UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Ashley Kavumkal

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

KA

Assignment Date: 9/10/2014

Agency: SMH

Age: 77

Admission Date: 9/9/2014

Marital Status: widow

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Pneumonia J15.9

Level of Education: Masters

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): retired from college

Number/ages children/siblings: 3children, 6 siblings

Served/Veteran: no

Code Status: full code

Living Arrangements: lives alone in a house in Sarasota

Advanced Directives: yes

If no, do they want to fill them out?
Surgery Date:
Procedure:

Culture/ Ethnicity /Nationality: US citizen

Religion: Christian

Type of Insurance: Medicare, Florida Blue

1 CHIEF COMPLAINT: intermittent cough, no pain

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient was admitted on 9/9/2014 with abdominal pain, nausea, vomiting and diarrhea. Symptoms started a week agocame to the ER that time and was given a course of flagyl which stopped her diarrhea. Symptoms worsened on 9/8/2014
including watery bowel movement, episode of emesis and difficulty keeping down liquids or solids. She also recently had
a bronchoscopy as an outpatient secondary to bronchiectasis. The pathophysiology showed a few bronchial epithelial cells
with macrophages and neutrophils.

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
Date

Operation or Illness
A- fibrillation
History of GI bleed
Hypothyroid
Hypertension
Aplastic anemia status post stem cell transplant
Chronic headaches

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

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Alcoholism

Surgery on toe
Bone marrow transplant in the setting of aplastic anemia

2007

Father
Mother
Brother
Sister
brother
brother
relationship

Comments: Include date of onset

1 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)
Adult Tetanus (Date)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
University of South Florida College of Nursing Revision August 2013

NO

occupational purposes? Please List

1 ALLERGIES
OR ADVERSE
REACTIONS

Medications

Other (food, tape,

latex, dye, etc.)

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Beta blockers
IV contrast
dilaudid
Lortab

Itching/rash tolerated sotalol 40mg po x1 on 4/30/2011

Itching /rash, anaphylaxis, disorientation, hypotension, hives
GI distress
GI distress

milk
shellfish

GI distress
Unknown reaction

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)
Pneumonia is an infection of the pulmonary parenchyma by a bacterial organism. It could be community acquired,
hospital acquired, ventilator associated or healthcare associated. Pathophysiology of pneumonia could be aerobic gram
negative bacilli: pseudomonas aeruginosa, E-coli,klebsiella pneumonia and acinetobacter sp; Gram positive cocci:
streptococcus sp and s. aureus. Risk factors include age>65 years, resistance to antibiotics, asthma, CAD, COPD, chronic
renal failure, CHF, diabetes, liver disease, HIV, hospitalization for more than 2 days etc. Diagnostic symptoms include
fever, chills, rigors, malaise, fatigue, dyspnea, cough with /without sputum, pleuritic chest pain, GI symptoms and altered
mental status and weakness in older adults. Treatment include azithromycin , doxycycline , levofloxacin, amoxicillin, and
also IV antibiotics.
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software]. Retrieved from
http://www.unboundmedicine.com/products/nursing_central

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

Concentration (mg/ml)

Route: inhale

Dosage Amount (mg) 3ml aerosol

Frequency Q6H WA

Pharmaceutical class: adrenergic

Home

Hospital

or

Both

Indication: bronchodilator to control & prevent reversible airway obstruction caused by asthma or COPD. Inhaln:quick relief agent for acute bronchospasm
Side effects/Nursing considerations: nervousness, restlessness, tremor, chest pain, palpitations, paradoxical bronchospasm
Name: amitriptyline

Concentration: 10 mg tab

Route: PO

Dosage Amount: 10 mg

Frequency: QHS

Pharmaceutical class:trycyclic antidepressant

Home

Hospital

or

Both

University of South Florida College of Nursing Revision August 2013

Indication: depression
Side effects/Nursing considerations: suicidal thoughts, lethargy, sedation, blurred vision, dry eyes, dry mouth, hypotension, constipation, arrhythmias, torsade
de pointes
Name: calcitonin

Concentration:

Route: intranasal

Dosage Amount
Frequency: 1 spray once a day

Pharmaceutical class: hypocalcemics (hormones)

Home

Hospital

or

Both

Indication: management of postmenopausal osteoporosis

Side effects/Nursing considerations: rhinitis, nausea, vomiting arthralgia, back pain, anaphylaxis, facial flushing
Name: ceftriaxone

Concentration : 1g infuse over 30 min in normal

saline 100ml
Frequency: Q24H

Route: IVPB
Pharmaceutical class: third generation cephalosporins

Home

Hospital

or

Dosage Amount 1g

Both

Indication: treatment of lower resp tract infections

Side effects/Nursing considerations: phlebitis at IV site, pseudomembranous colitis
Name: levothyroxine

Concentration: 0.088mg tab

Route: PO

Dosage Amount: 0.088mg (1 tab)

Frequency: AC 30 minutes before meal

Pharmaceutical class: thyroid preparation

Home

Hospital

or

Both

Indication:thyroid supplementation in hypothyroidism

Side effects/Nursing considerations:headache, arrhythmias,sweating, weightloss, heat intolerance (only with excessive dosage)
Name: Omeprazole

Concentration: 20mg Cap

Route: PO

Dosage Amount: 20 mg 1 cap

Frequency: once a day

Pharmaceutical class: proton pump inhibitor

Home

Hospital

or

Both

Indication: reduction of risk of GI bleeding, Gerd/ maintenance of healing in erosive esophagitis

Side effects/Nursing considerations:abdominal pain, pseudomembranous colitis
Name: Sotalol

Concentration: 80mg Tab

Route: PO

Dosage Amount: 40mg (0.5 tab)

