UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Natalie Drass

PATIENT ASSESSMENT TOOL .

Assignment Date: November 3, 2015

Agency: Florida Hospital Tampa

1 PATIENT INFORMATION
Patient Initials: M.V.

Age: 79

Admission Date: November 2, 2015

Gender: Male

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Septic arthritis, M00.9

Level of Education: Masters Degree

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired history professor

Number/ages children/siblings: 53 y.o. son, 50 y.o daughter
Twin brother, 79 y.o.

Served/Veteran: No

Code Status: full

Living Arrangements: lives with wife in two story house

Advanced Directives: Yes

Surgery Date: None

Procedure: None

Culture/ Ethnicity/Nationality: American

Religion: none

Type of Insurance: Florida Blue

1 CHIEF COMPLAINT:
Patient came to the ER on 11/02/15 with severe left knee pain (8/10 pain). Patient states I fell a about a week ago going
down the stairs and landed on my knees. I knew I probably did something to my knee but I thought it might heal with
time. Patient had a recent total knee replacement on his left knee September 9, 2015. The patients wife says, I am
worried that he may need another surgery. I wanted him to come to the hospital after his pain starting getting worse.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Pain started when fall occurred, about a week ago
Patient states the pain is all around my left knee
Pain is intermittent, the pain starts randomly and happens every few hours
Patient states it feels like a sharp pain when I am walking and a dull pain when it hurts randomly
The pain is worse after ambulating or bearing weight
Laying in bed or pain medicine reduces pain to around a 4/10
Patient is being given Percocet to treat pain
The pain today is 7/10

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

67

Mother

99

Brother

79

Maternal
Grandmother
Maternal
Grandfather

Tumor

Stroke

Stomach Ulcers

Seizures

Problems
Mental Health

Kidney Problems

Hypertension

(angina,
etc.)
Heart
MI,Trouble
DVT

Gout

Cancer

Bleeds Easily

Asthma

Cause
of
Death
(if
applicable
)
Car
accident
Natural
causes

Arthritis

2
FAMILY
MEDICAL
HISTORY

Anemia

Hypercholesterolemia, Lipitor 20 mg daily

Carotid endartectomy
Benign prostatic hyperplasia
Hypertension, Losartan 100 mg daily

Environmental
Allergies

1999
2003
2012
Early 90s

Alcoholism

Osteoarthritis
Stroke age 67

Age (in years)

2006
2003

Glaucoma

Operation or Illness

Diabetes

Date

Natural
causes
Heart
attack

Comments: Include date of onset

Neither patient or wife remember when each family member was diagnosed/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) Patient refused influenza vaccine in hospital,
11/03/15
University of South Florida College of Nursing Revision August 2013

NO

Pneumococcal (pneumonia) (Date) Patient refused pneumococcal

vaccine in hospital, 11/03/15
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Medications

Pollen

Watery eyes, headache

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)
Septic arthritis is an acute inflammatory response that starts when bacteria enters the joint. Polymorphonuclear
leukocytes release proteolytic enzymes and the synovial membrane releases lysozomes. These enzymes destroy
the matrix of the collagen and cartilage. Bacteria can enter a joint through arthroplasty, spread of infection, or
hematogenous spread (Hodler, Schulthess, & Zollikofer, 2005, p. 140). The infection in the joint can spread to
the bone so septic arthritis should be treated quickly. Septic arthritis is usually found in older patients, patients
with pre-existing joint disease, or immunocompromised patients. This condition is also found in patients with a
pre-existing joint disease (Reiser, Baur-Melnyk, Glaser, 2008, p. 102).
Radiography and a MRI can be used to detect septic arthritis. In radiography, early signs of this condition
appear as narrowing joint space due to cartilage destruction and erosion of the affected joint. Joint effusion and
soft-tissue swelling will also be visible. With a MRI, abscesses may be visible or there will be bone marrow
edema. Laboratory tests that may indicate septic arthritis would be values for inflammation (Reiser et al., 2008)
The clinical presentation of septic arthritis is severe pain, local warmth, erythema, swelling, low-grade fever,
and restricted movement. This condition progresses rapidly and causes significant damage. Complications of
septic arthritis would be sepsis, endocarditis, ankylosis, and joint deterioration (Reiser et al., 2008, p. 104).
Septic arthritis can be treated with antibiotics.
5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name Ceftriaxone

