UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Anthony Ortiz

Assignment Date: 7/21/2016
.
Agency: LRH
± 1 PATIENT INFORMATION
Patient Initials: RS Age: 66 Admission Date: 7/19/2016
Gender: M Marital Status: Divorced Primary Medical Diagnosis: Chronic back pain
Primary Language: English
Level of Education: High School Diploma, some college Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired contractor Acute blood loss anemia, alcoholic gastritis with
bleeding, rectal bleed
Number/ages children/siblings: two sons (one 30yrs, one deceased)
Two brothers (58yrs, 68yrs), sister (54yrs)
Served/Veteran: Code Status: Full code
If yes: Ever deployed? Yes or No
Living Arrangements: lives alone (low income housing) Advanced Directives:
If no, do they want to fill them out?
Surgery Date: Procedure:
Culture/ Ethnicity /Nationality: White, Non-Hispanic
Religion: Christian Type of Insurance: Medicare

± 1 CHIEF COMPLAINT:
“I came here because I had this unbearable pain in my back and left leg.”

± 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)

O: Injured back 2 years ago while working, but pain became severe 6 weeks ago.
L: Mostly in the mid to lower back as well as left leg.
D: A constant pain.
C: Stabbing, aching pain.
A: Sleeping on problem areas aggravates the pain.
R: None
T: None
S: 7 on a pain scale of 0 to 10.

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 ± 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
No procedures documented.

±2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

FAMILY

Mental Health
Age (in years)

Heart Trouble
Bleeds Easily

Hypertension
Cause
Alcoholism

MEDICAL

Glaucoma
of

Problems

Problems
Allergies

Diabetes

Seizures
Arthritis
Anemia

HISTORY
Asthma

Kidney
Cancer

Tumor
Death

Stroke
Gout
(if
applicable)
Father 86 Stroke
Mother 88 CHF
Brother #1 58
Brother #2 68
Sister 54
Son #1 30
Son #2 Motor
34 vehicle
accident
Comments: Include age of onset
Father: arthritis (76yrs), stroke (3 days prior to death at 86yrs)
Mother: environmental allergies (15yrs), arthritis (80yrs), heart trouble (85yrs)
Brother #1: alcoholism (38yrs)
Brother #2: environmental allergies (22yrs)
Sister: environmental allergies (17yrs), asthma (3yrs)
Son #2: asthma (8yrs), hypertension (28yrs)

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

± 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Iodinated
Burning sensation all over body.
radiocontrast dyes
Cardizem Hives, difficulty 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)
Chronic pain is defined as pain lasting longer than 3 to 6 months, or pain that lasts longer than expected after injury. Not
much is truly understood about chronic pain and it is usually out of scope of any visual tissue damage. Dysregulation of
Nociception caused by changes in the peripheral and central nervous systems is thought to be the cause of chronic pain.
Brain atrophy, often found in patients with chronic pain, can lead to deficits in coping with pain. These issues arise with
the constant burden of dealing with chronic pain, but can be reversed by controlling the pain. Early treatment of acute pain
is encouraged in order to prevent the onset of chronic pain. With chronic pain, the body has the ability to adapt, which
causes a misleading representation of the condition when patients do not actually appear to be in pain. Patients with
chronic pain often struggle with the desire for relief and the desire to hide their pain, so as to not be labeled as simple
complainers (Huether et al, 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: aspirin Concentration: 325 mg = 1 tab Dosage Amount: 1 tab

Route: Oral Frequency: Once daily

Pharmaceutical class: antiplatelet Home Hospital or Both
Indication: Treatment of inflammatory disorders, mild to moderate pain, and fever. Patient taking this medication to prevent blood clots.

Adverse/ Side effects: Hearing loss, tinnitus, GI bleeding, heartburn, abdominal pain, hepatotoxicity, anemia, allergic reactions

Nursing considerations/ Patient Teaching:

• Take with food or milk
• Report tinnitus (toxicity level reached)
• Avoid taking with other NSAIDS
• If the tabs smell like vinegar, they are no longer effective

• Contraindicated for children younger than 16 yr

Name: atorvastatin Concentration: 20 mg = 1 tab Dosage Amount: 1 tab

Route: Oral Frequency: Once daily

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Pharmaceutical class: HMG-CoA reductase inhibitor
Home Hospital or Both
Indication: Prevention of coronary heart disease. Patient taking medication for high cholesterol.
Adverse/ Side effects: dizziness, headache, insomnia, weakness, abdominal cramps, constipation, diarrhea, heartburn, nausea
Nursing considerations/ Patient Teaching:
• Take medication as directed
• Avoid drinking more than 1 quart of grapefruit juice per day during therapy
• Notify healthcare provider if unexplained muscle pain, tenderness, or weakness occurs, especially if accompanied by fever or malaise

