gUNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
1 CHIEF COMPLAINT: I have blisters all over my right leg.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in aition to the hospital !ourse"
The patient is a #$ year ol %emale that presente to the emergen!y room at &loria 'ospital (esley Chapel on )*+),+),
-resenting .ith !hest pain. The /01 sho.e a nonstemi. The patient .as transporte to &loria 'ospital Tampa
On )*+)2+), %or a CAB1 that .as one on the same ay. A%ter surgery the patient evelope blisters on right leg uner
The ressing over in!isions. 3i4 blisters surroune the in!ision an ha serous5 !lear5 yello. rainage !oming %rom the
Open blisters. Absorbant %oam ressing pla!e on the blisters to absorb rainage an antiba!terial topi!al treatment
Applie to prevent in%e!tion. &our blisters opene .hile t.o remaine !lose. Appears to be asso!iate .ith allergy to
Ahesive tape that patient .as not a.are o%.
6niversity o% 3outh &loria College o% 7ursing 8 Revision August 9*),
3tuent: 0imberly Cremerius
PATIENT ASSESSMENT TOOL .
Assignment Date: )*+99+),
1 PATIENT INFORMATION
Agen!y: &'T
-atient Initials: C3 Age: #$ Amission Date: )*+)2+),
1ener: &emale ;arital 3tatus: -rimary ;ei!al Diagnosis .ith ICD<)* !oe:
-rimary Language: /nglish 7on<stemi I9).2
Level o% /u!ation: Asso!iates egree Other ;ei!al Diagnoses: (ne. on this amission"
O!!upation (i% retire5 .hat %rom=": stay at home mom
7umber+ages !hilren+siblings: >#+& sister
Chilren: 2?+;@ ,?+&@ ,9+&
3erve+Aeteran: Coe 3tatus: &ull Coe
Living Arrangements: Lives alone in !ono on %irst %loor Avan!e Dire!tives: 7o
I% no5 o they .ant to %ill them out= Bes
3urgery Date: )*+)2+), -ro!eure: CAB1
Culture+ /thni!ity +7ationality: -olish+Italian
Religion: Lutheran Type o% Insuran!e: 6nite 'ealth Care
)
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY In!lue hospitaliCations %or any mei!al
illness or operation
Date Opeat!"# " I$$#e%%
)D#$ Regular Birth
)D>9 C<se!tion
)D>$ C<se!tion
)D$* 1um operation
9**? AnEle operation
9**> Catara!t surgery both eyes
2
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&ather #$
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Brother
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relationship
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relationship
Comments: In!lue ate o% onset
1 IMMUNI&ATION HISTORY
(;ay state 6 %or unEno.n5 e4!ept %or Tetanus5 &lu5 an -na" YES NO
Routine !hilhoo va!!inations
Routine ault va!!inations %or military or %eeral servi!e
Ault Diphtheria (Date"
Ault Tetanus (Date"
In%luenCa (%lu" (Date" )*+9*),
-neumo!o!!al (pneumonia" (Date"
'ave you ha any other va!!ines given %or international travel or
o!!upational purposes= -lease List
6niversity o% 3outh &loria College o% 7ursing 8 Revision August 9*), 9
1 ALLERGIES
OR ADVERSE
REACTIONS
7A;/ o%
Causative Agent
Type o% Rea!tion (es!ribe e4pli!itly"
;ei!ations
Other (%oo5 tape5
late45 ye5 et!."
