UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Bryan Trinh

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION
Patient Initials:
Gender:

R.L
Male

Assignment Date: Had patient on 6/16/15, 6/23/15,

6/30/15 and 7/7/15
Agency: VA

Age: 89

Admission Date: 12/6/13

Marital Status: Married

Primary Medical Diagnosis C3 ASIA D spinal

injury.

Primary Language: English

Reason for admission: Patient was admitted due to

a fall.

Level of Education: 2 years college

Other Medical Diagnoses: Hypertension on

admission, contracted MRSA 4/29/15
Hyponatremia 5/14/14, Hyperlipidemia 5/1/15,
Vitamin D deficiency 6/11/15
Suprapubic maceration 4/21/15

Occupation (if retired, what from?): Owner of multiple businesses such

as, Bags, and costumes. Also real estate for 35 years.
Number/ages children/siblings: 3 children and 2 brothers

Served/Veteran: US Army Air Corp

If yes: Ever deployed? No

Code Status: Full

Living Arrangements: Unable to walk. Permanent resident at the

VA. Uses motorized wheel chair to independently travel to physical
therapy or other personal places, such as, Walmart or the bank.

Advanced Directives:
Living will and I leave everything to my wife.
Surgery Date: 8/19/14 Procedure: Open
descending end transverse Colostomy
Surgery Date: 3/11/15 Procedure: Open
suprapubic cystostomy

Culture/ Ethnicity /Nationality: States Im American, white and I

believe there is a God or higher power.
Religion: I believe there is a God or a higher power. Does not
state a specific religion.

Type of Insurance: VA pays for care.

1 CHIEF COMPLAINT:
I had fallen and hit furniture and compressed my spinal cord in my neck from 2-7.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient suffers from chronic bilateral shoulder, neck, back, arms, and finger pain since admission to present date. Patient
states The pain is like sharp jabbing and I am unable to sleep on my sides at night. The pain in my arms and fingers is a
constant tingling like when your arm falls asleep but times 10. The patient also states Sleeping on my side makes it
worse. The patient states The sun makes it better and I also take Tylenol. The patient also receives topical Capsaicin

University of South Florida College of Nursing Revision September 2014

and states that physical therapy also makes the pain lessen. On admission the patient states I was barely able to move my
arms and hands. Now with physical therapy and hand exercises, I am able to brush my teeth, feed myself and use my IPad
and TV. The pain level is a constant 5/10 normally and I will have this pain for the rest of my life.
Patient has a small suprapubic maceration on the opening of his suprapubic foley catheter. He has the maceration since
4/21/15. Dressing change and cleaning promotes healing and makes it better. Continued moisture makes it worse. Nystatin
applied topically on area twice a day makes it better. Patient feels no pain from maceration.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
On admission

Operation or Illness
Hypertension: Managed nutritional status including food and fluid intake, promote physical activity,
weight management. Lisinopril 5mg daily. Under 1400 calorie diet.
Hyperlipidemia: Managed nutritional status including food and fluid intake. Interventions: prescribed
diets and teachings. Weight management, exercise promotion and nutrition monitoring.
Vitamin D deficiency. Treated with exposure to sun and improved diet.
Penicillin Allergy: Do not give this patient penicillin
Hyponatremia: Managed nutritional status including food and fluid intake. Monitor fluid and sodium
intake. Patient asks to have salt put on his food as part of his diet.
MRSA of the nares. Patient placed on contact isolation.

5/1/15
6/11/15
On admission
5/14/14
4/29/15

Father

88

Mother

88

Brother

87

Brother

72
10
3

Alive

67

Cancer

89

Old age

Grandmother
(maternal)
Grandfather
(maternal)
Grandmother
(paternal)

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Cause
of
Death
(if
applicable
)
unknown

Pulmonar
y edema
Alive

Arthritis

2
FAMILY
MEDICAL
HISTORY

Age (in years)

4/21/15

Anemia

3/11/15

Environmental
Allergies

Open descending end transverse colostomy: Change bag when 1/3 full and make sure it is placed and
sealed correctly. Make sure opening is clean and not infected.
Open suprapubic cystostomy: Make sure sterile technique is preformed when changing catheter to
avoid infection.
Suprapubic maceration: Change and clean dressing twice a day, once in the morning and evening.
Apply Nystatin when changing dressing to avoid fungal infection. Make sure to clean the wound and
thoroughly dry to avoid excess moisture.

Alcoholism

8/19/14

x
x

Old age
x

Comments: Include age of onset

Patient states My father died in the hospital but the cause was unknown. Onset of gout in his 70s
Mother had breast cancer in her 80s and suffered from dementia before death.
Brother was diagnosed with arthritis in his 60s.
Patient states Maternal grandfather died of cancer at 67 but I do not recall what kind of cancer.

University of South Florida College of Nursing Revision September 2014

 1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations Received whatever was available at the
time
Routine adult vaccinations for military or federal service Booster shots
Adult Diphtheria (Date) 4/1/03

YES
x
x
x

x
Refused
x
Refused

Adult Tetanus (Date) Is within 10 years?

Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?

x
4/8/13

Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Penicillin

NO

Type of Reaction (describe explicitly)

I havent been given penicillin since I was young.
My throat closes up. I get a big rash and I have problem breathing.

Medications

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
The patient has a blood pressure of 141/67 and can be diagnosed with stage 1 hypertension. Patients that have stage 1
hypertension have a systolic blood pressure of 140 and a diastolic blood pressure of 90 (Kee, Joyce, Evelyn Hayes, and
Linda McCuistion (2015) (633-648.) Even though the patients diastolic runs low, he is still considered hypertensive. The
exact cause of hypertension is unknown; however there are many contributing factors for hypertension, such as, family
history of hypertension, hyperlipidemia, diabetes, aging, stress, excessive alcohol ingestion, smoking and obesity.
Hypertension can also be caused by renal and endocrine disorders that cause secondary hypertension (Kee, Joyce, Evelyn
Hayes, and Linda McCuistion (2015) 633-648.) The patient is on the low side of being hypertensive and that is because he
takes Lisinopril daily. Lisinopril is a blood pressure medication that reduces blood pressure and can be given to patients
only if their blood pressure is about 110 systolic and above 50 diastolic. The patient has many factors that contribute to his
diabetes, such as, hyperlipidemia, old age (89 year old male), and obesity. He also has had a history of smoking and
excessive alcohol ingestion. All stages of hypertension are associated with increased risk of myocardial infarction, kidney
disease and stroke (Huether, S., & McCance, K. (2012) (587- 590.) Hypertension can be controlled by a variety of

University of South Florida College of Nursing Revision September 2014

medications such as, diuretics, ACE inhibitors, beta blockers, direct-acting arteriolar vasodilators, alpha blockers,
angiotensin II receptor blockers and calcium channel blockers (Kee, Joyce, Evelyn Hayes, and Linda McCuistion (2015)
(633-648.) Even with medications, it is important to maintain a healthy diet and to maintain a healthy weight. Weight loss
with a healthy diet and moderate exercise will reduce blood pressure levels and decrease the risk for developing life
threatening diseases.

5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name
Lisinopril
Route Oral

Concentration

Dosage Amount
5mg
Frequency
Daily 0900-1700

Pharmaceutical class
Home
Hospital
or
Both
ACE inhibitor
Indication
For hypertension hold if BP systolic <110 diastolic <50
Adverse/ Side effects Dizziness, fatigue, headache, weakness, cough, hypotension, chest pain, abdominal pain, diarrhea, nausea, vomiting, impaired renal
function, rashes, hyperkalemia, ANGIOEDEMA.
Nursing considerations/ Patient Teaching
Care for potassium and sodium. Do not double dose, take as prescribed, avoid driving and report adverse reactions. Hold if BP <110 systolic and <50 diastolic.
Avoid salt substitutes. Avoid alcohol and long periods of exercise that may increase orthostatic hypotension. Notify health care provider if rash, mouth sores, sore
throat, fever, swelling of the hands and feet, irregular heartbeat, chest pains, and difficulty swallowing and breathing occur.
Name
Concentration
Dosage Amount
Nystatin
Sufficient amount
Route
Frequency
Topical
BID
Pharmaceutical class
Home
Hospital
or
Both
Antifungals
Indication
Prophylaxis for fungal rash at the groins while hospitalized.
Adverse/ Side effects
Burning, itching, local hypersensitivity reactions, redness, stinging,
Nursing considerations/ Patient Teaching
Avoid eyes, wear well-fitting shoes and socks, report increase skin irritation. May stain fabric skin or hair. Therapy should be continued 2 days after symptoms
subside. Report increased irritation of mucous membranes or lack of therapeutic response to health care professional.
Name
Concentration
Dosage Amount
Gabapentin
1000mg
Route
Frequency
Oral
Q8H
Pharmaceutical class
Home
Hospital
or
Both
Anticonvulsants, mood stabilizers, analgesic adujuncts
Indication
Neuropathic pain, partial seizures, postherpetic neuralgia, anxiety,
Adverse/ Side effects
Suicidal thoughts, depression, drowsiness, dizziness, hypertension, abnormal vision, RHABDOMYOLYSIS, MULTIORGAN HYPERSENSITIVITY
REACTIONS
Nursing considerations/ Patient Teaching
Do not double dose. Take as prescribed . Take 2 hrs before any antacids. Avoid driving. Report adverse effects. Should not exceed 12 hrs between doses. Notify
healthcare provider if thoughts of suicide or dying occur or worsening depression. New worsening anxiety, feeling agitated, trouble sleeping, and dangerous
impulses should all be reported.
Name
Guaifenesin
Route

Concentration

Dosage Amount
400mg
Frequency
Q8H

Pharmaceutical class
Allergy, cold and cough remedies
Home
Expectorant
Indication
Cough associated with viral upper respiratory tract infections
Adverse/ Side effects
Dizziness, headache, nausea, diarrhea, stomach pain, vomiting, rash, urticaria
Nursing considerations/ Patient Teaching

Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Instruct the patient to cough effectively. Patient should sit upright and take several deep breaths before attempting to cough. Avoid driving and other alert
awareness activities. Advise patient to limit talking and stop smoking. Take sugar free gum or hard candy for cough. Contact health care provider if cough
persists more than a week and is accompanied by fever rash or headache and sore throat.
Name
Concentration
Dosage Amount
Docusate
200mg
Route
Frequency
Oral
BID
Pharmaceutical class
Home
Hospital
or
Both
Stool softener
Indication
Prevention of constipation
Adverse/ Side effects
Throat irritation, mild cramps, diarrhea, rashes
Nursing considerations/ Patient Teaching
Use for a short period of time to avoid dependence. Encourage patients to use other forms of bowel regulation, such as increase fluids and bulk in diet. Advise
patients not to use laxatives when abdominal pain, nausea, vomiting, or fever is present. Do not take docusate within 2 hrs of other laxatives.
Name
Concentration
Dosage Amount
Ascorbic acid
500mg
Route
Frequency
Oral
BID
Pharmaceutical class
Home
Hospital
or
Both
Vitamins
Indication
Maintain acidic urine. Treatment and prevention of vitamin C deficiency (scurvy) with dietary supplementation. Supplemetal therapy in some GI diseases.
Adverse/ Side effects
Drowsiness, fatigue, headache, insomnia, cramps, diarrhea, heartburn, nausea, vomiting, kidney stones, flushing.
Nursing considerations/ Patient Teaching
Take as prescribed. If dose is missed skip dose and return to dose schedule. Maintain a well balanced diet that consists of foods high in ascorbic acid such as
citrus fruits, tomatoes, strawberries and cantaloupe.
Name
Concentration
Dosage Amount
Capsaicin
Small amount 0.075%
Route
Frequency
Topical
Daily 1630-2230
Pharmaceutical class
Home
Hospital
or
Both
Non opioid analgesics
Indication
Treatment of pain associated with postherpetic neuralgia
Adverse/ Side effects
Cough and pain or transient burning . Increase blood pressure
Nursing considerations/ Patient Teaching
Instruct patient on the correct method for application. Cream should be rubbed in until no cream shows. Gloves should be worn during application or hands
should be washed immediately after application. Avoid eyes and notify provider if pain persists longer than a month or worsens. Or if signs of infection are
present.
Name
Concentration
Dosage Amount
Omeprazole
20mg
Route
Frequency
Oral
Daily
Pharmaceutical class
Home
Hospital
or
Both
Proton pump inhibitor
Indication
GERD/maintenance of healing in erosive esophagitis
Adverse/ Side effects
Dizziness, drowsiness, fatigue, chest pain, weakness and PSEUDOMEMBRANOUS COLITIS
Nursing considerations/ Patient Teaching
Take as prescribed. Do not double dose. Do not consume with alcohol. Notify the health care provider if there is blood in stool. Report tarry stool.
Name
Simvastatin
Route

Concentration

Dosage Amount
40mg
Frequency
Daily 2100

Pharmaceutical class
Home
Hospital
or
Both
HMG COA reductive inhibitors
Indication
For patients hyperlipidemia. Adjunctive management of primary hypercholesterolemia and mixed dyslipidemias.
Adverse/ Side effects
Amnesia, confusion, dizziness, headache, insomnia, weakness, abdominal cramps, constipation, diarrhea, nausea and RHABDOMYOLYSIS.
Nursing considerations/ Patient Teaching
Do not double dose. Avoid grapefruit juice. Do not drink alcohol. Take at night. Take as prescribed.

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Patient states he consumes
Analysis of home diet (Compare to My Plate and
<1430 calories
Diet patient follows at home? Regular and hospital is
considered patients home because he is a permanent
resident.
24 HR average home diet:
Breakfast: No breakfast unless on weekends, which
consists of raisin brand with 1% milk. On week days does
not eat breakfast but saves it for lunch.

Consider co-morbidities and cultural considerations):

Patient needs to remain sodium levels and watch fluid
intake. Patient should increase intake of vitamin D rich
foods.
Cup of raisin brand contains 1g fat 5g protein 47g
carbohydrates 230mg sodium and 190 calories 19g sugar
1 cup 1% milk contains 2g fat 8g protein 12g carbohydrates
100mg sodium 13g sugar and 100 calories.

Lunch: Omelet containing cheese and onions with a

sausage patty with V8 vegetable juice. Adds packet of salt
and pepper on food. I need salt in my diet.

Omelet contains 2 eggs with cheese and onion.

