UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Ellie Wertheimer

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION
Patient Initials:
Gender:

R. S.
Male

Assignment Date: 10/31/2014

Agency: VA

Age: 65

Admission Date: June 3, 2013

Marital Status: Married

Primary Medical Diagnosis

Primary Language: English

Respiratory distress and quadriplegic

Level of Education: BS in bussiness

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Military

Pressure ulcer stage 4

Number/ages children/siblings: Brother: 63 or 64

Brother: late 40s early 50s

Daughter: 42
Served/Veteran: Yes
If yes: Ever deployed? Yes

Code Status: Full code

Living Arrangements: Living currently at the hospital

Advanced Directives: Yes Full

If no, do they want to fill them out?
Surgery Date:
Procedure:

Culture/ Ethnicity /Nationality: Declinede to answer; white, nonhispanic or latino

Religion: Baptist

Type of Insurance: Medicare

1 CHIEF COMPLAINT:
Quadraplegia with neurogenic bowel and bladder, respiratory failure on vent, sacral decubitus ulcer.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The onset was during his time in Vietnam, he stepped on a land mine. The location is all four limbs, with limited
movement in his right and left arms, can lift arms in flexion and extension movement. He was diagnosed with
quadriplegia in March ninth of 1971. The characteristics are inability to move or have very limited movement. People
with quadriplegia or paraplegia, can have autonomic dysreflexia (AD), a condition in which the patient has high blood
pressure do having pain or pressure below the level of injury. This can include, having a full bladder or having stool,
having sex, not moving in the bed, or even a crinkle in the sheets. He relieves it by finding the problem and getting rid of
it or having to put a patch of nitroglycerin. He treats his paralysis with medication.

University of South Florida College of Nursing Revision September 2014

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

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable
)

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Debridement sacral, pressure ulcer, bone biopsy
Hypokalemic
Hypocalamia
Laparoscopic diverting colostomy
Excisional debridement of right ischial wound with right gluteal island advancement flap
Cystoscopy
Fat grafting left ischeial scar
Cystoscopy
Left ischial wound flap coverage
Right trochanter pedicle flap
Debridement and flap closure right trochanteric pressure ulcer
Scar revision excistium
Re-excision skin lesion/ cyst BACK
Cytolitolapaxy
cytoscopy
Diabetes mellitus type 2
Right heel wound debridement/ possible calcaned bone debridement
Debridement of right heel wound/leg wound
Right heel debridement bone and tissue with reapplication of wound vac
Wide wound debridement of bone nad tissue
Excision tracanteric ulcer, muscle flap closure
Excision and flap closure L trochanteric decubitus
Excision ischial ulcer, myocutaneous flap reconstruction
Quadriplegia

Alcoholism

Age (in years)

Date
Sep 08, 2014
Aug 16, 2014
Aug 05, 2014
Jul 30, 2014
Oct 09, 2013
Feb 12, 2013
Mar 02, 2012
Nov 01, 2011
Sep 02, 2011
Oct 20, 2010
Aug 27, 2010
Jul 15, 2010
Nov 21, 2008
Nov 17, 2008
Oct 24, 2008
Mar 13, 2008
Sep 24, 2007
Sep 20, 2007
Sep 17, 2007
Sep 13, 2007
Dec 03, 1993
Oct 13, 1993
Mar 17, 1993
Mar 09, 1971

Father
Mother
Brother
Brother
Granddaughter

Aunt
relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
University of South Florida College of Nursing Revision September 2014

NO
2

Routine childhood vaccinations

Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? 10/01/2009
Influenza (flu) (Date) Is within 1 years? 10/18/2002
Pneumococcal (pneumonia) (Date) Is within 5 years? 10/27/2010
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
Talwin injection
30 mg/mL

Type of Reaction (describe explicitly)

Rash, disorientated

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)
Immediately, after a spinal injury has occurred, there is a release of glutamate. This causes cellular damage and petechial
Hemorrhages where the injury occurred. Then a calcium influx causes a thrombus formation. The calcium also triggers a a
arachidonic acid cascade, which in turn releases free radicals, lactic acidosis and lipid peroxidation. The final cascade
quickens the ischemia of the white matter and destruction of the microvasculature. The destruction of the white matter
and microvasculature leads to permit paralysis.