Ahesive tape+stat Blister .here tape .as applie
lo!E
' PATHOPHYSIOLOGY: (in!lue A-A re%eren!e an in te4t !itations" (;e!hani!s o% isease5 risE %a!tors5 ho. to
iagnose5 ho. to treat5 prognosis5 an in!lue any geneti! %a!tors impa!ting the iagnosis5 prognosis or
treatment"
;yo!arial in%ar!tion (;I" happens .hen one o% the bloo vessels that supply bloo to the heart mus!le is blo!Ee o%%5
.hi!h results in ne!rosis o% the heart mus!le. A non<3T/;I is a ;I that is iagnose by oing an /C1 an seeing 3T
segment epression an T .ave inversion. A non<3T/;I usually o!!urs .hen a bloo !lot !logs a !oronary artery but
issolves on its o.n. RisE %a!tors in!lue high !holesterol5 high bloo pressure5 iabetes5 an smoEing. Treatment %or
a non<3T/;I in!lues amitting the patient to the !oronary !are unit5 aministering thrombolyti!s5 an per%orm
per!utaneous !oronary intervention (-CI" or a !oronary artery bypass gra%t (CAB1". A%ter initial treatment patient is put
on AC/ inhibitor an beta<blo!Eers to prevent a %uture ;I. ('uether5 9*)9"
' MEDICATIONS: FIn!lue both pres!ription an OTC@ home (re!on!iliation"5 routine5 an -R7 mei!ation. 1ive trae an
generi! name.G
Na(e: F!%) "!$ C"#*e#tat!"# +(g/($, 12--(g/ CAP D"%age A(".#t +(g, 12-- (g
R".te: PO Fe/.e#*0 TID
P)a(a*e.t!*a$ *$a%%: $!p!1 $"2e!#g age#t
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#: )0pe$!p!1e(!a
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%: 5e$*)!#g6 )eat5.#6 5$ee1!#g6 7!ta(!# D t"8!*!t0
Na(e: a%*"5!* a*!1 C"#*e#tat!"#: 2'-(g/TA3 D"%age A(".#t: '-- (g
R".te: PO Fe/.e#*0: Da!$0
P)a(a*e.t!*a$ *$a%%: 2ate %"$.5$e 7!ta(!#%
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#: %.pp$e(e#ta$ t)eap0
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%: 4at!g.e6 *a(p%6 DVT6 9!1#e0 %t"#e%
Na(e: a%p!!# C"#*e#tat!"#: :1 (g/TA3 D"%age A(".#t: :1 (g
R".te: PO Fe/.e#*0: Da!$0
P)a(a*e.t!*a$ *$a%%: %a$!*0$ate%
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#: p"p)0$a8!% "4 ta#%!e#t !%*)e(!* atta*9% a#1 MI
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%: GI 5$ee1!#g6 a$$eg!* ea*t!"#%6 ep!ga%t!* 1!%te%%
6niversity o% 3outh &loria College o% 7ursing 8 Revision August 9*), ,
Na(e: *a7e1!$"$ +C"eg, C"#*e#tat!"#: ;.2'(g/TA3 D"%age A(".#t: 12.' (g
R".te: PO Fe/.e#*0: 3ID
P)a(a*e.t!*a$ *$a%%: 5eta 5$"*9e
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#: )0pete#%!"#
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%: 5a10*a1!a6 HF6 p.$("#a0 e1e(a< %te7e#=>")#%"# %0#1"(
Na(e: *!ta$"pa( +Ce$e8a, C"#*e#tat!"#: 2- (g/TA3 D"%age A(".#t: ?- (g
R".te: PO Fe/.e#*0: Da!$0
P)a(a*e.t!*a$ *$a%%: SSRI
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#: 1epe%%!"#
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%: #e."$ept!* (a$!g#a#t %0#1"(e6 %.!*!1a$ t)".g)t%6 t"%a1e 1e p"!#te%
Na(e: 1"*.%ate %"1!.( C"#*e#tat!"#: 1--(g/CAP D"%age A(".#t: 1-- (g
R".te: PO Fe/.e#*0: @12)
P)a(a*e.t!*a$ *$a%%: %t""$ %"4te#e
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#: pe7e#t!"# "4 *"#%t!pat!"#
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%: (!$1 *a(p%6 t)"at !!tat!"#6 1!a)ea6 a%)e%
Na(e: 4e".% %.$4ate C"#*e#tat!"#: 32' (g/TA3 D"%age A(".#t: 32'
R".te: PO Fe/.e#*0: Da!$0
P)a(a*e.t!*a$ *$a%%: !"# %.pp$e(e#t%
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#: pe7e#t!"#/teat(e#t "4 !"# 1e4!*!e#*0 a#e(!a
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%: #a.%ea6 *"#%t!pat!"#6 1a9 %t""$%6 ep!ga%t!* pa!#6 1!AA!#e%%
Na(e: F"$!* a*!1 C"#*e#tat!"#: 1 (g/TA3 D"%age A(".#t: 1 (g
R".te: PO Fe/.e#*0: Da!$0
P)a(a*e.t!*a$ *$a%%: 2ate %"$.5$e 7!ta(!#%
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#: pe7e#t!"# "4 (ega$"5$a%t!* a#e(!a%
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%: a%)6 !!ta5!$!t06 1!44!*.$t0 %$eep!#g6 (a$a!%e6 *"#4.%!"#
Na(e: 4."%e(!1e C"#*e#tat!"#: ?- (g/ ? (L D"%age A(".#t: ?- (g
R".te: INB6 IV p.%) Fe/.e#*0: 3ID
P)a(a*e.t!*a$ *$a%%: $""p 1!.et!*
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#: )0pete#%!"#
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%: %te7e#=>")#%"# %0#1"(e< t"8!* ep!1e(a$ #e*"$0%!%
Na(e C"#*e#tat!"# D"%age A(".#t
R".te Fe/.e#*0
P)a(a*e.t!*a$ *$a%%
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%
Na(e C"#*e#tat!"# D"%age A(".#t
R".te Fe/.e#*0
P)a(a*e.t!*a$ *$a%%
H"(e H"%p!ta$ " 3"t)
I#1!*at!"#
S!1e e44e*t%/N.%!#g *"#%!1eat!"#%
6niversity o% 3outh &loria College o% 7ursing 8 Revision August 9*), 2
' NUTRITION: In!lue type o% iet5 92 'R average home iet5 an your nutritional analysis .ith re!ommenations.