Name: ipratropium Concentration: 21 mcg Dosage Amount: Two sprays

Route: Nasal Frequency: Three times daily

Pharmaceutical class: Anticholinergic Home Hospital or Both
Indication: Treatment of rhinorrhea. Patient taking for rhinorrhea.
Adverse/ Side effects: dizziness, headache, nervousness, blurred vision, sore throat, nasal dryness/irritation, GI irritation, allergic reactions
Nursing considerations/ Patient Teaching:
• Follow instructions for proper use of nasal spray, and take as directed.
• Pulmonary function tests will be scheduled

Name: lisinopril Concentration: 5 mg = 1 tab Dosage Amount: One tab

Route: Oral Frequency: Once daily

Pharmaceutical class: ACE inhibitor Home Hospital or Both
Indication: Used alone or with other agents in the management of hypertension.
Adverse/ Side effects: dizziness, fatigue, headache, insomnia, weakness, cough, taste disturbances, angina pectoris, hypotension, tachycardia
Nursing considerations/ Patient Teaching:
• Take as directed
• Report to healthcare provider immediately if chest pain, palpitations, or swelling of the lips, face, or tongue occurs.
• This medication may cause drowsiness.

Name: warfarin Concentration: 5 mg Dosage Amount: 1 tab

Route: Oral Frequency: Once daily

Pharmaceutical class: Clotting factor synthesis inhibitor Home Hospital or Both
Indication: Prophylaxis and treatment of venous thrombosis, pulmonary embolism, and atrial fibrillation with embolization. Patient taking medication for atrial
fibrillation.
Adverse/ Side effects: cramps, nausea, dermal necrosis, bleeding, fever
Nursing considerations/ Patient Teaching:
• Use a soft toothbrush, floss gently, and shave with an electric razor during therapy.
• Report any symptoms of unusual bleeding or bruising
• Do not drink alcohol
• Frequent laboratory tests will be done
• Wear a Medic-Alert bracelet at all times
• Inform all involved healthcare personnel of anticoagulant therapy before laboratory tests, treatment, or surgery

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects

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Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

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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? NPO Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Consider co-morbidities and cultural considerations):
24 HR average home diet: The patient is well over his recommended daily intake of
Breakfast: Eggs, toast 2,000 calories. At an intake of 2,702 calories, the patient
has 196% refined grain, 25% vegetables, 0% fruit, 29%
Lunch: sub sandwiches, hot dogs cheese, and 335% protein of the 100% target intake for
each. To improve his diet, the patient can increase their
Dinner: burgers, fried chicken intake of fruit and decrease their intake of refined grain and
protein. Another recommendation for this patient would be
Snacks: cheez-its, cheese and crackers to substitute healthier options, such as having grilled
chicken instead of fried and having fruits as a snack rather
Liquids (include alcohol): beer, water than cheese crackers.

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)
Who helps you when you are ill?
“My son means the world to me and always takes care of me.”
How do you generally cope with stress? or What do you do when you are upset?
“Whenever I’m stressed or have problems I pray.”

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“No, I haven’t had any issues like that.”

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.”

Have you ever felt unsafe in a close relationship? ___No____________________________________________________

Have you ever been talked down to?___No____________ Have you ever been hit punched or slapped?
__No____________

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_________No_________________________________ If yes, have you sought help for this? ______________________

Are you currently in a safe relationship?

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No

Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion 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 Erickson’s developmental stage for your
patient’s age group:
“The task of this stage is the acceptance of one’s life, worth, and eventual death. Ego integrity reflects a satisfaction with life and an
understanding of one’s place in the life cycle. A sense of loss, discomfort with life and aging, and a fear of death are seen in despair
(Treas et al, 2014).”
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient is at a stage in which they reflect on their lives and ponder their accomplishments and failures. This is a stage
that if someone feels that their lives were unproductive and full of regret, then they will feel guilt about their past and not
accomplishing the goals that they once had in place. This can lead to feelings of despair, depression, and hopelessness.
The patient exhibited signs of regret in regard to the loss of his son, stating, “I wish I had done things differently. If I had,
he might still be here. I never got the chance to be a real father to him.”