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:

Novolin

Route

Injection

Concentration: 100 units/mL

Frequency

Pharmaceutical class Pancreatics

Home

Hospital

Dosage Amount: 100 units/mL

QD
or

Both

Indication: Control of hyperglycemia in patients with type 1 or type 2 diabetes mellitus

Adverse/ Side effects:

Hypoglycemia, erythema, lipdystrophy, prurtis, swelling, allergic reactions including anaphylaxis

Nursing considerations/ Patient Teaching: how to discard syringes, swabs, cartilage pens. The medication helps control the hyperglycemia but does not cure
diabetes. Instruct on the proper testing of glucose and ketones.

University of South Florida College of Nursing Revision September 2014

Name: Albuterol premixed soln

Route

Concentration:

one vial

Inhaled

Dosage Amount

Frequency

Pharmaceutical class: Adrenergics

Home

Hospital

one vial

QD
or

Both

Indication: prevent reversible airway obstruction caused by asthma or COPD

Adverse/ Side effects: nervousness, restlessness, tremor, headache, insomnia, Paradoxical Bvronchospasm, chest pain, palpitations, angina, arrhythmias,
hypertension, nausea, vomiting, hyperglycemia, hypokalemia, tremor
Nursing considerations/ Patient Teaching: Do not double does or increase the dosage. The patient must prime the inhaler with4 pumps, and discharge after 200
uses.
Name

Guaifenesin

Route
Pharmaceutical class

Concentration

400mg

oral

Frequency

Guaifenesin

Indication

Dosage Amount

Home

Hospital

400mg

BID
or

Both

Coughs associated with viral upper respiratory tract infections

Adverse/ Side effects: dizziness, headache, nausea, diarrhea, stomach pain, vomiting, rash, urticaria
Nursing considerations/ Patient Teaching: Patient needs to couch effectively, sit upright and take deep breaths before coughing, advise the patient to limit
talking, smoking, maintain moisture in environmental air.
Name: ipratropium

Concentration: one vial

Route

inhalation

Pharmaceutical class: anticholinergics

Dosage Amount: one vial

Frequency: QD
Home

Hospital

or

Both

Indication: Maintenance therapy of reversible airway obstruction due to COPD, including chromic bronchitis and emphysemia
Adverse/ Side effects: dizziness, headache, nervousness, blurred vision, sore throat, bronchospasm, cough, hypotension, palpitations, GI irritation, nausea,
rahs, allergic reactions.
Nursing considerations/ Patient Teaching: Do not exceed 12 doses within 24 hours. If conditions have worsen, notify health care provider.
Name: lansoprazole

Concentration: 30mg

Route: NG tube

Dosage Amount: 30mg

Frequency QD

Pharmaceutical class: proton pump inhibitors

Home

Hospital

or

Both

Indication: Erosive esophagitis, duodenal ulcers, active benign gastric ulcer, short-term treatment of symptomatic GERD, healing and risk reduction of
NSAID-associated gastric ulcer, pathogenic hypersnesitvitiy conditions, including Zollinger-Ellison syndrome
Adverse/ Side effects: dizziness, headache, pseudomembranous colitis, diarrhea, abdominal pain, nausea, rash, hypomagnesemia, bone fracture
Nursing considerations/ Patient Teaching: take medication for the full course, do not stop. Avoid alcohol, products with NSAIDS, and foods that increases GI
irritation.
Name Ascorbic acid

Concentration 500 mg.

Route G tube

Dosage Amount 500mg.