Diet orere in hospital= Consistent !arbohyrates Analysis o% home iet (Compare to ;y -late an
Diet pt %ollo.s at home= Consier !o<morbiities an !ultural !onsierations":
92 'R average home iet:
BreaE%ast: /nglish mu%%in+bagel+bran mu%%in -atient has a .ell balan!e iet in!luing aeHuate amounts
9<, !ups o% !o%%ee a ay O% %ruits5 vegetables5 protein5 grains. C3 is a type
Lun!h: meat5 potatoes5 vegetables5 sala5 %ruit5 essert ) iabeti! an states that she oes not sna!E bet.een meals
6nless her sugar is lo.. This is goo be!ause it prevents
Dinner: san.i!h /4!essive !arbohyrate intaEe .hi!h !oul !ause a spiEe in
,9 oC o% .ater5 !ouple !ups o% tea Bloo glu!ose levels. DrinEs aeHuate amounts o% .ater
3na!Es: oes not eat bet.een meals Throughout the ay. Coul a more airy to her meals to
I% sugar is lo. eat peanut butter an !ra!Eers -revent osteoporosis.
LiHuis (in!lue al!ohol": no al!ohol
6se this linE %or the nutritional analysis by !omparing the patients
92 'R average home iet to the re!ommene portions5 an use
;y -late as re%eren!e.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts esigne to help guie your is!ussion"
(ho helps you .hen you are ill= 7o one5 I taEe !are o% mysel%
IIve never asEe %or help5 but !oul get some i% I asEe.
'o. o you generally !ope .ith stress= or (hat o you o .hen you are upset=
DonIt have too mu!h stress. I sit o.n5 use !omputer5 o puCCles5 little things to o!!upy my min.
Re!ent i%%i!ulties (&eelings o% epression5 an4iety5 being over.helme5 relationships5 %riens5 so!ial li%e"
7one o% those %eelings
C2 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.
'ave you ever %elt unsa%e in a !lose relationship= JJJJJ7oJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
'ave you ever been talEe o.n to=JJJ7oJJJJJJJJJJJJ 'ave you ever been hit pun!he or slappe= JJJ7OJJJJJ
'ave you been emotionally or physi!ally harme in other .ays by a person in a !lose relationship .ith you=
JJJ7OJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ I% yes5 have you sought help %or this= JJJJJJJJJJJJJJJJJJJJJJ
Are you !urrently in a sa%e relationship= 7ot !urrently in a relationship
6niversity o% 3outh &loria College o% 7ursing 8 Revision August 9*), ?
? DEVELOPMENTAL CONSIDERATIONS:
/riEsonIs stage o% psy!hoso!ial evelopment: Trust vs. ;istrust Autonomy vs. Doubt K 3hame Initiative vs. 1uilt Inustry vs.
In%eriority Ientity vs. Role Con%usion+Di%%usion Intima!y vs. Isolation 1enerativity vs. 3el% absorption+3tagnation /go Integrity vs. Despair
Che!E one bo4 an give the te4tbooE e%inition (.ith !itation an re%eren!e" o% both parts o% /ri!EsonIs evelopmental stage %or your
patientIs age group: The psy!hoso!ial !on%li!t in .hi!h elerly aults attempt to %in a sense o% meaning in their lives an
To a!!ept the inevitability o% eath (Rier5 9**D"
Des!ribe the stage your patient is in an give the !hara!teristi!s that the patient e4hibits that le you to your etermination:
C3 is in the ego integrity vs espair evelopmental stage an e4hibits the !hara!teristi!s o% integrity. 3he is involve in
Chur!h a!tivities an has %riens throughout her !hur!h !ommunity. 3he unerstans that she has live a %ull li%e an has
A!!epte the inevitability o% eath.
Des!ribe .hat impa!t o% isease+!onition or hospitaliCation has ha on your patientIs evelopmental stage o% li%e:
C3 unerstans that her !onition sho.s that her boy is .eaEening an one ay she .ill ie %rom problems o% her %ailing
Boy. 3he believes she has live a %ull li%e an is reay .hen ever 1o e!ies is her time.
C3 CULTURAL ASSESSMENT:
(hat o you thinE is the !ause o% your illness=
3omething .asnIt .orEing right in there I havenIt seen a !ariologist sin!e moving to Tampa > years ago
(hat oes your illness mean to you=
It means that I have to be more !are%ul. I !anIt ive into things
C3 SEDUALITY ASSESSMENT: +t)e 4"$$"2!#g prompts (a0 )e$p t" g.!1e 0". 1!%*.%%!"#,
Consider beginning with: I am asking about your se!ual history in order to obtain information that will screen for
possible se!ual health problems, these are usually related to either infection, changes with aging and"or quality of life.