1 egg consists of 5g of fat, 6g of protein, 0.6g
carbohydrates and 78 calories and 62mg sodium.
A serving of low fat cheese consists of 4.5g of fat 8g of
protein <1g carbohydrates 180mg sodium 70 calories
Sausage patty contains 9g of fat 5g of protein 1g
carbohydrates 220mg sodium and 100 calories.
V8 vegetable juice contains 0g fats 2g proteins 10g
carbohydrates 640mg of sodium and 6g sugar and 50
calories in a 8 oz can.
Salt packet added to food contains 300mg sodium

Dinner: a sandwich containing ham, cheese, mayo,

pickle and a cup of soup. The soup recorded was lobster
bisque.

ham and cheese sandwich with mayo contains 8g fat, 10g

protein, 16g carbohydrates 400mg sodium, and 175
calories.
A cup of lobster bisque contains 13g fat, 20g protein, 13g
carbohydrates, 850mg sodium, 10g sugar and 250 calories.

Snacks: 2 fruit cups and banana. Banana usually consumed

at night.

1 fresh fruit cup contains on average 0 fats, 1g protein, 19g

carbohydrates, 15mg sodium, 9g sugars and 70 calories.
Banana contains 0 fats, 1g protein, 27g carbohydrates, 1mg
sodium, 14g sugar, 420mg potassium.

Liquids (include alcohol): Water and V8 juice no alcohol

When compared to MyPlate.gov it can be seen that the

patient is consuming the correct amount of calories he
needs for his diet which is under 1430 calories as stated by
the patient.
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as a reference.

1304 Calories

Total Eaten:
Breakfast 0 Calories
EMPTY
Lunch 409 Calories
Omelet (milk added), with cheese, cooked with nonstick spray
2 large egg(s)
271 Calories
(101 Empty Calories)
My Favorite Remove Edit

University of South Florida College of Nursing Revision September 2014

Sausage, pork, cooked

1 patty
92 Calories
(48 Empty Calories)
My Favorite Remove Edit
Tomato and vegetable juice (V8)
8 fluid ounce(s)
46 Calories
(0 Empty Calories)
My Favorite Remove Edit
Dinner 605 Calories
Ham and cheese submarine sandwich, with lettuce, tomato and
mayonnaise
submarine sandwich
357 Calories
(102 Empty Calories)
My Favorite Remove Edit
Lobster bisque
1 cup
248 Calories
(99 Empty Calories)
My Favorite Remove Edit
Snacks 291 Calories
Fruit salad, fresh, (including citrus fruits), no dressing
2 cup
186 Calories
(0 Empty Calories
(these are prompts designed to help guide your discussion)

1 COPING ASSESSMENT/SUPPORT SYSTEM:

Who helps you when you are ill? The nurses help me when I am ill.

How do you generally cope with stress? or What do you do when you are upset?
I handle the situation and put it in the past and not carry it with me. When I am upset, I make the best of it and go make
peoples lives better.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient reports no recent difficulties. When asked the patient reports No, Im a very positive person.

+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? When I was a
kid, my mother took my grandpas leather belt to my ass. ______________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_________________Emotionally, Yes._________________________ If yes, have you sought help for this? __No, it
was a broken heart in my younger days.____________________

University of South Florida College of Nursing Revision September 2014

Are you currently in a safe relationship? Yes, my wife has been phenomenal.

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 x Ego Integrity vs. x 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: Stage 8: Ego Integrity Versus Despair (Over 65 years)
This is the stage of life where acceptance of ones life, worth and eventual death is realized. Ego integrity is a reflection of satisfaction
with ones life and understanding of their life in the life cycle. Despair can be felt from the sense of loss and discomfort with life and
aging and fear of the death. (Treas, L., & Wilkinson, J. (2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

According to Eriksons stages, my patient falls into the Ego integrity versus Despair stage due to his age (89). My patient
exhibits Ego integrity but not despair. He has accepted everything that has happened in his life and even calls his paralysis
Just another stubbly block in the path of life. He realizes he has lived a good and fulfilling life. He is also states I
believe there is a date for everyone, so you dont have to fear death. With this quote, I feel my patient does not fear death
nor feels despair with the thought of aging and dying.

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

As stated earlier my patient believes that his paralysis is Just another stubbly block in the path of life. And that he goes
about living every day of his life the best he can. He also believes that There is no point of being depressed and upset all
the time. If situations occur that bother me, I like to talk them out and come to an understanding to solve problems.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
This is not an illness, it was caused by a fall, causing paralysis.
It was just an accident that could have been avoided. Patient states I was having my usual vodka martini during the
day, but I forgot I had taken my antibiotics. When I stood up I blacked out and ended up falling and hitting my head on
furniture.

What does your illness mean to you?

Patient does not like the word illness, so I asked him what does your paralysis mean to you?
Just another stubbly block in the path of life.