Frequency QD

Pharmaceutical class water soluble vitamins

Home

Hospital

or

Both

Indication: Supplemental therapy in some GI diseases during long-term parenteral nutrition or chronic hemodialysis
Adverse/ Side effects: drowsiness, fatigue, headache, insomnia, cramps, diarrhea, hearburn, nausea, vomiting, kidney stones, flushings, deep vein thrombosis,
hemolysis, sickle cell crisis, pain at subcut or IM sites
Nursing considerations/ Patient Teaching: take medication as prescribed, do not go over dose prescribed. Patients need to take more vitamin C as it can lead to
a deficiency.
Name: Bisacodyl

Concentration: 10 mg

Route: oral

Dosage Amount: 10 mg
Frequency: QD

Pharmaceutical class: stimulant laxatives

Home

Hospital

or

Both

Indication: treatement of constipation

Adverse/ Side effects: abdominal cramps, nausea, diarrhea, rectal burning, hypokalemia, muscle weakness, protein-losing enteropathy, tetany
Nursing considerations/ Patient Teaching: Fluid intake should be increased to 1500-2000 mL a day. Patient with cardiac disease to avoid straining during bowel
movements
Name: hydrocortisone

Concentration varies

Dosage Amount: vaires

University of South Florida College of Nursing Revision September 2014

Route: topical

Frequency: QD

Pharmaceutical class: anti-inflammatories

Home

Hospital

or

Both

Indication: management of inflammation and pruitis associated with various allergic/immunologic skin problems.
Adverse/ Side effects: allergic contact dermatitis, atrophy, burning, dryness, edema, folliculitis, hypersensitivity reactions, hypertrichosis, hypopigmentation,
irritation, maceration, miliaria, perioral dermatitis, secondary infection, striae, adrenal suppresion
Nursing considerations/ Patient Teaching: use as directed, inform health care provider if condition worsens or does not improve.
Name: Insulin novo

Concentration: 48 units

Route: subcutaneous

Dosage Amount: 48 units

Frequency: QD

Pharmaceutical class pancreatics

Home

Hospital

or

Both

Indication: Control of hyerpglycemia in patients with diabetes mellitus

Adverse/ Side effects: hypoglycemia, lipodystrophy, pruritus, erythema, swelling, allergic reactions including anaphylaxis
Nursing considerations/ Patient Teaching: demonstrate proper technique, to watch for hypoglycemia, insulin helps control the symptoms of diabetes, but does
not cure diabetes.

Name: Ketoconazole cream

Concentration: vaires

Route: topical

Dosage Amount: varies

Frequency QD

Pharmaceutical class: imidazoles

Home

Hospital

or

Both

Indication: treatment of different kinds of fungal infections including, athletes foot, jock itch, ringworm and dandruff
Adverse/ Side effects: burning, itching, local hypersensitivity reactions, redness, stinging, hair loss (shampoo)
Nursing considerations/ Patient Teaching: take the medication for full course of therapy, if there is increased skin irritation or no response to medication talk to
your provider.

Name: magnesium oxide

Concentration: 420 mg

Route oral

Dosage Amount: 420 mg

Frequency: QD

Pharmaceutical class: salines

Home

Hospital

or

Both

Indication: treats or prevents hypomagnesemia

Adverse/ Side effects: diarrhea, flushing sweating
Nursing considerations/ Patient Teaching: Do not take medication within 2 hours of taking this medication especially fluoroquinolones, nitrofurantion and
tetracyclines
Name: metformin

Concentration: 850 mg

Route: oral

Dosage Amount: 850 mg

Frequency: QD

Pharmaceutical class: biguanides

Home

Hospital

or

Both

Indication: helps manage type 2 diabetes

Adverse/ Side effects: abdominal bloating, diarrhea, nausea, vomiting, unpleasant metallic taste, lactic acidosis, decreased vitamin B12 levels
Nursing considerations/ Patient Teaching: Take around the same time every day, take missed dose as soon as possible, helps control the symptoms of diabetes but
does not cure diabetes, blood glucose levels should still be monitored closely.
Name: metoclopramdie

Concentration: 10 mg

Route: oral

Dosage Amount: 5 mg
Frequency: QD

Pharmaceutical class: antiemetics

Home

Hospital

or

Both

Indication: treatment of postsurgical and diabetic gastric stasis

Adverse/ Side effects: drowsiness, extrapyramidal reactions, restlessness, neuroleptic malignant syndrome, anxiety, depression, irritability, tardive dyskinesia,
arrhythmias, hypertension, hypotension, constipation, diarrhea, dry mouth, nausea, gynecomastia, methemoglbinemia, neutropenia, leukopenia, agranulocytosis
Nursing considerations/ Patient Teaching: If the patient has missed a does, they need to take it as soon as possible, can causes drowsiness, avoid driving or other
activates with heavy machinery, avoid alcohol or CNS depressants while on this medication.
Name: oxybutynin
Route: oral