#ll of these questions are confidential and protected in your medical record
'ave you ever been se4ually a!tive=JJJBesJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
Do you pre%er .omen5 men or both geners= JJJJ;enJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
Are you a.are o% ever having a se4ually transmitte in%e!tion= J7oJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
'ave you or a partner ever ha an abnormal pap smear= JJJ7oJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
'ave you or your partner re!eive the 1arasil ('-A" va!!ination= J7oJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ

Are you !urrently se4ually a!tive= JJJJJJ7oJJJJJJJJJJJJJJJ(hen se4ually a!tive5 .hat measures o you taEe to
prevent a!Huiring a se4ually transmitte isease or an unintene pregnan!y= JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
'o. long have you been .ith your !urrent partner=JJJJDoesnIt have a !urrent partnerJJJJJJJJJJJJJJJJJJJJJJJJJJ
'ave any mei!al or surgi!al !onitions !hange your ability to have se4ual a!tivity= JJJ7oJJJJJJJJJJJJJJJJJJJJ
Do you have any !on!erns about se4ual health or ho. to prevent se4ually transmitte isease or unintene pregnan!y=
7o
6niversity o% 3outh &loria College o% 7ursing 8 Revision August 9*), #
E1 SPIRITUALITY ASSESSMENT: (in!luing but not limite to the %ollo.ing Huestions"
(hat importan!e oes religion or spirituality have in your li%e=
JReally big in%luen!e in my li%e. -eople at !hur!h mean a lot to me. They are the people I so!ialiCe .ith.JJJJJJJJJJJJJJJ
JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
Do your religious belie%s in%luen!e your !urrent !onition=
JJBes5 %eels oE to leave. I .oul %eel ba about people le%t behin5 but .oul be oEay to ie. IIve live #$
yearsJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
C3 SMOFING6 CHEMICAL USE6 OCCUPATIONAL/ENVIRONMENTAL EDPOSURES:
). Does the patient !urrently5 or has he+she ever smoEe or use !he.ing toba!!o= Ye% 7o
I% so5 .hat= 'o. mu!h=(spe!i%y aily amount" &or ho. many years= L years
A pa!E a .eeE (age 9* thru 99 "
-a!E Bears:
I% appli!able5 .hen i the
patient Huit= 99
Does anyone in the patientIs househol smoEe toba!!o= I%
so5 .hat5 an ho. mu!h= 7o
'as the patient ever trie to Huit= yes
9. Does the patient rinE al!ohol or has he+she ever ranE al!ohol= Ye% 7o
(hat= 'a some as teenager5 but never 'o. mu!h= (give spe!i%i! volume" &or ho. many years=
mu!h (age thru "
I% appli!able5 .hen i the patient Huit=
DoesnIt rinE .ith type ) iabetes
,. 'as the patient ever use street rugs su!h as mariMuana5 !o!aine5 heroin5 or other= Bes N"
I% so5 .hat=
'o. mu!h= &or ho. many years=
(age thru "
Is the patient !urrently using these rugs=
Bes 7o
I% not5 .hen i he+she Huit=
2. 'ave you ever5 or are you !urrently e4pose to any o!!upational or environmental 'aCars+RisEs
7o
6niversity o% 3outh &loria College o% 7ursing 8 Revision August 9*), >
1- REVIEG OF SYSTEMS
Ge#ea$ C"#%t!t.t!"# Ga%t"!#te%t!#a$ I((.#"$"g!*
Re!ent .eight loss or gain 7ausea5 vomiting5 or 1!a)ea Chills .ith severe shaEing
I#teg.(e#ta0 Constipation Irritable Bo.el 7ight s.eats
Changes in appearan!e o% sEin 1/RD Chole!ystitis &ever
-roblems .ith nails Inigestion 1astritis + 6l!ers 'IA or AID3
Danru%% 'emorrhois Bloo in the stool Lupus
-soriasis Bello. Mauni!e 'epatitis Rheumatoi Arthritis
'ives or rashes -an!reatitis 3ar!oiosis
3Ein in%e!tions Colitis Tumor