+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 to an
extent___________________________________________________________________
Do you prefer women, men or both genders?
__Women___________________________________________________________
Are you aware of ever having a sexually transmitted infection? _____Gonorrhea many years ago in my

University of South Florida College of Nursing Revision September 2014

20s__________________________________________
Have you or a partner ever had an abnormal pap smear?
_________No____________________________________________ Have you or your partner received the Gardasil
(HPV) vaccination? __________________No_________________________
Are you currently sexually active? ___________No________________ If yes, are you in a monogamous relationship?
______Still in a monogamous relationship with out sex______________ When sexually active, what measures do you
take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? ______________Condoms but not
sexually active.____________________
How long have you been with your current partner?_______________30 years
married_________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _______Yes tetraplegic
incomplete.____________________
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 September 2014

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

What importance does religion or spirituality have in your life?
_At this time a minor importance. Im not looking for God to help me because he who needs help, helps
himself.____________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_I believe there is a date for everyone, so you dont have to fear death. I am very practical and
realistic.____________________________________________________________________________________________________
_
______________________________________________________________________________________________________

+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)
Cigars, Cigarettes
Recreational cigars
5 a day.

Yes
No
For how many years? 4 years
(age 26

thru

30

If applicable, when did the

patient quit? 60 years ago from
cigarettes.

Pack Years: 1

Does anyone in the patients household smoke tobacco? If

so, what, and how much?

Has the patient ever tried to quit?

If yes, what did they use to try to quit? Yes, cold turkey.
Had a very strong desire to quit.

Father for many years until mid 50s.

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Everything including moonshine. How much? Patient does not know
Volume: Big vodka martini daily.
Frequency: Daily
If applicable, when did the patient quit?
The day I had my fall.

For how many years?

(age 35

thru

86

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much? Couldve bought
Marijuana, Cocaine, LSD, Crack, Shrooms
For how many years?
20 new cars.
(age

Is the patient currently using these drugs?

Yes No

55

thru

86

If not, when did he/she quit? 86

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Always at risk in a hospital.
5. For Veterans: Have you had any kind of service related exposure? No.

University of South Florida College of Nursing Revision September 2014

10

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health? Other than my paralysis, Im very healthy.

Integumentary: The only change in appearance of skin is due to the maceration on the opening of the patients
suprapubic foley catheter. Patient shows no signs of dandruff, psoriasis, hives or rashes and no skin infections.
The patient does not use sunscreen and showers twice a week. Patients genitals and face are cleaned daily.
HEENT: The patient wears glasses but reports no difficulty seeing while wearing glasses. Patient does not have
cataracts or glaucoma. Patient has no signs of ear infections or difficulty hearing. Patient reports no sinus pain or
infections, and reports so signs of post-nasal drip. Patient has no oral/pharyngeal infection or dental problems.
Patient brushes his teeth once a day and visits the dentist As often as necessary. Patient receives a vision
screening Once every few years. I have retained the same eye sight for years.
Pulmonary: Patient reports no difficulty breathing or cough. Patient does not have asthma, bronchitis,
emphysema, pneumonia, tuberculosis or any environmental allergies. Patients last CXR was in March 2015
Cardiovascular: Patient does have hypertension and hyperlipidemia. Patient reports no chest pain/angina. Patient
has not had a myocardial infarction. Patient does not have CAD/PVD or CHF. No reports of murmurs or
thrombus. Patient does not have rheumatic fever, myocarditis or arrhythmias. Last EKG screening was in
January 2015
GI: Patient reports no nausea, vomiting, constipation or diarrhea. Patient does not have GERD, indigestion,
hemorrhoids, jaundice, pancreatitis, colitis, diverticulitis, appendicitis, abdominal abscess or irritable bowel. The
patient does not have cholecystitis, ulcers, blood in stool or hepatitis. Patient has an open descending end
transverse colostomy since 8/19/14
GU: Patient does not experience nocturia, dysuria, hematuria, polyuria or have kidney stones. Reports no
bladder or kidney infections. Patient has a suprapubic catheter and has normal urination at 30mL/hr
Women/Men Only: Patient reports no infection of male genitalia/prostate. Patients last prostate exam was ten
years ago. Patient does not have BPH or urinary retention.
Musculoskeletal: Patient is a tetraplegic incomplete. C3 ASIA D. Patient has weakness in lower extremities and
chronic pain due to injury at a rating of 5/10. Patient does not have gout, osteomyelitis, or arthritis.
Immunologic: Patient does not have chills or severe shaking. Patient does not have night sweats or fever. Patient
does not have HIV/AIDS, lupus, rheumatoid arthritis, or sarcoidosis. Patient has no tumors or enlarged lymph
nodes. Patient is allergic to penicillin.
Hematologic/Oncologic: Patient does not have anemia. Patient does not bleed or bruise easily. Patient does not
have cancer or has had any blood transfusions. Patient blood type is A positive.
Metabolic/Endocrine: Patient does not have diabetes. Patient does not have hypothyroid/hyperthyroidism.
Patient is not intolerant to hot or cold. Patient does not have osteoporosis.
Central Nervous System: Patient has not had CVA. Patient does not experience dizziness or severe headaches
and migraines. Patient has not experienced seizures, ticks or tremors, encephalitis or meningitis.
Mental Illness: Patient does not have depression, schizophrenia, anxiety, or is bipolar.
Childhood Diseases: Patient has not had measles, mumps, polio or scarlet fever. Patient has had chicken pox