(Rocephin)

Concentration (mg/ml)

Route IV

Dosage Amount 2

grams 100mL/hr

Frequency daily

Pharmaceutical class cephalosporins

Indication

2000mg/100mL

Home

Hospital

or

Both

infection

Side effects/Nursing considerations: Seizures

(high doses), pseudomembranous colitis, diarrhea, cholelithiasis, gallbladder, rashes, urticaria,

bleeding, leukopenia, thrombocytosis, hemolytic anemia, allergic reactions (anaphylaxis), superinfection
Advise patient to report signs of superinfection (furry overgrowth on the tongue, lose stools), report allergic reaction, report fever and
diarrhea
Name Vancomycin

Concentration 1250mg/250mL

Dosage Amount 1.25

University of South Florida College of Nursing Revision August 2013

grams 250mL/hr

Route IV

Frequency daily

Pharmaceutical class antibiotics

Indication

Home

Hospital

or

Both

infection

Side effects/Nursing considerations:

ototoxicity, hypotension, nausea, vomiting, nephrotoxicity, rashes, leukopenia, phlebitis, back and neck
pain, hypersensitivity, anaphylaxis, red man syndrome, superinfection
Report hearing loss or vertigo, report if no improvement is seen in a few days
Name Losartan

Concentration

(Cozaar)

Dosage Amount 100mg

Route PO

Frequency daily

Pharmaceutical class angiotension

Indication high

II receptor antagonists

Home

Hospital

or

Both

blood pressure

Side effects/Nursing considerations: dizziness,

fatigue, headache, insomnia, weakness, chest pain, edema, hypotension, nasal congestion,
hypoglycemia, diarrhea, nausea, impaired renal function, hyperkalemia, back pain, angioedema, fever
Take as directed, avoid foods that contain high levels of potassium, avoid driving or other activities until response to medication is known,
report swelling of face, eyes, lips, or tongue, monitor blood pressure, exercise
Name Acetaminophen-hydrocodone

(Percocet)

Concentration

Dosage Amount 5mg/325mg

Route PO

Frequency Q4H

Pharmaceutical class nonopioid

analgesics/opioid analgesics

combination
Indication Pain

Home

Hospital

or

Both

Side effects/Nursing considerations: confusion,

dizziness, sedation, headache, euphoria, blurred vision, respiratory depression, hypotension,

bradycardia, constipation, nausea, sweating, urinary retention, dependence
Do not take more than the prescribed dose, avoid alcohol and activities requiring alertness with taking medication, change positions slowly
to minimize orthostatic hypotension, prevention of constipation
Name Baclofen

Concentration

(Gablofen)

Dosage Amount 10mg

Route PO

Frequency PRN

Pharmaceutical class skeletal

muscle relaxants (centrally

acting)
Indication

Home

Hospital

or

Both

muscle spasms

Side effects/Nursing considerations:

Seizures, dizziness, drowsiness, fatigue, weakness, headache, insomnia, nasal congestion, edema,
hypotension, pruritus, rash, ataxia, weight gain, hypersensitivity
Do not abruptly stop taking this medication, avoid driving until medication response is known, change positions slowly, avoid alcohol,
report signs of itching
Concentration

Name Aspirin

Dosage Amount 81mg

Route PO

Frequency daily

Pharmaceutical class salicylates

Indication

Home

Hospital

or

Both

prophylaxis of MI

Side effects/Nursing considerations:

tinnitus, GI bleed, dyspepsia, epigastric distress, nausea, anorexia, anemia, hemolysis, rash, urticaria,
anaphylaxis, laryngeal edema
Take with full glass of water, report tinnitus, avoid alcohol, sodium-restricted diet, take as directed
Concentration
Name Atorvastatin (Lipitor)
Dosage Amount 20mg
Route PO