6se o% suns!reen 3-&: Diverti!ulitis Li%e threatening allergi! rea!tion
Bathing routine: 9<, times a .eeE@ sho.er Appeni!itis /nlarge lymph noes
Other: Abominal Abs!ess Other:
Last !olonos!opy= 9*))
HEENT Other: sigmoi< no problems He(at"$"g!*/O#*"$"g!*
Di%%i!ulty seeing Ge#!t".!#a0 Anemia
Cataa*t% or 1lau!oma no!turia Blees easily
Di%%i!ulty hearing ysuria Bruises easily
/ar in%e!tions hematuria Can!er
3inus pain or in%e!tions polyuria Bloo Trans%usions
7ose blees Einey stones Bloo type i% Eno.n: ON
-ost<nasal rip 7ormal %reHuen!y o% urination: ?<#4+ay Other:
Oral+pharyngeal in%e!tion Blaer or Einey in%e!tions
Dental problems 0iney in%e!tions .hen pregnant Meta5"$!*/E#1"*!#e
Routine brushing o% teeth 9 4+ay Diabetes Type: )
Routine entist visits 4+year ;ammogram<last %e. years@ nothing 'ypothyroi +'yperthyroi
Aision s!reening: every year Abnormal Intoleran!e to hot or !ol
Other: havenIt been to entist in a.hile5 Bone ensity<results normal Osteoporosis
At least ? years Diarrhea< taEe Imoium 9<, times a Other:
P.$("#a0 .eeE
Di%%i!ulty Breathing Ce#ta$ Ne7".% S0%te(
Cough < ry or prou!tive GOMEN ONLY CAA
Asthma In%e!tion o% the %emale genitalia DiCCiness
Bron!hitis ;onthly sel% breast e4am 3evere 'eaa!hes
/mphysema &reHuen!y o% pap+pelvi! e4am ;igraines
-neumonia Date o% last gyn e4am= 3eiCures
Tuber!ulosis menstrual !y!le regular irregular Ti!Es or Tremors
/nvironmental allergies menar!he age= /n!ephalitis
last CLR= )*+)2 menopause age= 2$ ;eningitis
Other: Date o% last ;ammogram KResult: Other:
Date o% D/LA Bone Density K Result:
Ca1!"7a%*.$a MEN ONLY Me#ta$ I$$#e%%
'ypertension In%e!tion o% male genitalia+prostate= Depression
'yperlipiemia &reHuen!y o% prostate e4am= 3!hiCophrenia
Chest pain + Angina Date o% last prostate e4am= An4iety
;yo!arial In%ar!tion B-' Bipolar
CAD+-AD 6rinary Retention Other:
C'& M.%*.$"%9e$eta$
;urmur InMuries or &ra!tures broEen anEle C)!$1)""1 D!%ea%e%
Thrombus (eaEness ;easles
Rheumati! &ever -ain ;umps
;yo!aritis 1out -olio
Arrhythmias Osteomyelitis 3!arlet &ever
Last /01 s!reening5 .hen= )*+99 Arthritis Chi!Een -o4
Other: Other: Other:
6niversity o% 3outh &loria College o% 7ursing 8 Revision August 9*), $
Is there any problem that is not mentione that your patient sought mei!al attention %or .ith anyone=
7o peripheral vision in right eye be!ause o% small stroEe in eye
Any other Huestions or !omments that your patient .oul liEe you to Eno.=
6niversity o% 3outh &loria College o% 7ursing 8 Revision August 9*), D
E1- PHYSICAL EDAMINATION:(Des!ribe abnormal assessment belo. non !he!Ee bo4es"
1eneral 3urvey: AKO4, 'eight: )?> !m (eight:$$.9 B;I: ,?.>$ -ain: (in!lue rating K lo!ation"
7o pain
-ulse: $> Bloo
-ressure: ),2+?$ right arm
(in!lue lo!ation"
Temperature: (route taEen="
D$.) oral
Respirations: )$
3pO9 D2 Is the patient on Room Air or O9: room air
Overall Appearan!e: FDress+grooming+physi!al hani!aps+eye !onta!tG
!lean5 hair !ombe5 ress appropriate %or setting an temperature5 maintains eye !onta!t5 no obvious hani!aps
Overall Behavior: Fe.g.: appropriate+restless+o mannerisms+agitate+lethargi!+otherG
a.aEe5 !alm5 rela4e5 intera!ts .ell .ith others5 Mugment inta!t
3pee!h: Fe.g.: !lear+mumbles +rapi +slurre+silent+otherG
!lear5 !risp i!tion
;oo an A%%e!t: pleasant !ooperative !heer%ul talEative Huiet boisterous %lat
apatheti! biCarre agitate an4ious tear%ul .ithra.n aggressive hostile lou
Other:
I#teg.(e#ta0
3Ein is .arm5 ry5 an inta!t
3Ein turgor elasti!