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 September 2014

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10 PHYSICAL EXAMINATION:
General survey __Patient is a 89 year old male who is alert and orient X3. He shows no signs of distress or trouble
breathing. He is an incomplete tetraplegic and is able to control his arms but not his legs. He does have sensation
throughout his body.___________________________________________________________________________________
Height ______5ft 8in______Weight____199.7lb______ BMI ____30.43_______ Pain (include rating and
location)_______5/10 chronic pain bilaterally in shoulders neck back arms and hands____________ Pulse____67___
Blood Pressure (include location)_________141/67____________Temperature (route taken)_____97.8 Oral_______
Respirations______16______ SpO2 ______97___________ Room Air or O2_______Room air________________
Overall Appearance
Patient is an incomplete tetraplegic. Has thin gray hair and tan skin. No signs of lesions or tears in skin. Alert and
orient X3, maintains eye contact and conversation. No odor and is very
cooperative._______________________________________________________________________________
Overall Behavior
Patient is awake, relaxed, and interacts well with nurses and his roommate. Patient engages in active conversation
and is very cheerful. _______________________________________________________________________________
Speech
Patients speech is clear and crisp. Patient speaks in complete sentences, and correct grammar. Patient is also very
respectful. _________________________________________________________________________________________
Mood and Affect
Patient is pleasant, cooperative, cheerful and talkative. When the patient wants something corrected; he politely
states how he likes it done and politely and respectfully explains it to the nurse or student taking care of him. For
example, how to put on his sucks correctly and how he likes his bedside table set up.
__________________________________________________________________________________
Integumentary
Patients skin is warm, dry and intact. The patient is well hydrated and skin turgor is elastic. Nails have no clubbing
stating the patient is not hypoxic and the capillary refill is less than 3 seconds. Hair is clean and evenly distributed.
Patient does have maceration around suprapubic catheter opening. The bandage needs to be changed twice a day. It
shows that it has been healing and shows no signs of further infection. Color is clear with minimum blood and
purulent fluid, no odor and it is consistently clear with a small amount. Nurse noted it is healing very well.
__________________________________________________________________________________
IV Access
The patient has no IV site
_______________________________________________________________________________________
HEENT
The patients facial features are symmetric and reports no pain in sinus region, No pain or clicking of TMJ. The
trachea is midline and the thyroid is not enlarged. There are no palpable lymp nodes and the patients sclera is white
with no signs of discharge from the conjunctiva. The patients eyebrows, eyelids, orbital area, eyelashes, and
lacrimal glands are symmetrical and with out edema or tenderness. The patient pupils are equal round and reactive
to light and accommodate bilaterally. Patients EOM intact through 6 cardinal fields without nystagmus. Patients
ears are symmetrical without lesions or discharge. Whisper test in both ears is roughly 18 in. Patients nose has no
lesions or discharge. Lips are not cracked and buccal mucosa, floor of mouth, and tongue are pink and moist and
absent of lesions.
__________________________________________________________________________________________
Pulmonary/Thorax
The patient has regular and unlabored respirations. Patient has a normal transverse to AP ratio of 2:1 and chest
expansion is symmetrical. Percussion resonant throughout all lung fields and dull towards posterior bases. The
patient produces no sputum. Lung sounds in all five quadrants are clear.
________________________________________________________________________________
Cardiovascular
The patient has no lifts, heaves, or thrills and heart sounds are regular with no signs of murmurs or adventitious
heart sounds. Patient reports negative calf pain bilaterally. The patients apical pulse is normal. Carotid pulse is
normal. Brachial pulse is normal. Radial pulse is normal. Femoral pulse is normal. Popliteal pulse is normal.
Dorsalis pedis pulse is normal and posterior tibialis pulse is normal. No signs of temporal or carotid bruits and no

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signs of edema. Extremities are warm with capillary refill less than 3
seconds.____________________________________________________________________________________
GI
Bowl sounds active X4 quadrants, no bruits auscultated, no organomegaly. Percussion is dull over liver and spleen
and tympanic over stomach and intestine and patient reports no tenderness. Patient has a open descending end
transverse colostomy. Stool is soft medium brown. Patient does not report any nausea or emesis. Patients genitalia
are clean without any discharge or
lesions._____________________________________________________________________________________________
GU
Patient has a suprapubic foley catheter. There is a slight maceration on the opening that is the nurse has reported as
healing. The bandage over the wound needs to be changed twice a day. Urine in the foley is clear and yellow.
Previous recorded urine output was 900mL
_______________________________________________________________________________________________
Musculoskeletal The patients strength bilaterally in a 5 against full resistance in his upper extremities. Patients
lower extremities are rated a 2 bilaterally. Patient does not have kyphosis or scoliosis. Patient is an incomplete
tetraplegic and has chronic pain of 5/10 due to C3 spinal injury but does not show signs of pallor.
_____________________________________________________________________________________
Neurological Patient is a wake alert, oriented to person, place, time and date. The patient is not confused and is able
to communicate easily. The patient is unable to stand due to spinal injury and cannot perform standing tests such as
Rombergs and does not have DTR due to spinal injury.

