidentifiable cause. A seizure occurs when there is a
sudden imbalance between the excitatory and inhibitory forces within the neurons that favors a sudden-onset net excitation, hence a
seizure. Since the brain is involved in nearly every bodily function, the symptoms of the seizure are based on what part of the brain the
seizure is taking place in. Some seizures will involve the entire brain, starting in one specific location (generalized seizures). Other
seizures may begin in one place in the brain and remain in that place for the entire seizure (partial seizures). This patient had
generalized seizures, so this pathophysiology section will focus on that.
The best understood explanation of generalized seizures is altered thalamocortical rhythms. Typical thalamocortical rhythms involve
alternating periods of increased excitation with increased inhibition. It is when these rhythms are interrupted that generalized seizures
can result. (It is a similar process that is thought to cause absence seizures as well.)
The T-calcium channels in the brain have three states: open, closed and inactivated. The cells also have GABA receptors. When the
cells receive tonic activation from GABA, it can result in a hyperpolarization state that moves the T-calcium channels from the
inactivated state to the closed state, which allows them to be activated if needed. This switch permits the simultaneous opening of a
large amount of the T-calcium channels every 100 milliseconds or so which creates the oscillations seen on the EEG when a person is
having a seizure.
Patients are usually treated with anti-convulsant medication such as Keppra. Medications are adjusted and changed according to what
works for the patient. Treatment of epilepsy is very individualized and may need to be adjusted throughout therapy.
Prognosis for epilepsy depends on the type of seizures the patient presents with. If unconsciousness occurs during the seizure, it can
result in unexpected morbidity and mortality. Trauma is common with seizures and can result in injury and even death if severe
enough.
Usually, when patients medications are adjusted appropriately, their prognosis is good and the seizures are well-controlled. Some
patients can also be considered for surgery to remove the part of the brain where the seizure begins (Ko, 2014).

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name: cholecalciferol (vitamin D3)

Concentration (mg/ml)

Route: PO

Dosage Amount (mg): 2000 IU

Frequency: Daily

Pharmaceutical class: fat soluble vitamin

Home

Hospital

or

Both

Indication: prevention of vitamin B deficiency

Side effects/Nursing considerations: side effects: headache, irritability, photophobia, arrhythmias, hypertension, nausea, vomiting, weight loss, pancreatitis,
hypercalcemia, bone pain, muscle pain
Nursing considerations: assess for symptoms of vitamin deficiency before and periodically during therapy; assess patient for bone pain during therapy; monitor
serum calcium throughout therapy; monitor for signs of toxicity (hypercalcemia, hypercalciuria, hyperphosphatemia)

University of South Florida College of Nursing Revision August 2013

Name: Cyanocobalamin

Concentration

Dosage Amount: 2500 mcg

Route: PO

Frequency: Daily

Pharmaceutical class: water soluble vitamin

Home

Hospital

or

Both

Indication: vitamin B12 deficiency prevention

Side effects/Nursing considerations: Side effects: headache, heart failure, diarrhea, hypokalemia, pulmonary edema
Nursing considerations: assess patient for signs of B12 deficiency before and periodically throughout therapy
Name: Folic acid

Concentration

Dosage Amount: 1 mg

Route: PO

Frequency: BID

Pharmaceutical class: vitamins

Home

Hospital

or

Both

Indication: prevention of anemia

Side effects/Nursing considerations: Side effects: rash, irritability, confusion, fever, difficulty sleeping, malaise
Nursing considerations: assess patient for signs of anemia before and periodically throughout therapy; monitor H&H lab values periodically
Name: levetiracetam (Keppra)
Concentration
Dosage Amount: 500 mg
Route: PO

Frequency: BID

Pharmaceutical class: anticonvulsants

Home

Hospital

or

Both

Indication: epilepsy
Side effects/Nursing considerations: Side effects: suicidal thoughts, aggression, agitation, anger, anxiety, depression, dizziness, weakness, Stevens-Johnsons
Syndrome, toxic epidermal necrosis
Nursing considerations: assess location, duration and characteristics of seizure activity; assess patient for CNS adverse effects throughout therapy; monitor
mood changes and assess for suicidal thoughts; assess for rash periodically throughout therapy (may cause Stevens-Johnson Syndrome)
Name: Pantoprazole (Protonix)

Concentration

Dosage Amount: 40 mg

Route: PO

Frequency: Daily

Pharmaceutical class: antiulcer agent; PPI

Home

Hospital

or

Both

Indication: prophylactic for stomach ulcers due to stress of hospitalization

Side effects/Nursing considerations: Side effects: headache, pseudomembranous colitis, abdominal pain, diarrhea, hyperglycemia
Nursing considerations: assess patient frequently for epigastric or abdominal pain and for frank or occult blood in the stool; may cause abnormal liver function
tests; monitor serum magnesium throughout therapy (may cause hypomagnesemia)
Name: sertraline (Zoloft)