Frequency: BID

Pharmaceutical class:antiarrhythmics

Home

Hospital

or

Both

Indication:maintenance of normal sinus rhythm in patients with afib

Side effects/Nursing considerations:fatigue, weakness, arrhythmias, bradycardia, HF, pulmonary edema
Name:Acetaminophen

Concentration: 325mg tab

Route: PO

Dosage Amount : 625mg 2 tab

Frequency: Q4H PRN

Pharmaceutical class: antipyretic, nonopioid analgesics

Home

Hospital

or

Both

Indication:pain, fever
Side effects/Nursing considerations: hepatoxicity with increased doses
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route
Pharmaceutical class

Frequency
Home

Hospital

or

Both

Indication

University of South Florida College of Nursing Revision August 2013

Side effects/Nursing considerations

Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

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? Lactose free diet
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? Lactose free diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: oatmeal cooked in water, boiled egg
The patient should incorporate more fibers into her diet as
well as protein. Since she is following a lactose free diet
she needs to find an alternative for dairy products. She also
need to add foods that contain more minerals like
magnesium and hosphorus as well as vitamins A,D E and
K- however, since she takes multivitamin daily that would
be balanced.
Lunch: Meat and potato, boiled vegetables
Dinner: turkey sandwich with lettuce & tomato
Snacks: fruits- apple slices, green grapes
Liquids (include alcohol): orange juice (1 glass)
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? neighbours
How do you generally cope with stress? or What do you do when you are upset?
Prayer helps

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Feeling Lonely

+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? _no_________

University of South Florida College of Nursing Revision August 2013

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?
no______________________
Are you currently in a safe relationship? Patient lives alone, keeps good relationship with neighbours

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
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 is in her late adulthood with an integrity stage. When reflecting on his or her life, the older adult may
feel a sense of satisfaction (integrity) or failure (despair) (Myers, 2008, p.87).
Reference:
Myers, D. G., (2008). Development through the life span: Psychology in everyday life (pp. 78) New York, Worth Publishers.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient seems very happy when she talks about her retired life and her family- especially her grandchildren.

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

The disease did not seem to affect the patients developmental stage that much. She is very positive about recovering from
the pneumonia.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Low calcium
What does your illness mean to you?
I might be doing something wrong about my health.

+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? _do not know_______________________________
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? __________________________________
How long have you been with your current partner? NA___________________________________________________

University of South Florida College of Nursing Revision August 2013

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?
Catholic- goes to church on Sundays and do daily
prayers______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
__prayer helps me feel better when depressed and when in
pain.____________________________________________________________________________________________________
______________________________________________________________________________________________________

+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
none

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:
Bathing routine:
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: dry eyes and dry mouth

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?
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 aplastic
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

x/day

Hematologic/Oncologic

Metabolic/Endocrine
x/day
x/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?
Other:

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age? 54
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
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

10

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

University of South Florida College of Nursing Revision August 2013

11

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

General Survey:
Temperature: (route taken?)
98F

Height: 157.5cm
Pulse: 75
Respirations: 18

Weight:44.4kg BMI:17.9
Blood
Pressure: 142/76

Pain: none

(include location)

SpO2 98
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

Peripheral IV site Type:

Location:
no redness, edema, or discharge
Fluids infusing?
no
yes - what? ns
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?

talkative
withdrawn

right AC 20

quiet
boisterous
aggressive
hostile

flat
loud

Date inserted: 9/9/2014

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 / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: difficulty hearing
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

University of South Florida College of Nursing Revision August 2013

12

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:
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:
Carotid:
Brachial:
Radial:
Femoral:
Popliteal:
DP:
PT:
No temporal or carotid bruits
Edema:
[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 9 / 8
/ 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 _______ RUE _______ LUE _______ RLE

& _______ 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 parathesias

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:

Biceps:

Brachioradial:

Patellar:

Achilles:

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
WBC

Dates
16.5 H

(09/9/2014)

Normal (4.5-11)

Trend
WBC are trending
upwards indicating either
an infection or
inflammatory process is
occurring.

Magnesium 0.8 L

9/9/2014

low

Hemoglobin 13 normal
RBC 4.6
Platelet 321

9/9/2014
9/9/2014
9/9/2014

normal
normal
normal

Analysis
Number of infection
fighting cells. High WBC
indicates the presence of
an infection or
inflammation. High WBC
is often indicated in an
exacerbation of ulcerative
colitis.
Dietery intake
insufficient
normal
normal
normal

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Lactose free diet, activity- bedrest, chest x-ray,

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

1.risk for fall
2.ineffective breathing pattern
3.diarrhea
4.sensory perception alteration :auditory
5. cardiac output decreased (afib)

 15 CARE PLAN
Nursing Diagnosis: (Which nursing diagnosis you are doing your care plan on goes here.)
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Patient will remain free from falls
Located near nurses station, call
To make sure patient does not
All interventions are done
light in place and educated to use,
move out of bed without assistance
bed alarm, non-skid socks, fall risk to avoid risk of fall
arm band, top side rails up, bed
positioned in the lowest possible
height , hourly rounds

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 appts
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
Lung sounds will be normal
bilaterally

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Educate and remind to use
To facilitate normal airflow and to
incentive spirometer,
measure lung volumes
administration of meds, turn cough
and deep breaths

Evaluation of Interventions on
Day care is Provided
All interventions done this shift.

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 appts
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
diarrhea

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Dietary considerations,
To prevent dehydration and
administration of meds, educate to electrolyte loss
use call light for assistance

Evaluation of Interventions on
Day care is Provided
All interventions done

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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No

Rehab/ HH
Palliative Care

References
Myers, D. G., (2008). Development through the life span: Psychology in everyday life (pp. 78) New York, Worth
Publishers.
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software]. Retrieved from
http://www.unboundmedicine.com/products/nursing_central