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
7.33

Dates
2/19/15

9.69

3/14/15

7.78

4/8/15

Normal (3.90 9.90)

IMM GRAN #
0.04

Trend
The patients white blood
cell count was the highest
in March and then
showed a decrease trend
into April. Even though
both levels are within
normal range, the sudden
spike in WBC from
February can indicate an
acute infection or
inflammatory response.
The IMM GRAN #
spikes to a high of 0.08 in
April from a normal
value of 0.04 in March,
but then decreases into
June with a normal value
of 0.02.

Analysis
The sudden spike in
WBC from February to
March indicates a
possible infection or
inflammation. As seen
after March in April the
WBC count drops within
normal range.

As stated within the lab

3/14/15
results Immature
granulocytes include
0.08 H
4/8/15
neutrophilic
metamyelocytes,
0.02
6/3/15
myelocytes, and
promyelocytes. Increased
Normal (0.00 0.05)
values are associated with
acute infection,
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Glucose
82

2/26/15

117 H

3/9/15

101

3/14/15

89

6/3/15

Normal (65 110)

Sodium
131 L

2/19/15

133 L

2/26/15

132 L

3/9/15

131 L

3/14/15

132 L

6/3/15

Normal (136 145)

The patients glucose

levels spike from
February into the
beginning of March. The
glucose level then
dramatically decrease
five days later. I assume
the high level was
documented and the
patients diet was
changed accordingly. It
can be seen that the
patient has been
maintaining a healthy
glucose level diet through
June.

There is a consistant low

sodium serum
concentration trend from
the February to June.

inflammatory responses.
The IMM GRAN #
results indicate a possible
infection could have
occurred between March
and April. WBC in March
further supports this
claim. Patient was also
diagnosed with MRSA of
the nares during the
month of April, which
could have had an
increase effect on the
IMM GRAN#
The American Diabetes
Association (ADA)
defines impaired fasting
glucose (IFG) as 100-125
mg/dL. Individuals with
levels of 100- 125 mg/dL
are at increased risk for
type II diabetes.
According to the patients
lab results, the patient
was at risk for type II
diabetes in the month of
March, but the lab results
were noticed and
interventions were made
to lower the IFG.
According to the lab
results the interventions
worked and the patient
has maintained a healthy
level since.
According to the results
the patients sodium
levels are slightly lower
than normal. The patient
shows no signs of
hyponatremia and tries to
maintain a steady sodium
level in his diet. Since the
trend has lasted the past
few months with no ill
effects, the low sodium
level could be the base for
this particular patient. As
long as the patient keeps a
steady sodium intake,

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there should not be any

signs of hyponatremia.
Watching fluid intake
levels can increase
sodium serum levels.

Vitamin D (25HYDROXY)
6/3/15

The lab result is only

shown for the month of
June.

22.6 L
Normal (30.0 100.0)

HEMOGLOBIN A1C
6/3/15
5.2
Normal (4.4 6.0)

Hemoglobin A1C has

only been taken recently
and the 5.2 result falls
within the normal range
of 4.4 6.0

According to the lab

results a lower than
normal 25-OH vitamin D
level can result from a
dietary deficiency, poor
absorption of vitamin or
impaired metabolism of
the sterol in the liver.
Deficiency can lead to
bone diseases such as
rickets, osteomalacia, and
osteoporosis. Exposure to
sunlight and dietary
supplementation can
increase vitamin D levels
along with vitamin D rich
food.
The current American
Association of Diabetes
(ADA) guidelines note
A1C > 6.5 is diagnostic
of diabetes mellitus. A1C
of 5.7 to 6.4 indicates
high risk of future
development of diabetes.
The patient falls below
both ranges, which
indicates he is not at risk
for developing diabetes.
As long as the patient
maintains his current diet
he will not develop
diabetes

+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 usually wakes up at 0900 for perineal care. Since the patient has maceration at the opening of his
suprapubic foley catheter, the dressing must be changed once in the morning and once at night. Color, odor,
consistency and amount should be documented for each dressing change. The patient face and under arms are
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also cleaned. The patient is then transported to his motorized wheelchair where he is then dressed. He then takes
his medication and brushes his teeth and hair. This all must be done before by 1000 when he then goes to physical
therapy. The patient returns from physical therapy at about 1300 where he then takes his medication and
consumes his lunch which is usually his breakfast he saved for that day. After lunch the patient performs hand
strengthening exercises and interacts with fellow patients. He may also run errands and usually goes outside to
receive sunlight to increase his vitamin D level. The patient takes medication at 1700 along with dinner then is
put back into bed by 1830. The patients dressing is then changed again.

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

1.

Wound Infection, Impaired tissue integrity r/t wound, presence of infection

2.

