UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Jennifer Carter

Assignment Date: July 19, 2016
.
Agency:
1 PATIENT INFORMATION
Patient Initials: LSW Age: 53 Admission Date: July 17, 2016
Gender: Female Marital Status: Married Primary Medical Diagnosis End Stage Renal
Disease
Primary Language: English
Level of Education: Tenth grade Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?):N/A; house wife Reflux nephropathy, pulmonary embolism,
Number/ages children/siblings: 2 children, ages 35, 34, 31

Served/Veteran: Code Status: Full

If yes: Ever deployed? Yes or No
Living Arrangements: Lives with husband Advanced Directives: NO
If no, do they want to fill them out?
Surgery Date: Procedure:
Culture/ Ethnicity /Nationality: Irish
Religion: Christianity Type of Insurance: Medicare and UMR

1 CHIEF COMPLAINT: Unable to use dialysis fistula

3 HISTORY OF PRESENT ILLNESS:
Ms. Weatherford is a 53 year old female with past medical history of End Stage Renal Disease on home dialysis five
times a week and history and history of difficulty cannulating graft during home dialysis. She was recently admitted and
discharged after being evaluated by vascular surgery and IR was consulted for suspected thrombosed graft. She underwent
fistulogram with thrombectomy and received dialysis post procedure. Although her potassium and hemodialysis was
high, she was adamant about being discharged. She agreed to perform home dialysis immediately upon discharge.
Unfortunately, home dialysis was not possible and she returned.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
N.D. Anemia
10/2013 Blood transfusion
2007 Colon cancer; 18 cm sigmoid colon resection with colostomy then reversal
1975 Duodenal ulcer; perforated
ND ESRD; hemodialysis at home 5 to 6 days per week; renal diet
ND Methicillin Susceptible staphylococcus Aureus
ND Pulmonary Embolism; life long anticoagulant: warfarin( Coumadin) 5 mg PO daily
ND Thyroid disease
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 ND Tourettes Syndrome

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause

Alcoholism
MEDICAL

Glaucoma

Problems

Problems
Allergies
of

Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY

Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father X X
Mother X
Brother X
Sister X
relationship

relationship

relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations X
Routine adult vaccinations for military or federal service X
Adult Diphtheria (Date) X
Adult Tetanus (Date) Is within 10 years? X
Influenza (flu) (Date) Is within 1 years? X
Pneumococcal (pneumonia) (Date) Is within 5 years? X
Have you had any other vaccines given for international travel or
occupational purposes? Please List X
If yes: give date, can state U for the patient not knowing date received

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Penicillin Anaphylactic shock

Medications

N/A N/A
Other (food, tape,
latex, dye, etc.)

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 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)
End Stage Renal Disease, also termed chronic renal failure, is the progressive loss of kidney function. This disease is
characterized by a declining glomerular filtration rate and tubular function with changes that manifest throughout the
entire organ system (Huether & McCance, 2012). Factors contributing to the progression of the disease involve the
interaction of many cells, cytokines, and structural alterations. These factors include proteinuria, progressive destruction
of nephrons, and increased angiotensin II activity, glomerular hypertension, hyperfiltration, hypertrophy, and
glomerulosclerosis (Huether & McCance, 2012). Angiotensin II, a systemic vasoconstrictor, leads to glomerular
hypertension and hyperfiltration, thus stimulating high intraglomerular pressure and the presence of protein in the urine.
The presence of protein in the urine enhances tubular injury and consequently causes the release of macrophages that
promote inflammation and fibrosis (Huether & McCance, 2012). Chronic renal failure can be diagnosed in a number of
ways including: lab results showing elevated creatinine, urea nitrogen, ultrasound, CT scans or X-rays that illustrate a
small kidney, or a renal biopsy (Huether & McCance). Unfortunately, there is not a cure for chronic kidney failure.
However, individuals with this disease may seek dialysis, a renal diet, or a kidney transplant. Along with the mentioned
treatments methods, individuals may seek restricting protein and phosphate, vitamin D supplementation, sodium and fluid
maintenance, adequate caloric intake, management of dyslipidemia, and use of erythropoietin (Huether & McCance,
2012).