Frequency daily

Pharmaceutical class hmg

coa reductase inhibitors

Home
Hospital
or
Both
management of hypercholesterolemia
Side effects/Nursing considerations: amnesia, confusion, dizziness, headache, insomnia, weakness, rhinitis, bronchitis, chest pain, abdominal
cramps, constipation, diarrhea, heartburn, nausea, hyperglycemia, rashes, rhabdomylosis, arthritis, angioneurotic edema
Take medication as directed, diet restrictions (fat, cholesterol, alcohol), notify health care professional if unexplained muscle pain or
weakness
Name Ondansetron (Zofran)
Dosage Amount 4mg
Indication

University of South Florida College of Nursing Revision August 2013

Route IV

push

Frequency PRN

Pharmaceutical class five

Indication

ht3 antagonists

Home

Hospital

or

Both

nausea

Side effects/Nursing considerations:

headache, dizziness, drowsiness, fatigue, torsade de pointes, constipation, diarrhea, dry mouth, abdominal
pain, extrapyramidal reactions
Report if symptoms of irregular heart beat or involuntary movement of eyes, face, or limbs

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? Heart healthy cardiac (low
Analysis of home diet (Compare to My Plate and
sodium, fat, cholesterol)
Diet pt follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: 1 cups of grits with salt and butter, 1 banana
The protein amount in under by 1 ounce. Boiled eggs could
be added to the breakfast foods to increase the amount of
protein.
Lunch: Buffalo chicken wings, 2 celery stalks
Only of a cup of vegetables is being consumed. Add
vegetables to the regular diet as snacks or as a side dish to
the main meals. Vegetables such as zucchini could be added
to the lasagna. Carrots could be eaten as a snack with some
light ranch dressing.
Dinner: Lasagna with beef
There should be less than 300 empty calories in the home
diet and 617 empty calories are being eaten. Try eating
frozen fruits for dessert instead of ice cream. Eat popcorn
that is unsalted with no butter instead of chips. This change
will add fiber to your diet and reduce the amount of sodium
that is consumed.
Snacks: Single serving bag of tortilla chips, strawberry fat
The sodium intake is high and almost past the 2300mg
free yogurt, scoop of vanilla ice cream
limit. The home diet should be low sodium due to the past
stroke and hypertension. Triscuits or Wheat Thins could be
a substitute for chips. Maybe the grits could be made
without added salt. Replace the chips with vegetables or
protein.
Liquids (include alcohol): 1 cup of orange juice, 2 fluid
ounces of whiskey, 3 cups of water
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 wife helps me all the time
How do you generally cope with stress? or What do you do when you are upset?
I like to read books or go out to eat with my wife. I dont get stressed or upset very often.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I dont have any of that. I have a loving wife that makes sure I never feel sad or anxious.

+2 DOMESTIC VIOLENCE ASSESSMENT

University of South Florida College of Nursing Revision August 2013

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? _____No________________
Are you currently in a safe relationship? Yes

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:

Integrity is a sense of integrity and fulfillment; willingness to face death; wisdom and despair is the dissatisfaction
with life; denial of or despair over prospect of death (Halter, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is in the ego integrity stage. The patient states, I am happy with everything I have done. The patient is
content with his life and is happy. He talks about his wife constantly and they are very happy together. When asked about
death the patient states Im not afraid of dying. My wife and children will miss me but I have done everything I have
ever wanted to do. The patient has a bucket list and claims that he has checked everything off. He has a sense of
fulfillment about his life.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The patient is happy that he has been able to accomplish so much through all of his health problems. Patient states, I had
a stroke but I still completed everything on my bucket list. My wife helped me. His knee problems might have had an
impact on completing his bucket list but it is complete.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
My fall. I probably shouldve been more careful.
What does your illness mean to you?
It means that I have trouble walking. I wish I could walk without pain.