Chronic Pain, r/t spinal injury of C3, numbness and tingling type pain in upper extremities, back and neck

3. Blood pressure alteration, High blood pressure r/t hypertension

4. Nutrition, Imbalanced: Less than body requirements r/t vitamin D deficiency

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 15 CARE PLAN
Nursing Diagnosis: Wound Infection: Impaired tissue r/t wound, presence of infection
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
(Short term/long term goal)
Providing perineal care twice a day. Providing perineal care twice a day The goal was met each time for the
Prevent further infection of
Once before the patient gets out of will keep surrounding area of
day. Perineal care and dressing
maceration
bed or in the morning and once
wound clean and prevent infection. change of maceration was
before bed.
performed at 0900. Assessment of
wound and dressing was
documented and nystatin was
applied. Nurse states that second
dressing change was done at 1800
when the patient was put into bed.
Wound and dressing was
documented and nystatin was
applied.
(Short term/long term goal)
The dressing for the maceration
Changing of the dressing twice a
The following week assessment of
Promote wound healing
should be changed twice a day.
day allows the nurse to witness
the maceration showed great
Once in the morning before the
changes in the wound throughout
improvement stated by the nurse.
patient gets out of bed and once at
the day. It also allows the wound to Excess fluid from the wound was
night before the patient goes to
be cleaned promoting healing.
very minimal and clear without
bed.
Cleaning, drying and changing the signs of blood. Wound nearly
dressing also prevents further
healed and skin integrity was
impaired tissue integrity due to
nearly repaired. Evaluation proved
fluid excess (Ackley, B., &
goals have been met daily and
Ladwig, G. (2011). (841-843.)
goals for prevention of further
infection of wound and promotion
of wound care have been met. Long
term goal to prevent reoccurrence
of impaired skin integrity has been
met and skill continues.
(Long term goal) Prevent
The dressing should be checked for Checking the dressing for color,
reoccurrence of impaired skin
color, odor, consistency and
odor, consistency and amount
integrity and infection.
amount each time the dressing is
allows the health care provider
changed.
determine if the wound is healing
Patient Goals/Outcomes

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or getting worse. (Ackley, B., &

Ladwig, G. (2011). (841-843.)
Assessment of the wound should
Monitoring the site of impaired
be noted each time the dressing is
tissue integrity must be
changed.
documented to determine if the
wound is healing or getting worse
(Ackley, B., & Ladwig, G. (2011).
(841- 843).
The wound and surrounding area
Monitoring the status of the skin
should be thoroughly cleaned and
around the wound and minimizing
dried before a new dressing is
exposure of the skin impairment
placed.
site to areas of moisture or wound
drainage prevents further impaired
skin integrity (Ackley, B., &
Ladwig, G. (2011).( 841-843).
Nystatin should be applied on dry
Nystatin is used for treatment of a
skin around the wound and perineal variety of cutaneous fungal
area after area has been cleaned.
infections and to decrease
Nystatin is applied twice a day
symptoms of fungal infection
after wound and perineal area is
(Nystatin. Nursing Central 2015.)
clean and dry. Pat and spread
Keeping the skin clean and dry
Nystatin to avoid clumping.
prevents fungal growth and further
impaired skin integrity due to fluid
excess. Moisture also causes the
topical nystatin to clump, hindering
its efficiency.
The nurse will teach the patient to
If the patient reports to the nurse of
report any symptoms of infection;
any symptoms of infection, the
such as pain, redness, discharge
nurse can assess the situation and
and increased body temperature.
implicate further actions to treat the
patient. Fever is usually the first
sign of infection.

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: Patient is a permanent resident and views the hospital as his home. If patient was to leave the hospital, he
would need help with bathing and suprapubic catheter care. The patient will also need assistance getting into his motorized wheelchair. The
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patient will also need full body assessments to determine if there is impaired skin integrity. Daily care plan for impaired skin integrity*.
Medications would have to be given as prescribed and transportation to physical therapy will need to be provided. Even though patient
reports understanding of diet and physical activity; Diet will still need to be monitored to maintain blood pressure and overall health. The
patient requires assistance a hospital can provide at all times and that is primarily a reason the patient is a long term care resident.
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

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References

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Ackley, B., & Ladwig, G. (2011). Tissue Integrity, Impaired. In Nursing Diagnosis Handbook (9th ed., pp. 841- 843). St. Louis, Missouri: Mosby
Elsevier.

Huether, S., & McCance, K. (2012). Alterations of Cardiac Function. In Understanding Pathophysiology (5th ed., pp. 587- 590). St. Louis, Missouri:
Elsevier Saunders.

Hypertension and Elevated Blood Pressure, Treatment. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved July 13,
2015. Retrieved from.
http://nursing.unboundmedicine.com/nursingcentral/ub/

Nystatin. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved July 13, 2015. Retrieved from.
http://nursing.unboundmedicine.com/nursingcentral/ub/

Kee, Joyce, Evelyn Hayes, and Linda McCuistion. "Antihypertensive." Pharmacology A Patient-Centered Nursing Process Approach. 8th ed. St.
Louis: Elsevier Saunders, 2015. 633-648. Print.

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Treas, L., & Wilkinson, J. (2014). Development: Infancy Through Middle Age. In Basic Nursing Concepts, Skills and Reasoning (164-165).
Philadelphia, PA: F.A. Davis Company.

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