Concentration: 5mg

Dosage Amount5mg
Frequency: QD

University of South Florida College of Nursing Revision September 2014

Pharmaceutical class urinary tract antispasmodics

Home

Hospital

or

Both

Indication: overactive bladder with symptoms of urge incontinence, urgency and frequency
Adverse/ Side effects: dizziness, drowsiness, agitation, confusion, hallucinations, headache, blurred vision, hoarseness, chest pain, edema, tachycardia,
constipation, dry mouth, nausea, abdominal pain, anorexia, diarrhea, dysphagia, increase thirst, urinary retention, decreases in sweating, hot, hyperthermia,
anaphylaxis, angioderma
Nursing considerations/ Patient Teaching: If the patient misses a dose, the patient needs to take it as soon as possible, may cause drowsiness or blurred vision,
avoid driving heavy machinery. Do not drink alcohol or any CNS depressants while on this drug
Name: simethicone

Concentration: 160mg

Route: oral

Dosage Amount

160mg

Frequency: QD

Pharmaceutical class: antiflatulent

Home

Hospital

or

Both

Indication: relief of painful symptoms of excess gas in the Gi tract

Adverse/ Side effects: no significant effects
Nursing considerations/ Patient Teaching: The best way to help with gas is dieting and exercise, the medicine does not prevent gas, if the symptoms still persist,
notify the health care provider.
Name: triamcinolone

Concentration: varies

Route: topical

Dosage Amount: varies

Frequency: QD

Pharmaceutical class: corticosteroids

Home

Hospital

or

Both

Indication: to help with various allergic and immunologic skin problems

Adverse/ Side effects: allergic contact dermatitis, atrophy, burning, dryness, edema, folliculitis, hypersensitivity reactions, hypertrichosis, hypopigmentation,
irritation, maceration, miliaria, perioral dermatitis, secondary infection, striae,
Nursing considerations/ Patient Teaching: avoid the eyes when putting the medication on, if the infection continues or worsens, contact health care provider
Name: zinc sulfate

Concentration: 440 mg

Route: G tube

Dosage Amount: 440 mg

Frequency: QD

Pharmaceutical class trace metals

Home

Hospital

or

Both

Indication: supplements for people with zinc deficiency

Adverse/ Side effects: gastric irritation, nausea, vomiting
Nursing considerations/ Patient Teaching: the patient needs to comply with diet recommendations, they need to not exceed RDA, patients receiving zinc need to
notify their health care provider.
Name: diazepam

Concentration: 5 mg

Route: oral

Dosage Amount: 5 mg
Frequency: QD

Pharmaceutical class: benzodiazepines

Home

Hospital

or

Both

Indication: to help with anxiety disorder, stiffman syndrome, skeletal muscle relaxant
Adverse/ Side effects: dizziness, drowsiness, lethargy, depression, hangover, ataxia, slurred speech, headache, paradoxical excitation, blurred vision, respiratory
depression, hypotension, constipation, diarrhea, nausea, vomiting, weight gain, rashes, pain, phlebitis, venous thrombosis, physical dependence, psychological
thrombosis
Nursing considerations/ Patient Teaching: do not take more than prescribed, may cause drowsiness, clumsiness or unsteadiness. With Geri: increased risk for
CNS effects and potential for falls
Name: docusate

Concentration: 100 mg

Route: oral

Dosage Amount: 100mg

Frequency: QD

Pharmaceutical class: stool softeners

Home

Hospital

or

Both

Indication: prevents constipation and softens fecal impaction

Adverse/ Side effects: throat irritation, mild cramps, diarrhea, rashes
Nursing considerations/ Patient Teaching: long term with laxatives can cause electrolyte imbalance and dependence. Do not take docusate within 2 hours of
other laxatives
Name: flunisolide