+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? __Women___________________________________________________
Are you aware of ever having a sexually transmitted infection? __No_________________________________________
Have you or a partner ever had an abnormal pap smear?_No________________________________________________

University of South Florida College of Nursing Revision August 2013

Have you or your partner received the Gardasil (HPV) vaccination? ___No_____________________________________
Are you currently sexually active? ___Yes______When sexually active, what measures do you take to prevent acquiring
a sexually transmitted disease or an unintended pregnancy? _Nothing_______________________________
How long have you been with your current partner?__ For as long as I can remember ___________________________
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?
_My wife is religious and she prays for me every day.
____________________________________________________________________________________________________
______________________________________________________________________________________________________
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)
1 pack a day

Yes
No
For how many years? 25 years
(age 35

thru 59

If applicable, when did the

patient quit? 20 years ago

Pack Years: 24
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? Yes

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Whiskey
How much? (give specific volume)
2 fluid ounces a few times a week

For how many years?

age 18 through now

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
No

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Gastrointestinal

Changes in appearance of skin

Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen none
SPF:
Bathing routine:

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis

Other:

Abdominal Abscess

Integumentary

Last colonoscopy?
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
2 x/day
Routine dentist visits
1 x/year
Vision screening once a year
Other: Wears glasses

Genitourinary
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 5 x/day
In hospital 5 x/day
Bladder or kidney infections

Immunologic
Chills with severe shaking
Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other: Fever of 101.6 last night at 2300,
afebrile at 0300

Hematologic/Oncologic
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: A+
Other:

Metabolic/Endocrine
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? ED 11/02/15
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias

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?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam? Every 2
years
Date of last prostate exam? 2015
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- left knee injury
Weakness
Pain 7/10 left knee pain
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision August 2013

10

Last EKG screening, when? ED

11/02/15
Other: Stroke age 67

Arthritis (Osteoarthritis)
Other:

Chicken Pox
Other:

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

11

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

General Survey: Patient is a
well-developed 39 y.o. male
who is alert & oriented x 3
Temperature: (route taken?)
Oral, 98 F

Height: 177.8 cm
Pulse: 58
Respirations: 17

Weight: 82.2kg
Blood
Pressure: 110/80

BMI: 26

Pain: (include rating & location)

7/10

(include location)

Is the patient on Room Air or O2: room air

SpO2 92
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 Speech is a little slurred from previous stroke. Wife says that this is normal for him.
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 Left knee
erythematous
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin

talkative
withdrawn

quiet
boisterous
aggressive
hostile

flat
loud

Peripheral IV site Type: 20 gauge Location: left hand

Date inserted: 11/02/15
no redness, edema, or discharge
Fluids infusing?
no
yes - what? Ceftriaxone 100ml/hr, Vancomycin 250ml/hr
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Date inserted:
Fluids infusing?
no
yes - what?
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 3mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 6 inches & left ear- 6 inches
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
Breathing is harder when ambulating, I think I have to breath harder when my
knee hurts and I walk on it
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th intercostal space midclavicular 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)
Not on tele

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3
No temporal or carotid bruits
Edema: +1 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: left lateral knee +1
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:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: 11/01/15
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
Not assessed, patient alert, oriented, denies problems
Other Describe: Patient requires help to get to the bathroom, wife usually helps but nurse would prefer if tech was called

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ___5____ RUE __5_____ LUE ____5___ RLE & ____3___ 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
Pain only from left knee
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
positive

Biceps: +2

Brachioradial: +2

Patellar: +1

Achilles: +2

Ankle clonus: positive negative Babinski:

negative

Unbalanced gait from left knee replacement and injury, wife says that he was a little off balance from the surgery but is
worse after fall

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):

Lab
U/S ext lower venous
duplex LT
XR tibia/fibula 2V LT,
XR knee min 4V LT
BUN

Dates

Trend
No DVT present

Analysis
Check for DVT

Total knee arthroplasty,

age related changes
The patients BUN levels
have been normal. Two of
this patients medications
can increase the BUN
(vancomycin and
ceftriaxone). Vancomycin
is nephrotoxic and the
BUN should be
monitored to evaluate
renal function.

Visualize damage to the

knee
BUN is used to assess
renal function. Urea is
formed in the liver from
ammonia and excreted by
the kidneys as an end
product of protein
metabolism. Blood urea
nitrogen levels reflect the
balance of nitrogen
ingested and excreted.

The creatinine levels have

been normal but close to
the higher end of the
normal range.
Ceftriaxone can increase
creatinine. Renal function
should be monitored
when taking vancomycin
and ceftriaxone.