7o rashes5 lesions5 or e%ormities
7ails .ithout !lubbing
Capillary re%ill O , se!ons
'air evenly istribute5 !lean5 .ithout vermin
3Ein .arm an ry@ le%t leg in!ision !lean5 not reness or s.elling@ !hest
In!ision no reness or s.elling@ blisters aroun in!ision site on right leg
# blisters5 2 open@ serous rainage<!lear yello.@ open blister on le%t thigh
6ner stat lo!E %or %oley. -robably !ause by tape allergy
-eripheral IA site Type: Lo!ation: Date inserte:
no reness5 eema5 or is!harge
&luis in%using= no yes < .hat=
-eripheral IA site Type: Lo!ation: Date inserte:
no reness5 eema5 or is!harge
&luis in%using= no yes < .hat=
Central a!!ess evi!e Type: IP Lo!ation: right Mugular Date inserte: )*+9)+),
&luis in%using= no yes < .hat=
HEENT: &a!ial %eatures symmetri! 7o pain in sinus region 7o pain5 !li!Eing o% T;P Tra!hea miline
Thyroi not enlarge 7o palpable lymph noes s!lera .hite an !onMun!tiva !lear@ .ithout is!harge
/yebro.s5 eyelis5 orbital area5 eyelashes5 an la!rimal glans symmetri! .ithout eema or tenerness
-/RRLA pupil siCe + , mm -eripheral vision inta!t /O; inta!t through # !arinal %iels .ithout nystagmus
/ars symmetri! .ithout lesions or is!harge (hisper test hear: right ear< # in!hes K le%t ear< # in!hes
7ose .ithout lesions or is!harge Lips5 bu!!al mu!osa5 %loor o% mouth5 K tongue pinE K moist .ithout lesions
Dentition:
Comments:
7o peripheral vision in right eye
6niversity o% 3outh &loria College o% 7ursing 8 Revision August 9*), )*
P.$("#a0/T)"a8: Respirations regular an unlabore Transverse to A- ratio 9:) Chest e4pansion symmetri!
Lungs !lear to aus!ultation in all %iels .ithout aventitious souns
CL 8 Clear
-er!ussion resonant throughout all lung %iels5 ull to.ars posterior bases
(' 8 (heeCes
3putum prou!tion: t)!*9 thin Amount: %*a#t small moerate large
CR < Cra!Eles
Color: .hite pale yello. 0e$$"2 arE yello. green gray light tan bro.n re
R' 8 Rhon!hi

D 8 Diminishe
3 8 3trior
Ab < Absent
Ca1!"7a%*.$a: 7o li%ts5 heaves5 or thrills -;I %elt at: ?
th
inter!ostal spa!e Le%t ;CL
'eart souns: S1 S2 Reg.$a Irregular 7o murmurs5 !li!Es5 or aventitious heart souns 7o PAD
Rhythm (%or patients .ith /C1 tra!ing 8 tape # se!on strip belo. an analyCe"
Cal% pain bilaterally negative -ulses bilaterally eHual Frating s!ale: *<absent5 )<barely palpable5 9<.eaE5 ,<normal5 2<bouningG
Api!al pulse: Caroti: Bra!hial: Raial: 9 &emoral: -opliteal: D-: 9 -T:
7o temporal or !aroti bruits /ema: Frating s!ale: *<none5 N) ()<9mm"5 N9 (,<2mm"5 N, (?<#mm"5 N2(><$mm" G
Lo!ation o% eema: le%t %oot N9 p!tt!#g non<pitting right %oot N)
/4tremities .arm .ith !apillary re%ill less than , se!ons
GI/GU: Bo.el souns a!tive 4 2 Huarants@ no bruits aus!ultate 7o organomegaly
-er!ussion ull over liver an spleen an tympani! over stoma!h an intestine Abomen non<tener to palpation
6rine output: Clear Clouy Color: yello. -revious 92 hour output: 29,* mLs 7+A
&oley Catheter 6rinal or Bepan Bathroom -rivileges .ithout assistan!e or .ith assistan!e
CAA pun!h .ithout reboun tenerness
Last B;: (ate )* +9) +), " F"(e1 3emi<%orme 6n%orme 3o%t 'ar LiHui (atery
Color: Light bro.n Me1!.( 3"2# DarE Bro.n Bello. 1reen (hite Co%%ee 1roun ;aroon Bright Re
'emo!!ult positive + negative (leave blanE i% not one"
1enitalia: Clean5 moist5 .ithout is!harge5 lesions or oor 7ot assesse5 patient alert5 oriente5 enies problems
Other 8 Des!ribe:
M.%*.$"%9e$eta$: L &ull RO; inta!t in all e4tremities .ithout !repitus
3trength bilaterally eHual at JJJ2JJJJ R6/ JJJ2JJJJ L6/ JJJ2JJJJ RL/ K JJJJ2JJJ in LL/
Frating s!ale: *<absent5 )<tra!e5 9<not against gravity5 ,<against gravity but not against resistan!e5 2<against some resistan!e5 ?<against %ull resistan!eG
vertebral !olumn .ithout Eyphosis or s!oliosis
7eurovas!ular status inta!t: peripheral pulses palpable5 no pain5 pallor5 paralysis or parathesias
3.elling in legs
Ne."$"g!*a$: -atient a.aEe5 alert5 oriente to person5 pla!e5 time5 an ate Con%use@ i% !on%use atta!h mini mental e4am
C7 9<)9 grossly inta!t 3ensation inta!t to tou!h5 pain5 an vibration RombergIs 7egative
3tereognosis5 graphesthesia5 an proprio!eption inta!t 1ait smooth5 regular .ith symmetri! length o% the strie
DTR: Frating s!ale: *<absent5 N) sluggish+iminishe5 N9 a!tive+e4pe!te5 N, slightly hypera!tive5 N2 'ypera!tive5 .ith intermittent or transient !lonusG
Tri!eps: Bi!eps: Bra!hioraial: -atellar: A!hilles: AnEle !lonus: positive negative BabinsEi: positive negative
E1- PERTINENT LA3 VALUES AND DIAGNOSTIC TEST RESULTS (in!lue pertinent normals as .ell as
abnormals5 in!lue rationale an analysis. List ates .ith all labs an iagnosti! tests":
-ertinent in!lues labs that are !he!Ee .hen on !ertain mei!ations5 monitore %or the isease pro!ess5 nee
prior to an a%ter surgery5 an pertinent to hospitaliCation. Do not %orget to in!lue iagnosti! tests5 su!h as
6ltrasouns5 L<rays5 CT5 ;RI5 'IDA5 et!. I% a lab or test is not in the !hart (su!h as one that is one preop" then
in!lue .hy you e4pe!t it to be one an .hat results you e4pe!t to see.