Concentration

Dosage Amount: 50 mg

Route: PO

Frequency: BID

Pharmaceutical class: antidepressant; SSRI

Home

Hospital

or

Both

Indication: depression
Side effects/Nursing considerations: Side effects: neuroleptic malignant syndrome, suicidal thoughts, drowsiness, headache, fatigue, insomnia, agitation, anxiety,
confusion, chest pain, palpitations, diarrhea, dry mouth, nausea, abdominal pain, sexual dysfunction, menstrual disorders, increased sweating, hot flashes,
hyponatremia, tremor, serotonin syndrome, fever
Nursing considerations: assess for suicidal tendencies, especially during early therapy; assess for serotonin syndrome; monitor mood changes and inform
healthcare provider of any significant changes; may cause hyperglycemia and diabetes-monitor for signs and symptoms; may cause false positive urine screening
tests for benzos

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with
recommendations.
Diet ordered in hospital? Regular
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patient eats more refined grains and cheese/fats than
necessary. She does not eat enough vegetables, fruit, or
protein. I would suggest that she try to eat more
vegetables and fruit and replace some of her fat intake
with protein. I would also suggest that she start exercises
at least 3 times a week to avoid the development of comorbid illnesses such as diabetes.
Breakfast: 2 medium pancakes, 2 tablespoons syrup, 2
pieces of bacon (medium sized), 2- oz cups of coffee
Lunch: 2 pieces of white bread; 4 thin slices of turkey, 2
slices of cheese (2 oz), 2 tablespoons mayo, 1 can of coke,
1-8 oz cup of water

Dinner: 3 slices of pizza with meat and vegetables, medium

cinnamon bun, 1 bottle of apple juice (10 oz), 1-8 oz cup of
water
Snacks: 1 medium chocolate chip cookie, 1 single serving
bag of potato chips, 3-8 oz cups of water
Liquids (include alcohol): See above
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 reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My mom and my aunt
How do you generally cope with stress? or What do you do when you are upset? I usually try to call my mom and talk
to her about whatever is stressing me out.

University of South Florida College of Nursing Revision August 2013

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life): None

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? No____________________________________________________
Have you ever been talked down to? No____________ Have you ever been hit punched or slapped? No___________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
No_______________________________________ If yes, have you sought help for this? ______________________
Are you currently in a safe relationship? Not currently in a relationship

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs.

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 patients age group puts her in the intimacy vs. isolation stage of psychosocial development. It refers to a
stage in early adulthood where people are generally trying to create and sustain personal, meaningful relationships. Those who are
successful in this stage form relationships that are meaningful and secure. Those that are unsuccessful tend to lack close relationships
or have insecure and meaningless relationships (Cherry).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: I believe
that my patient is in the intimacy stage. Although she is not in a relationship at this time, she has meaningful relationships with close
friends and her family. Additionally, she states that she is looking for a new relationship since she got out of one about a year ago.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: I think that her
hospitalization has little effect on her developmental stage. Her friends and family are frequently at the bedside supporting her. She
does say that her disease has had an impact on her relationships. She is unable to do some things with her friends because of her
disease and she says that that has made some of her friends stop being her friend. However, she is happy because she now knows
who her true friends are and has become closer to them.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? I think there is something wrong in my brain that is causing my
illness.
What does your illness mean to you? It doesnt really mean anything to me, I just want them to localize where the
seizures are starting so I can stop having them. Right now it really gets in the way of my life and I would like to be able
to live a normal life again.

+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____________________________________________________

University of South Florida College of Nursing Revision August 2013

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______________________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? Condoms and birth control
pills______________________________
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
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision August 2013

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life? None at all
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition? No
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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?
How much?(specify daily amount)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much?

Has the patient ever tried to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)

For how many years?

(age

thru

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks? Not that I am aware
of.

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF: 20
Bathing routine: daily
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? Never
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

4-5/day

Hematologic/Oncologic

Metabolic/Endocrine
2/day
2/year

Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? Unknown
Other:

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam: yearly
Date of last gyn exam? May 2013
menstrual cycle
regular
irregular
menarche
age? 15
menopause
age?
Date of last Mammogram &Result: Never
Date of DEXA Bone Density & Result:
Never
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision August 2013

Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No

Any other questions or comments that your patient would like you to know? No

University of South Florida College of Nursing Revision August 2013

10

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: Patient is
Height: 47
Weight: 296 lb BMI:68.8
Pain: (include rating & location) 0
alert and oriented times 3 and Pulse: 82
Blood
appears to be in no acute
Pressure: 119/72 left arm
(include location)
distress; appears stated age
and obese
Temperature: (route taken?)
Respirations: 18
SpO2: 99
Is the patient on Room Air or O2: Room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
Other:
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

talkative
withdrawn

Peripheral IV site Type: 20 gauge

Location: Right forearm
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
Location:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Fluids infusing?
no
yes - what?

quiet
boisterous
aggressive
hostile

flat
loud

Date inserted: 2/3/14

Date inserted:
Date inserted:

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 3 /3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 12 inches & left ear- 12 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Good, all teeth present and appear normal, no pain or lesions
Comments:

University of South Florida College of Nursing Revision August 2013

11

Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th intercostal space, mid-clavicular line
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 2+ Carotid: 2+ Brachial: 2+ Radial: 2+ Femoral: 2+
Popliteal: 2+
DP: 2+ PT: 2+
No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color:
Previous 24 hour output:
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 2 / 4 /14
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at _5___ RUE ___5___ LUE ____5__ RLE

& ___5___ in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: 2+

Biceps: 2+

Brachioradial: 2+

Patellar: 2+

Achilles: 2+

Ankle clonus: positive negative Babinski: positive negative

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
EEG

Dates
Continuous

Trend
Normal except when
seizure activity is taking
place

Analysis
These results are typical
for a person with
epilepsy.