5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name: Acetaminophen Concentration n/a Dosage Amount 650 mg

Route oral Frequency every six hours

Pharmaceutical class: Analgesic Home Hospital or Both
Indication: mild pain (pain score 1-3)
Adverse/ Side effects: Hepatoxicity, hypersensitivity, skin reactions
Nursing considerations/ Patient Teaching: avoid alcohol

Name albumin human Concentration 25% solution Dosage Amount 12.5 g

Route Intravenous Frequency as needed

Pharmaceutical class: plasma substitutes Home Hospital or Both
Indication: hypovolemia
Adverse/ Side effects: anaphylactoid reactions, fever, chills, nausea, vomiting
Nursing considerations/ Patient Teaching: Nurse should inspect dosage for turbidity and discoloration; the solution should not be diluted with sterile water for
injection.

Name: warfarin (Coumadin) Concentration Dosage Amount: 5 mg

Route: oral Frequency: daily

Pharmaceutical class: anticoagulant Home Hospital or Both
Indication: to prevent blood clotting
Adverse/ Side effects: anorexia, nausea, vomiting, hemorrhage
Nursing considerations/ Patient Teaching: Teach patient the signs of bleeding; advise the patient to avoid smoking because it increases drug metabolism; As a
nurse, monitor INR.

Name: tramadol (Ultram) Concentration Dosage Amount: 50 mg

Route: oral Frequency: every 8 hour
Pharmaceutical class: opioid Home Hospital or Both
Indication: moderate pain (pain 4-6)

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Adverse/ Side effects: nausea, vomiting, constipation, urinary retention, respiratory depression
Nursing considerations/ Patient Teaching: Teach the patient not to use alcohol or CNS depressants, check patient for dependence, record patients intake and
output

Name: ferric citrate (Auryxia) Concentration Dosage Amount 210 mg

Route: oral Frequency: 3 times a day

Pharmaceutical class: Phosphate binder Home Hospital or Both
Indication: control serum phosphorus levels in patients with kidney disease
Adverse/ Side effects: diarrhea, nausea, constipation, vomiting, cough
Nursing considerations/ Patient Teaching: take with meals

Name: alprazolam (Xanax) Concentration Dosage Amount: 0.25 mg

Route: oral Frequency: two times daily

Pharmaceutical class: Benzodiazepine Home Hospital or Both
Indication: anxiety
Adverse/ Side effects: lethargy, drowsiness, headache, constipation, decreased libido, depression, impaired coordination
Nursing considerations/ Patient Teaching: Encourage patient to avoid alcohol, antidepressants, antipsychotics, and opioid drugs; advise patient not to drive a
motor vehicle or operate machinery; monitor vital signs, especially respirations and blood pressure, use bed alarm for older patients or patients receiving the
first dose.

Name: sodium bicarbonate Concentration: 1 mEq/mL Dosage Amount: 50 mEq

Route: Intraveous Frequency: once

Pharmaceutical class: antacid, antiulcer drug Home Hospital or Both
Indication: hyperkalemia
Adverse/ Side effects: hypernatremia, water retention, metabolic alkalosis, acid rebound
Nursing considerations/ Patient Teaching: Encourage a patient to drink 2 ounces of water after use; advise patient to notify provider of any pain, diarrhea,
constipation; monitor electrolytes, urinary pH, calcium, and phosphate levels.

Name: heparin Concentration Dosage Amount

Route: Intravenous Frequency

Pharmaceutical class: anticoagulant Home Hospital or Both
Indication: prevent blood clot formation
Adverse/ Side effects: itching, burning, bleeding, hematuria, angioedema, osteoporosis, heparin- induced thrombocytopenia
Nursing considerations/ Patient Teaching: Advise patient to use a soft tooth brush to prevent bleeding gums, monitor pT; encourage patient not to smoke; check
stools for bleeding, check for petechiae.

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Renal Diet Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Renal Diet Consider co-morbidities and cultural considerations):
24 HR average home diet: Based on the 24 hour average home diet, Ms. Weatherford
is following a diet that is therapeutic and conducive.
However, Ms. Weatherford enjoys bananas with her
breakfast despite being aware that they are high in
potassium.
Breakfast: Banana, English muffin with grape jelly, glass of
water, cream of wheat

Lunch: turkey sandwich with mayonnaise, yogurt

Dinner: salmon and broccoli or spinach

Snacks: unsalted popcorn

Liquids (include alcohol): water, apple juice, coffee ,

cranberry juice

Use this link for the nutritional analysis by comparing the

patients 24 HR average home diet to the recommended portions,
and use My Plate as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Patient uses a therapist to cope with symptoms of post traumatic stress disorder. Along with the support of the therapist,
the patient relies on her eldest daughter and husband for emotional support and help with her illnesses.