Creatinine is used to
assess renal function.
Creatine is from the
skeletal muscle, where it
participates in metabolic
reactions. A small amount
of creatine is converted to
creatinine and is excreted
in the kidneys. This level
determines the rate at
which the kidneys are

11/02/15
11/02/15

16mg/dL 16 mg/dL

Normal (6-20 mg/dL)

11/03/15 11/02/15

Creatinine
1.2 mg/dL 1.2 mg/dL

Normal (0.6-1.3 mg/dL)

11/03/15

11/02/15

White blood cells

9.1 12.5 H
Normal (4.5-11.1)

11/03/15

11/02/15

Lymphocytes %
8% L

9% L

Normal (12-14%)
11/03/15

11/02/15

Segmental neutrophils %
80% H 84% H
11/03/15

11/02/15

The white blood cell

count should be high with
infection. The white
blood cell count was high
yesterday. Antibiotics
were held yesterday due
to mild leukocytosis and
the patient being afebrile.
Patient developed at
101.6 fever at 2300 and
antibiotics were started.
Lymphocytopenia can
indicate sepsis. Low
levels indicate viral
infections affecting bone
marrow. The lymphocyte
count is low.
The patients results are
high. High levels indicate
infection.

Normal (51-72%)

clearing creatinine from

the blood.
White blood cells are
cells that are involved
with the immune system.
These cells provide
protection from viruses
and bacteria. The white
blood cell count can be
increased with infection
or inflammation.
Lymphocytes are
responsible for the bodys
immune protection. High
levels indicate infection
and low levels indicate
viral infections affecting
bone marrow.
Segmental neutrophils are
the primary white blood
cells that fight infections.
High levels indicate
infection.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Heart healthy cardiac diet, was NPO and changed to heart healthy cardiac diet because doctor has not seen patient
in 24 hours
Wife helps patient get to bathroom, encouraged to wait for tech or nurse before getting up and walking around
Daily blood work
Consult physical therapy to improve gait

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

1. Delayed surgical recovery related to postoperative infection as evidenced by septic arthritis a month after total knee
replacement
2. Risk for falls related to previous fall
3. Impaired physical mobility related to knee replacement and injury as evidenced by patient having trouble walking by
himself

4.
5.

 15 CARE PLAN
Nursing Diagnosis: Risk for falls related to previous falls
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Patient will remain free of falls
Fall risk assessment
This will see how severe the risk
throughout hospitalization and after
for falls is
discharge
Screen for balance and mobility
skills
The nurse will know if the patient
is able to ambulate on their own or
Fall precautions (risk for fall
not
wristband, lower bed, possible bed
alarm, call light close to patient,
non-skid footwear)
Fall precautions alert staff for
increased vigilance and mobility
Evaluate medications to determine assistance
which medications increase the risk
for falls
Medications can cause orthostatic
hypotension, orthostatic
Routinely assist client with
hypotension causes dizziness upon
toileting
standing
Patient Goals/Outcomes

Change environment to minimize

the incidence of falls

Fall precautions (risk for fall

wristband, lower bed, possible bed
alarm, call light close to patient,
yellow socks)

The patient will not need to get up

on their own to go to the bathroom
if the nurse checks every hour if
the patient needs to go to the
bathroom
Fall precautions alert staff for
increased vigilance and mobility
assistance

Evaluation of Goal on Day care

is Provided
Moderate fall risk on Hendrich II
Fall Risk Model
The patients balance is worse
after fall, wife says he didnt have
good balance after surgery and
that it is worse now
Fall precautions implemented

Vancomycin, Losartan, Perocet,

and Baclofen have the side effect
of hypotension, patient changed
positions slowly
Patient was assisted to the
bathroom every few hours, patient
was asked about needing to use
the bathroom every hour
Fall precautions implemented
Lights kept on

Adequate lighting

Patient will be able to see obstacles

when ambulating

Discuss home environment (ex.

Are their stairs in your home?