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The patient’s current hospitalization has caused him to think back on his life more than ever before. He’s has multiple
hospitalizations up to this point, and is becoming increasingly more exhausted and frustrated with the process.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“I don’t really think much about what’s wrong with me except why it’s happening.”

What does your illness mean to you?

“It gets in the way a lot. I’m in the hospital a lot and I hate it.”

+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? _Gonorrhea
(twice)______________________________________________
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?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? __________________________________

How long have you been with your current partner? No current
partner______________________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity?
___No________________________

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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?
“My religion is really important to me. I always pray and ask God for help.”
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
“No not at all.”
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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? 48 years
Smoked cigarettes 1 pack/day (age 17 thru 65)

If applicable, when did the

Pack Years:
patient quit?
10 months ago
Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? If yes, what did they use to try to quit? Prayer
Patient lives alone

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years? 50 years
Beer Volume: 10 pints (age 16 thru present)
Frequency: 3x/wk
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?
Cocaine, meth, marijuana, acid How much? For how many years? 15 years
N/A (age 20 thru 35)

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No
1985

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

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

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± 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health?
“I don’t know what I did to deserve this.”
Integumentary: no changes in skin appearance, no rashes, no skin infections, so psoriasis, no edema, warm, dry
HEENT: no difficulty with vision, no sinus pain/infection, cavities, no ear pain/infection, no cataracts/glaucoma
Pulmonary: no difficulty breathing, no cough, no asthma, no pneumonia, no tuberculosis, no environmental
allergies
Cardiovascular: hypertension, no thrombus, no chest pain, no murmur, no rheumatic fever
GI: no nausea, vomiting, or diarrhea, no constipation, no abdominal pain, no blood in stool, hepatitis, gastritis
GU: no dysuria, no kidney stones, no polyuria, no nocturia
Women/Men Only: no infection of genitals/prostate, prostate exam once/yr, last prostate exam 6/2015, no BPH
Musculoskeletal: no injuries/fractures, no weakness, lower back/left leg pain, no gout, no arthritis
Immunologic: no chills, no night sweats, no fever, no rheumatoid arthritis, no HIV/AIDS, no allergic reaction
Hematologic/Oncologic: anemia, no cancer, bleeds easily, bruises easily, no blood transfusions
Metabolic/Endocrine: type 2 diabetes mellitus, no hot/cold interolerance
Central Nervous System: no dizziness, no headaches, no seizures, no migraines, no CVA, no ticks/tremors
Mental Illness: depression, no anxiety, no schizophrenia, no bipolar disorder
Childhood Diseases: chicken pox, no measles, no mumps, no polio, no scarlet fever

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
None

Any other questions or comments that your patient would like you to know?
None

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±10 PHYSICAL EXAMINATION:
General survey _____________________________________________________________________________________
Height ___188cm_________Weight___100.4 kg_______ BMI __28 kg/m2_________ Pain (include rating and
location)__7, lower back/leftleg_________________ Pulse__124_____ Blood Pressure (include location)__143
mmHg/71 mmHg, right arm___________________Temperature (route taken)___98.7 F, oral_________
Respirations___19_________ SpO2 ____98%_____________ or O2___Room air________________________
Overall Appearance: clean, maintained eye contact, no obvious handicaps, dressed appropriately for
setting/temperature
Overall Behavior: awake, calm, relaxed, interacts well with others, judgment intact Speech: clear, crisp diction
Mood and Affect: cooperative, flat, fatigued
Integumentary: skin warm, dry, and intact, skin turgor elastic, no rashes/lesions/deformities, capillary refill < 3
seconds, nails without clubbing
IV Access: 22 gauge in left AC (7/19/16), no redness/edema/discharge, fluids infusing
HEENT: facial features symmetric, no sinus pain, no enlarged thyroid, lymph nodes not palpable, sclera white and
conjunctiva clear, peripheral vision intact, EOM intact through 6 cardinal fields without nystagmus
Pulmonary/Thorax: respirations regular and unlabored, chest expansion symmetric, percussion resonant
throughout all lung fields, dull towards posterior bases
Cardiovascular: no lifts, heaves or thrills, S1+S2 audible, tachycardia, no JVD
GI: bowel sounds active x4, no bruits, percussion dull over liver/spleen and tympanic over stomach/intestine, last
BM 7/21/16 semi-formed/brown, no nausea, genitalia not assessed, patient alert, oriented, denies problems
GU: urine clear, previous output 1,800 mL, patient can ambulate to bathroom with walker
Musculoskeletal: full ROM intact in all extremities, strength 2+ bilaterally, vertebral column inline, peripheral
pulses palpable, no pain, pallor, paralysis, or paresthesia
Neurological: patient awake, A+O x3, sensation intact to touch/pain/vibration

±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 Dates Trend Analysis

Platelet – 317 k/mcL This is the only lab value. Platelet count within
(07/21/2016) normal range of 150
k/mcL-450 k/mcL.