+2 DOMESTIC VIOLENCE ASSESSMENT

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? N/A

Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: X Generativity vs. Self absorption/Stagnation

Generativity: the desire and motivation to guide the next generation (Treas & Wilkinson, 2014).
Ms. Weatherford is in the generativity stage. Generativity refers to being productive and making your mark; and she does

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not allow her illness to keep her stagnant. She states that she is active in her grandchildrens lives, and refuses to miss
family events and outings.
I believe Ms. Weatherfords disease and hospitalization does not hinder her developmental stage. She uses her faith as
reassurance and motivation to continue to live life to her fullest.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?: Patient states the cause of her illness is a congenital urinary tract defect.
She is unsure of the exact name.

What does your illness mean to you?: Patient states that her illness is of natural causes. There is good and bad in this
world. I guess this is just some of the bad.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
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? No
Are you currently sexually active? Patient states to be somewhat sexually active, but not since hospitalization.
If yes, are you in a monogamous relationship? Yes When sexually active, what measures do you take to prevent acquiring
a sexually transmitted disease or an unintended pregnancy? Postmenopausal, does not use condoms

How long have you been with your current partner? Thirty years
Have any medical or surgical conditions changed your ability to have sexual activity? Yes
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
NO

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Ive always known god is with me. Ive been sick all of my life. My faith is reassuring.
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? Yes No
If so, what? How much?(specify daily amount) For how many years? 20 years
Former smoker 1 pack daily 1984- 2004
Former chewing tobacco
If applicable, when did the
Pack Years:
patient quit?
February 26, 2004
Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? If yes, what did they use to try to quit?
No

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? N/A How much? N/A For how many years? N/A
Volume:N/A (age thru )
Frequency: N/A
If applicable, when did the patient quit?
N/A

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what? Marijuana
How much? For how many years?
Every day, all day Thirty years

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No
2003

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
NO

5. For Veterans: Have you had any kind of service related exposure?
N/A

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health?
Ive Been sick all [of] my life.
Integumentary: Pt. states that her skin has been dry lately.
HEENT: Pt. states she needs glasses for reading, but no other complaints.
Pulmonary: Pt. states that there are no problems.
Cardiovascular: Pt. states she has hypertension.
GI: Pt. is a colon cancer survivor.
GU: Pt. does not void.
Women/Men Only:
Musculoskeletal: Pt. states there are no problems.
Immunologic: Pt. states there are no problems.
Hematologic/Oncologic: Pt. is a colon cancer survivor.
Metabolic/Endocrine: Pt. states there are no problems.
Central Nervous System: Pt. states there are no problems.
Mental Illness: Pt. states that she sees a therapist to manage her PTSD and anxiety.
Childhood Diseases: Pt. states she has a congenital urinary tract defect.

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

10 PHYSICAL EXAMINATION:
General survey Alert to person, place, and time
Height: 147. 3 cm Weight: 72. 8 kg BMI N/A Pain (include rating and location) rating a one at groin and
atrioventricular fistula site Pulse: 84 Blood Pressure (include location): 126/64 at right arm Temperature (route
taken): 99.1 F at oral
Respirations: 18 SpO2: 100% on O2
Overall Appearance: No signs of distress.
Overall Behavior: cooperative, not disorderly
Speech: clear and precise

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Mood and Affect: patient is calm and in a talkative mood
Integumentary: skin color, texture, turgor normal. No rashes or skin lesions.
IV Access: Patient currently not hooked to the IV, but it is in reach.
HEENT: Normocephalic, atraumatic, PERRL, conjunctiva clear, mucosa normal, no drainage or sinus pressure
Pulmonary/Thorax: clear to auscultation bilaterally, respirations unlabored, no carotid bruit
Cardiovascular: regular rate and rhythm. Bruit auscultated at Erbs point.
GI: soft, nontender, bowel sounds active, no masses
GU: Patient does not void
Musculoskeletal: no weakness, extremities normal, no cyanosis or edema.
Neurological: normal strength and sensation throughout.