No labs completed

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
The patient is on a continuous EEG to monitor for seizure activity. Additionally, her seizure medications are
being titrated down to try to induce a seizure so that the focus can be localized further.

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

1. Risk for injury r/t environmental factors during seizure
2. Risk for aspiration r/t impaired swallowing during seizure activity
3. Anxiety r/t threat to role functioning aeb patients statements about not being able to work or do normal activities
anymore
4. Risk for impaired memory r/t seizure activity
5. Risk for acute confusion r/t post seizure state
6. Risk for ineffective airway clearance r/t accumulation of secretions during seizure
7. Risk for falls r/t uncontrolled seizure activity
8. Risk for social isolation r/t unpredictability of seizures

 15 CARE PLAN
Nursing Diagnosis: Risk for injury
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Patient will remain free of injury
1. Bed rails will be padded
1. Bed rail padding is used to
1. Patient remained free from
on my shift and throughout hospital 2. Bed will be in low position at all ensure that the patient does not hurt injury and seizures on the day that I
stay.
times and bed rails will be up at all themselves if they have a seizure.
cared for her.
times.
2. Keep bed in low position and
2. Teaching about medications and
3. Patient will be instructed to call
side rails up to avoid the patient
her aura was performed to help
for assistance when ambulating.
falling off during a seizure.
with discharge instructions.
3. Patient will call when
ambulating to ensure that a seizure
does not take place while they are
ambulating and if it does, there is
someone there to help.
Patient will explain methods to
4. Teach patient to take
4. Taking medications as prescribed
prevent injury before discharge.
medications as prescribed in order
will help the patient to have fewer
to help prevent seizures and injury seizures and therefore less of a risk
at home.
of trauma.
5. Teach patient that when her aura 5. Teaching the patient about her
present to get to a safe, soft place
aura will help her to prevent injury
where she will not hit her head as
at home when a seizure does occur.
quickly as possible.
6. Instructing patient to push the
6. Patient will be instructed to push call light when her aura presents
the call button when her aura is
will make sure that someone is in
present to alert staff that a seizure
the room to ensure her airway is
is about to occur.
open and prevent injury during the
seizure.
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
Patient Goals/Outcomes

*F/U appointments
*Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes * No
Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Anxiety
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
1. Patient will identify, verbalize,
1. Assess the patients level of
1. Assessing the patients level of
1. Patient identified and verbalized
and demonstrate some techniques
anxiety and physical reactions to
anxiety will allow the nurse to
some techniques to control anxiety,
to control anxiety before the end of anxiety (tachycardia, tachypnea,
know if the anxiety is reduced or
but did not demonstrate them on
my time on the unit.
etc.)
increased at all on the shift.
my shift.
2. Provide teaching about
2. Backrubs and massages are a
backrubs/massages to help
useful way for some people to
decrease the clients anxiety in and relieve stress and reduce anxiety.
out of the hospital.
3. Guided imagery provides the
3. Suggest the use of guided
patient with a place to relax even if
imagery as a way to reduce anxiety the outside world is not relaxing
and explain to the patient how to
them at the time.
do it.
2. Patient will verbalize absence of 4. Suggest yoga to the client as a
4. Yoga is a great way for some
2. Patient was offered much advice
or decrease in subjective distress
means of relaxation and anxiety
people to relax as well as it offers
on how to control her anxiety and
by discharge.
reduction.
some exercise for the patient.
taught proper and healthy
5. Provide client with a means to
5. Music of the patients choice
techniques to assist with discharge
listen to music if they desire to help will allow them to relax and escape planning.
with anxiety. Or if they prefer,
the situation that is causing them
provide quiet.
anxiety.
6. Remove the source of the
6. Removing the stressor will in
anxiety wherever possible.
turn remove the anxiety; however,
it is not always possible.
DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Patient Goals/Outcomes

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

15 CARE PLAN
Patient Goals/Outcomes

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References

Evaluation of Interventions on
Day care is Provided

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

References
Cherry, K. (n.d.). About.com Psychology. Retrieved from Erikson's Stages of Psychosocial Development :
http://psychology.about.com/od/psychosocialtheories/a/psychosocial_3.htm
Ko, D. (2014, February 10). Epilespy and Seizures. Retrieved from Medscape: http://emedicine.medscape.com/article/1184846overview#aw2aab6b2b6