Concentration: 2 puffs

Route: inhalation

Dosage Amount: 2 puffs

Frequency: QD

Pharmaceutical class: corticosteroids

Home

Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Indication: seasonal or perennial allergic rhinitis

Adverse/ Side effects: nasal burning, epistaxis, nasal dryness, nasal irritation, nasopharyngeal fungal infection, pharyngitis, aftertaste, nausea, adrenal
suppression, cough
Nursing considerations/ Patient Teaching: take medicine directing as directed, if miss a dose, take it as soon as possible. Instruct the patient in the correct
technique for administering the medicine, if symptoms do not improve within 3 weeks, notify health care provider
Name: gabapentin

Concentration: 200 mg

Route: oral

Dosage Amount: 200mg

Frequency: BID

Pharmaceutical class: anticonvulsants

Home

Hospital

or

Both

Indication: for partial seizures, postherpetic neuralgia, and restless legs syndrome
Adverse/ Side effects: suicidal thoughts, confusion, depression, dizziness, drowsiness, sedation, anxiety, malaise, vertigo, weakness, abnormal vision, nystagmus,
hypertension, weight gain, anorexia, flatulence gingivitis, rhabdomyolysis, arthralgia, increase in creatine kinase
Nursing considerations/ Patient Teaching: Advise patient not to take gabapentin within 2 hours of an antacid, notify health care provider if there is thoughts of
suicide or dying.
Name: levetiracetam

Concentration: 250 mg

Route: oral

Dosage Amount: 250 mg

Frequency: QD

Pharmaceutical class: pyrrolidines

Home

Hospital

or

Both

Indication: for partial onset seizures

Adverse/ Side effects: suicidal thoughts, aggression, agitation, anger, anxiety, apathy, depersonalization, depression, dizziness, hostility, irritability, personality
disorder, weakness, drowsiness, dyskinesia, fatigue, coordination difficulties, steven-johnson syndrome, toxic epidermal necrolysis
Nursing considerations/ Patient Teaching: if there is any sucide thoughts or depression, contact the provider, can causes dizziness careful when operating heavy
machinery.
Name: mineral oil

Concentration: 30 mL

Route: oral

Dosage Amount: 30 mL
Frequency: QD

Pharmaceutical class: lubricant laxatives

Home

Hospital

or

Both

Indication: used to soften impacted feces in the management of constipation

Adverse/ Side effects: lipid pneumonia, diarrhea, anal irritation, rectal seepage of mineral oil
Nursing considerations/ Patient Teaching: laxatives should be used for short term purposes only, avoid straining when making a bowel movement
Name: prednisone

Concentration: 10 mg

Route: oral

Dosage Amount: 10 mg
Frequency: QD

Pharmaceutical class: anti-inflammatories

Home

Hospital

or

Both

Indication: can be used for hypercalcemia, for chronic illnesses, and inflammatory, allergic, hematologic, neoplastic, autoimmune disorders
Adverse/ Side effects: depression, euphoria, headache, personality changes, psychoses, restlessness, cataracts, increased intraocular pressure, hypertension,
peptic ulceration, anorexia, nausea, vomiting, acne, decreased wound healing, ecchymosess, fragility, hirsutism, petechiae, adrenal suppression, hyperglycemia,
fluid retention, hypokalemia, hypokalemic alkalosis, thromboembolism, thrombophlebitis, weight gain, weight loss, muscle wasting, osteoporosis avascular
necrosis of joints, muscle pain, cuhingoid appearance, increased susceptibility to infection
Nursing considerations/ Patient Teaching; may have adrenal insufficieny (anorexia, nausea, weakenss, fatigue, dyspnea, hyptension, hypoglycemia) stop taking
medcation and seek a health care provider immediately.
Name: simethicone

Concentration: 160 mg

Route: oral

Dosage Amount: 160mg

Frequency: QD

Pharmaceutical class: antiflatulent

Home

Hospital

or

Both

Indication: relief of excess gas in Gi tract

Adverse/ Side effects: none significant
Nursing considerations/ Patient Teaching:
symptoms still persist, contact your health care provider
Name: sennosides

the medication does not prevent gas, the best way to control gas is though diet and exercise, if