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS

Lab Dates Trend Analysis

Heparin (aPTT) aPTT high, but levels are A high aPTT indicates
74.3 7/18/2016 trending downward. that the patient is at risk
32.6 7/19/2016 for bleeding and the
heparin dosage needed to
reduced.
Potassium Potassium level high but A high potassium level is
6.5 7/18/2016 are trending downward. common is ESRD. The
4.2 7/19/2016 decrease in potassium
indicates the use of
sodium bicarbonate was
therapeutic.
Phosphorus Phosphorus level high Patient was initially NPO
5.4 7/18/2016 and trending upward. upon admission, but is
5.9 7/19/2016 now eating. Eating has
increased the patients
phosphorus.
Albumin Protein at a steady rate. The patients albumin
3.4 7/18/2016 (protein) level is slightly
3.4 7/19/2016 low. This may indicate
adherence to the low
protein renal diet.
Anti XA Only one lab value This value indicates that
0.6 7/19/2016 available. heparin is in the
therapeutic range.
INR INR levels trending The higher value of INR
1.9 7/18/2016 downward. indicates that the patients
1.7 7/19/2016 blood is clotting more
slowly than desired. The
downward trend indicates
that the blood is clotting
quicker.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

The patient is currently receiving a renal diet. Her vital signs are taken every four hours while being monitored
for infection and signs of bleeding. Ms. Weatherford is also receiving diagnostic tests that monitor anti xa, pTT,
phosphorus, and INR. The diagnostic tests are used to monitor the effectiveness or toxicity of the heparin and
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warfarin medication.

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

1. Risk for infection as evidenced by right femoral central venous dialysis and post surgical incision on left chest.
2. Electrolyte imbalance related to end stage renal disease as evidenced by hyperkalemia, hyperphosphatemia, and
hypoalbuminemia.
3. Risk for fluid imbalance as evidenced by decreased urine output and nonexisting kidney function.
4. Risk for injury as evidenced by Coumadin and Heparin therapy.

5. Disturbed sleeping pattern related to procedures during rest period as evidenced by dialysis.

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 15 CARE PLAN
Nursing Diagnosis: Electrolyte imbalance related to end stage renal disease as evidenced by hyperkalemia, hyperphosphatemia, and
Patient Goals/Outcomes
Short term: Electrolyte imbalance
resolved
Long term: Maintenance of
electrolytes within normal range
University of South Florida College of Nursing Revision September 2014
hypoalbuminemia.
Nursing Interventions to Achieve
Goal
Monitor vital signs at least three
times a day
Monitor cardiac rhythm and status Alterations in serum phosphate and Goal met: patient placed on
Review medications and potential
contribution to the electrolyte
imbalance
Anticipate need for corrective
medications
Ongoing evaluation of vital signs,
weight, intake/output, laboratory
values, electrocardiogram,
Implement and teach the
importance of a proper diet
Teach appropriate method of
administering hemodialysis.
Rationale for Interventions Evaluation of Goal on Day Care
Provide References is Provided
Imbalances in electrolytes can lead Goal met: vital signs stayed within
to a variety of clinical clients range
manifestations.
potassium have life-threatening telemetry
effects on the heart.
Some medications may cause an Goal met: all medications
alteration in serum electrolyte conducive
levels, and may need to be
reevaluated or closely monitored.
With the continuation or Goal met: corrective medications
progression of electrolyte not needed at the current moment
imbalance, the patient may need
medication to restore the balance.
Imbalances in electrolytes may be Goal met: patient has follow up
sudden, life-threatening, and appointments with nephrologist
presented in clinical upon discharge.
manifestations.
There is a strict diet that needs to Goal met: patient understands the
be followed with ESRD and importance and components of
hemodialysis that can be beneficial renal diet
to electrolyte balance.
Appropriate use of hemodialysis Goal met: Patient family
can be conducive to regulating understands how to administer
electrolytes. hemodialysis.
11
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
X Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
X 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

Huether, S.E., McCance, K,L. (2012). Alterations of renal and urinary tract infection. Understanding
pathophysiology. St. Louis, MO: Mosby/Elsevier
Kee, J.L., Hayes, E.R., McCuistion, L.E. (2015). Pharmacology: a patient centered nursing process approach.
St. Louis, MO: Elsevier.
Treas, L.S., Wilkinson, J.M. (2014). Development: infancy through middle age. Basic nursing: concepts, skills,
and reasoning. Philadelphia, PA: F.A. Davis Company.
MedBroadcast. (n.d.). Albumin (human) solution usp. Retrieved from:
http://www.medbroadcast.com/Drug/GetDrug/Albumin-Human-Solution-USP
Medscape. (n.d.). Ferric citrate. Retrieved from: http://reference.medscape.com/drug/auryxia-ferric-citrate-
999932#0

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