La5 Date% Te#1 A#a$0%!%
'1B
D.? L
)*.* L
7ormal ()9<)#"
()*+9*+),"
()*+99+),"
The patient hemoglobin
Levels are in!reasing
a%ter her CAB1.
A%ter surgery it is
!ommon to see e!rease
'1B levels. In!reasing
tren sho.s patientIs
boy is prou!ing more
bloo !ells
B67
#* '
#* '
7ormal (#<9*"
()*+9*+),"
()*+99+),"
The B67 is remaining
!onstant at elevate levels
The in!rease B67 !an
be elevate be!ause o%
C3Is C'&
Creatinine
).D '
).9 '
7ormal (*.?<).*"
()*+9*+),"
()*+99+),"
The !reatinine is
e!reasing but is still
elevate above the
normal level
The e!reasing !reatinine
rates suggests that the
Eineys are returning to
normal %un!tioning
C2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet5 vitals5 a!tivity5 s!heule
iagnosti! tests5 !onsults5 a!!u !he!Es5 et!. Also provie rationale an %reHuen!y i% appli!able."
In!entive spirometer< prevention o% pneumonia5 ?4 per hour
Consistent !arbohyrate iet
Change ressing on le%t leg< Eeep open blisters !lean to prevent in%e!tion
A!tivity< in!rease patient strength@ physi!al therapy on!e a ay
: NURSING DIAGNOSES (a!tual an potential < liste in orer o% priority"
). Impaire sEin integrity r+t allergy to ahesive tape aeb blisters on lo.er right leg an le%t thigh
9. RisE %or in%e!tion r+t presen!e o% open sores on legs
,. A!tivity intoleran!e r+t re!ent !aria! surgery aeb inability
2.
?.
E 1' CARE PLAN
N.%!#g D!ag#"%!%: Impaire sEin integrity r+t allergy to ahesive tape aeb blisters on lo.er right leg an le%t thigh
Pat!e#t G"a$%/O.t*"(e% N.%!#g I#te7e#t!"#% t" A*)!e7e
G"a$
Rat!"#a$e 4" I#te7e#t!"#%
P"7!1e Re4ee#*e%
E7a$.at!"# "4 G"a$ "# Da0 *ae !%
P"7!1e1
)" Regain integrity o% sEin sur%a!e )" 0eep area o% sEin breaE !lean )" -revents other organisms %rom Although the patients sEin integrity
Be%ore patient is is!harge %rom an apply antiba!terial ointment inhibiting the .ouns to heal i not repair itsel% in one shi%t5
hospital properly .hi!h .as not e4pe!te5 the
9" Dis!ontinues use o% ahesive interventions to ai healing .ere
Tapes an stat lo!E evi!es 9" -revents %uture in!ien!es o% per%orme. Antiba!terial ointment
sEin breaE o.n that .oul nee applie5 an absorbent banages
," Apply absorbent banage to to be aresse .ere applie to the sEin.
A%%e!te area o% sEin
," The absorbent banages .ill
Absorb the serous rainage %rom
The blisters5 ai healing o% the
(ouns an prevent other sores
&orming %rom the moist sEin the
OoCing blisters .oul !ause.
E2 DISCHARGE PLANNING: (put a Q in %ront o% any pt eu!ation in above !are plan that you .oul in!lue %or is!harge tea!hing"
C"#%!1e t)e 4"$$"2!#g #ee1%:
R33 Consult
RDietary Consult
R-T+ OT
R-astoral Care
RDurable ;ei!al 7ees
R&+6 appts
L ;e Instru!tion+-res!ription I#%t.*t pat!e#t a5".t )"2 t" app$0 a#t!5a*te!a$ "!#t(e#t a#1 )"2 t" *)a#ge 1e%%!#g "# $eg%.