Concentration: 353mg

Route: G tube

Dosage Amount: 10mL

Frequency: QD

Pharmaceutical class: stimulant laxatives

Home

Hospital

or

Both

Indication: treatment for constipation

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects: cramping, diarrhea, nausea, pink-red or brown-black discolartion of urine, electrolyte abnormalities, laxative dependence
Nursing considerations/ Patient Teaching: Urine may turn pink, red, violet, yellow or brown

Name: Acetomephen

Concentration: 325mg

Route: oral

Dosage Amount: 2
Frequency: UD PRN

Pharmaceutical class: nonopiod analgesics

Home

Hospital

or

Both

Indication: treatment of moderate to severe pain

Adverse/ Side effects: headache, dizziness, drowsiness, intraventricular hemoorhage, psychic disturbances, amblyopia, blurred vision, tinnitus, arrhythmias,
edema, hypertension, GI bleeding hepatitis, constipation, dyspepsia, nausea, necrotizing enterocolitis, vomiting, abdominal discomfort, cystisis, hematuria, renal
failure, exfoliative dermatisi, stevens Johnson syndrome, toxic epidermal necrolysis, rashes, injection site reaction, anemia, blood dyscrasas, prolonged bleeding
time, allergic reactions including anaphylaxis
Nursing considerations/ Patient Teaching: take with a full glass of water, avoid taking with alcohol, aspirin, acetaminophen and other OTC or herbal products
without consulting a health care provider. Can increase GI bleeding

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
1800 cal care controlled diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? 1800 cal care controlled diet
Consider co-morbidities and cultural considerations):
24 HR average home diet: 1800 cal care controlled diet
In total he ate 1308 calories
Breakfast: eggs, biscuit, turkey sausage
He needs more calories and protein to help heal his stage 4
pressure ulcer
Lunch: chicken wrap, fries, peaches, grapes
Dinner: chicken breast, rice, vegetable medley
Snacks:
Liquids (include alcohol):
Orange juice, Gatorade, water
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
My wife
How do you generally cope with stress? or What do you do when you are upset?
Do alright with it

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
No we all have that sometimes

University of South Florida College of Nursing Revision September 2014

+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?
________________probably __________________________ If yes, have you sought help for this?
______________________
Are you currently in a safe relationship? guess so

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

Ego integrity is feeling that one has had accomplishments in life, such as having a family, a successive job and doing
activities in life that are meaningful. The person enjoys retirement and is happy about their life. The patient was happy to
answer questions and would add jokes into the questions. He was happily married and talked to his wife frequently.
He also was happy about getting his BS in business. He does not like to talk much about being a veteran and being in
Vietnam.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The impact of being in the hospital seems not to have too much of an impact on his mood. He seems to enjoy life and
likes to joke around with the nurses and doctor.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Paralysis
What does your illness mean to you?
not a whole lot

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?_______yes__________________________________________________________
Do you prefer women, men or both genders? ___________women____________________________________________
Are you aware of ever having a sexually transmitted infection? _____no_______________________________________

University of South Florida College of Nursing Revision September 2014

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?
_______yes_____________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _________condoms_________________________
How long have you been with your current partner?_________48 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

University of South Florida College of Nursing Revision September 2014

10

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

What importance does religion or spirituality have in your life?
__Baptist___________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
____Yeah sort of__________________________________________________________________________________
______________________________________________________________________________________________________

+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)
yes
Half a pack a day
Pack Years: 1970 to 1980
Does anyone in the patients household smoke tobacco? If
so, what, and how much?
no

Yes
No
For how many years? 10 years
(age 21 thru

31

If applicable, when did the

patient quit?
Yes, 1980
Has the patient ever tried to quit?
If yes, what did they use to try to quit? nothing

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
How much? few beers, every now
What?
and then
yes
Volume: unknown to patient
Frequency: unknown to patient
If applicable, when did the patient quit?

For how many years?

(age

thru

Unknown to patient

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?
No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
no
5. For Veterans: Have you had any kind of service related exposure?
Yes, agent orange in Vietnam

University of South Florida College of Nursing Revision September 2014

11

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health?