RBC – 2.5 million/mcL
WBC – 7.6 k/mcL
PT – 138.2 seconds
Creatinine – 1.2 mg/dL
University of South Florida College of Nursing – Revision September 2014
(07/21/2016) This is the only lab value. RBC count is low due to
anemia. Normal range
within 4.7-6.1
million/mcL.
(07/21/2016) This is the only lab value. WBC count within
normal range of 4.5-11
k/mcL.
(07/21/2016) This is the only lab value. PT is high due to anemia.
Normal range within 9.4-
12.5 seconds.
(07/21/2016) This is the only lab value. Creatinine within normal
range of 0.8-1.3 mg/dL.
11
 BUN – 41 mg/dL (07/21/2016) This is the only lab value. BUN level high due to
diet high in protein.
Normal range within 7-18
mg/dL.
Glucose – 145 mg/dL (07/21/2016) This is the only lab value. Glucose level high due to
intake of added sugars.
Normal levels within 70-
100 mg/dL

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)

Diet: balanced diet with appropriate intake of calories (2,000 calories) and adequate servings of each food group.
Reducing refined grain and protein intake to appropriate levels to attain a balanced diet. Removing added sugar
from diet as well as processed grains to help manage diabetes.
Vitals: taken ever 4 hours based on hospital protocol.
Activity: physical therapy to help treat back pain
Scheduled Diagnostic Tests: none

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

1. Chronic pain related to work related injury as evidenced by patient statement of having constant pain.

2. Impaired mobility related to chronic pain as evidenced patient statement of pain when they rise up from bed.

3. Imbalanced nutrition related to inadequate dietary intake as evidenced by high intake of refined grain and protein.

4. Risk for sedentary lifestyle related to discomfort while in motion.

5. Ineffective self-health management related to poor diabetes control as evidenced by high blood glucose levels.

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± 15 CARE PLAN
Patient Goals/Outcomes
Patient will state a pain level of 3
on a scale from 0-10 by end of
shift.
Patient will state ability to continue
normal ADL’s during treatment.
*Patient will state understanding of
resources available for long-term
pain management.
University of South Florida College of Nursing – Revision September 2014
Nursing Diagnosis: Nursing Diagnosis goes here
Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
“Manage chronic pain using a “Multimodal analgesia combines Patient stated that pain level was a
multimodal approach (Ackley et al, two or more medications, or 3 on a scale of 0-10.
2013).” methods, from different
pharmacological classes that target
different mechanisms along the
pain pathway (Pasero & Portenoy,
2011; Pasero et al, 2011b).”
“Encourage the client to plan “Clients will find it easier to Patient stated being able to perform
activities around periods of greatest perform their ADL’s and enjoy normal ADL’s during periods of
comfort whenever possible. Pain social activities when they are comfort during pain management.
impairs function (Ackley et al, rested and pain is under control
2013).” (Ackley et al, 2013).”
“Explore appropriate resources for “Most clients with cancer or Patient repeated teaching of
management of pain on a long-term chronic non-cancer pain are treated resources available to them for
basis (e.g., hospice, pain care for pain in outpatient and home long-term pain management.
center) (Ackley et al, 2013).” care settings. Plans should be made
to ensure ongoing assessment of
the pain and the effectiveness of
treatments in these settings (APS,
2008).”
13
Include a minimum of one
Long term goal per care plan
±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
□SS Consult
□Dietary Consult
□PT/ OT
□Pastoral Care
□Durable l Needs
□F/U appointments
□Med Instruction/Prescription
§ □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
□Palliative Care

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 References

• Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology (Fifth ed.). St.

Louis, MO: Mosby/Elsevier.

• Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based

guide to planning care (Tenth ed.). Maryland Heights, MO: Elsevier.

• Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing: Concepts, skills, & reasoning

(First ed.). Philadelphia, PA: F.A. Davis Company.

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