To ensure that the patient can

safely ambulate around his house

Patient lives in home with stairs,

wife will move things from
upstairs to downstairs

Rugs?)
Explain methods to prevent injury

Explain how to use call light and

when to use it

*Referral to physical therapy for

gait training and strengthening
Skin integrity remains intact during
hospitalization

Help patient change positions

Assess for signs of infection of

dehydration that led to falling

Blood work

Patient will be able to ambulate

independently in preparation for
discharge

Physical therapy consult

Assist patient to ambulate around
the unit

and get to where he needs to be

without increasing the risk for falls
Patient will use call light and wait
for assistance instead of getting up
by himself and walking across the
room
Physical therapy can explain
methods for the patient to prevent
injury, how to avoid falling at
home
Patient may stay in bed for long
periods of time due to pain when
ambulating, assist patient with
moving from bed to chair or
changing positions
Dehydration or infection can
increase risk for falls
Patient will learn how to avoid
falling and improve
strength/balance
Practice ambulating will increase
strength in affected knee

Patient used call light when his

wife wasnt with him

Physical therapy worked with him

and showed him how to prevent
falling again
Patient was able to move himself,
his wife made sure he got up and
moved around every few hours
Labs show increased WBC count
and antibiotics were started, septic
arthritis diagnosed
Patient worked with physical
therapy, learned how to improve
balance
Patient walked around with his
wife

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 patient should go to outpatient physical therapy, did not attend physical therapy after total knee replacement
Pastoral Care
Durable Medical Needs
*F/U appts
*Med Instruction/Prescription-self-catheterization
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH

Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Delayed surgical recovery related to postoperative infection as evidenced by septic arthritis a month after total knee replacement
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Patient demonstrates ability to
Walk with patient around unit
Patient can practice walking to
Pain caused patient to stop
move about
improve balance and stability
ambulating, balance was improving
* Referral to physical therapy for
after pain medicine was
gait training and strengthening
Patient will learn how to walk
administered
correctly to avoid falling again,
improve recovery of total knee
Physical therapy explained how
replacement and knee injury
patient should be walking and how
he can avoid falling again
State that pain is relieved after
Pain management with Percocet
Pain medicine can reduce pain and Patient states pain 7/10 an hour
nursing interventions, pain level >3 every four hours when pain is <3
allow patient to ambulate without
after Perocet was administered,
pain
the swelling makes the pain
Use non-pharmacological
worse
strategies to reduce pain (watch
TV, play music of clients choice,
When pain medication is not due to Patient watched TV with wife and
meditation)
be given yet the patient can use
did not say anything about pain
distraction or meditation to reduce during this time
pain
Have surgical area that shows
evidence of healing: no redness,
induration, draining, or immobility

Administer IV antibiotics
Use a hot or cold compress to
reduce swelling

IV antibiotics will fight off

infection that is causing erythema,
swelling, and pain

Left lateral knee still swollen and

erythematous, lab results show 9.1
WBC count

A hot or cold compress can

Patient states that the pain was a

6/10 after hot and cold compress
and went back to a 7/10

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 patient should participate in outpatient physical therapy, patient did not attend physical therapy after total knee replacement

Pastoral Care
Durable Medical Needs
F/U appts
*Med Instruction/Prescription-learn exercises
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

References
Ackley, B. (2010). Nursing Diagnosis Handbook: An Evidence-based Guide to Planning Care (9th Ed).
Maryland Heights, Missouri: Mosby.
Food Tracker. (n.d.). Retrieved November 4, 2015, from https://www.supertracker.usda.gov/foodtracker.aspx
Halter, M. (2014). Varcarolis' foundations of psychiatric mental health nursing: A clinical approach.
(7th ed., p. 23). St. Louis, Missouri: Elsevier.
Hodler, J., Schulthess, G. K., & Zollikofer, C. L. (2005). Musculoskeletal diseases: Diagnostic imaging and
interventional techniques. Milan, New York: Springer.
Reiser, M., Baur-Melnyk, A., & Glaser, C. (2008). Musculoskeletal imaging. Stuttgart, New York: Thieme.
Unbound Medicine. (2014). Nursing Central (Version 1.24 (414)) [Mobile application software]. Retrieved
from: http://nursing.unboundmedicine.com/nursingcentral