R are any o% the patientIs mei!ations available at a is!ount pharma!y= RBes R 7o
RRehab+ ''
R-alliative Care
E 1' CARE PLAN
N.%!#g D!ag#"%!%: RisE %or in%e!tion r+t open sores on the legs
Pat!e#t G"a$%/O.t*"(e% N.%!#g I#te7e#t!"#% t" A*)!e7e
G"a$
Rat!"#a$e 4" I#te7e#t!"#%
P"7!1e Re4ee#*e%
E7a$.at!"# "4 I#te7e#t!"#% "#
Da0 *ae !% P"7!1e1
)" -atient remains %ree o% )" Observe %or signs o% in%e!tion )" Observing %or signs o% in%e!tion -atient remaine %ree o% symptoms
symptoms o% in%e!tion uring shi%t. su!h as reness at .oun site or !an alert the nurse to the in%e!tion throughout the shi%t. I observe
in!rease boy temperature .hi!h !an then begin to be treate. %or signs o% in%e!tion throughout
the shi%t5 .ashe my hans be%ore
9" 6se appropriate han hygiene 9" 'an hygiene .ill prevent an a%ter ealing .ith patient5 an
be%ore an a%ter !oming in !onta!t organisms %rom nurses hans to be Eept the .oun !lean an applie
.ith the patient sprea to open areas o% sEin on the the antiba!terial ointment
patient.
," 0eep area o% open sEin !lean
an apply antiba!terial ointment to ," -revents ba!teria %rom in%e!ting
site the open areas o% the sEin.
E DISCHARGE PLANNING: (put a Q in %ront o% any pt eu!ation in above !are plan that you .oul in!lue %or is!harge tea!hing"
C"#%!1e t)e 4"$$"2!#g #ee1%:
R33 Consult
RDietary Consult
R-T+ OT
R-astoral Care
RDurable ;ei!al 7ees
L &+6 appts
R;e Instru!tion+-res!ription
R are any o% the patientIs mei!ations available at a is!ount pharma!y= RBes R 7o
RRehab+ ''
R-alliative Care
E 1' CARE PLAN
N.%!#g D!ag#"%!%:
Pat!e#t G"a$%/O.t*"(e% N.%!#g I#te7e#t!"#% t" A*)!e7e
G"a$
Rat!"#a$e 4" I#te7e#t!"#%
P"7!1e Re4ee#*e%
E7a$.at!"# "4 I#te7e#t!"#% "#
Da0 *ae !% P"7!1e1
)" -atient is able to .alE o.n to )a" -atient ambulates .ith physi!al )a" Tells .hether supplemental O9 )" patient ambulate to nurses
7urses station an ba!E to room therapy measuring O9 saturation is neee uring a!tivity. I% patient 3tation an ba!E .ithout
(ithout supplemental o4ygen .ith an .ithout o4ygen O9 saturation rops .ithout 3upplemental o4ygen neee.
7e!essary o4ygen5 patient still reHuires
)b" 6se .alEer an gait belt uring supplemental o4ygen uring 9" -atient e4!eee the number o%
9" Demonstrate in!rease toleran!e ambulation a!tivity RO; e4er!ises that the physi!al
To a!tivity throughout stay in )b" The .alEer provies support therapist asEe her to !omplete
hospital 9a" In!rease number o% RO; %or the patient uring ambulation.
e4er!ises aily epening on level the gait belt allo.s the nurse to
O% a!tivity toleran!e sa%ely lo.er patient to groun in
!ase o% a %all
9" (ith graual in!rease in a!tivity
toleran!e .ill !ontinue to in!rease.
E DISCHARGE PLANNING: (put a Q in %ront o% any pt eu!ation in above !are plan that you .oul in!lue %or is!harge tea!hing"
C"#%!1e t)e 4"$$"2!#g #ee1%:
R33 Consult
RDietary Consult
L -T+ OT
R-astoral Care
RDurable ;ei!al 7ees
R&+6 appts
R;e Instru!tion+-res!ription
R are any o% the patientIs mei!ations available at a is!ount pharma!y= RBes R 7o
L Rehab+ '' 8 !#%t.*t pat!e#t a5".t )"(e )ea$t) "pt!"#%. L!7e% 50 )e%e$4 !# *"#1" "# 4!%t 4$"". Re4.%e% e)a5.
R-alliative Care
Re%eren!es
'uether5 3. /.5 K ;!Can!e5 0. L. (9*)9". 6nerstaning -athophysiology (?
th
e.". 3t. Lousi5 ;O: ;osby.
I3B7: D>$<*<,9,<*>$D)
Rier5 /. A.5 K 3igelman5 C. 0. (9**D". Li%e<3pan 'uman Development (#
th
e.". Belmont: (as.orth5
Cengage Learning.