Not to good right now

Integumentary: pressure ulcer stage 4, no sunscreen use, problem with nails (clubbing), no dandruff, psoriasis,
haves or rash, skin infections or changes in appearance of skin. Bed bath once a day.
HEENT: Brushes teeth once a day, Dentist visit once a year, no vision screening. Slight discomfort in eyes with
light. No dental problems, oral/pharyngeal infections, ear infections, difficulty hearing, cataracts or glaucoma, or
difficulty seeing.
Pulmonary: Difficulty breathing, on a respiratory vent. No asthma, emphysema, pneumonia, tuberculosis or
environmental allergies. Does have bronchitis, treated with medication, has had it for months. Cough is dry,
gives pain in chest, pain is a 2, has been cough for the past week, treating with medication.
Cardiovascular: Hypertension, runs in the family, no pain, treated with medication. No hyperlipidemia, chest
pain/angina , CAD/PVD, CHF, Murmur, thrombus, rheumatic fever, myocarditis, arrhythmnias. Has myocardial
infarction, treated with medication, symptoms have been reduced by the medication, no pain, duration has been
years.
GI: Constipation., has no pain from it, but can have AD symptoms. Treats with medication to relieve the
constipation, several different laxatives. Has a colostomy bag on left side(LUL). No GERD, nausea, vomiting,
diarrhea, irritable bowel syndrome, cholecytitis, gastritis/ulcers, blood in the stool, hepatisis, indigestion,
hemorrhoids, yellow jaundice, pancreatitis, colitis, diverticulitus, appendicitis, or abdominal abscess.
GU: Normal frequency of urination: about 730 mL every 24 hours. No nocturia, dysuria, hematuria, polyuria,
bladder or kidney infections or kidney stones.
Women/Men Only: No infection of the genitalia/prostate, or urinary retention. Does have BPH, has screening
for the BPH. Has a prostate exam every year. Does not remember last prostate exam
Musculoskeletal: Has weakness do to medication and paralysis. Arthritis is treated with medication, states that it
is painful, has had it for years, and is genetic. Does not have injuries or fractures, pain, gout, or osteomyelitis.

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Immunologic: Does not have chills, night sweats, fever, HIV or AIDS, Lupus, rheumatoid arthritis, sarcodisis,
tumor, life threating allergic reaction or enlarged lymph nodes.
Hematologic/Oncologic: Does not have anemia, bleed easily, bruises easily, cancer, or blood transfusion.
Metabolic/Endocrine: Does have diabetes type 2 treats it with medication and a steady diet, occurred in 2008.
Has an intolerance to cold, must be under blankets. Does not have hypothyroid or hyperthyroid, or osteoporosis.
Central Nervous System: Does not have CVA dizziness, severe headaches, migraines, ticks or tremors,
encephalitis, or meningitis. Does have seizures, does take seizure medication, last from 1 minute to 3 minutes.
He is a quadriplegic, diagnosed in 1971after a landmine accident. Has some mobility in his arms (flexion and
extension)
Mental Illness: Dos not have depression, schizophrenia, anxiety, bipolar.
Childhood Diseases: Did have measles, mumps, and chicken pox as a child. Did not have scarlet fever or polio.

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: Seemed very tired, and weak
Height: 70 in Weight: 181.4 lb BMI: 26.08 Pain (include rating and location): 4, sacrum
Pulse: 94
Blood Pressure (include location): 97/66 cuff automatic, left upper arm
Temperature (route taken): 98.4 oral
Respirations: 10
SpO2 : 98
Room Air or O2: room air
Overall Appearance: Pallor, weekend mobility in arms, groomed well, shaved, clean skin, hair well groomed

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Overall Behavior: very willing to answer questions, kind, very tired in appearance, judgment intact
Speech: quiet speech, soft and difficult to understand, mumbles
Mood and Affect: mellow, smiled, very weak and tired, but having a positive attitude, cooperative and cheerful
Integumentary: stage 4 pressure ulcer on sacrum, healing, no dehydration, had capillary refill in less than 3
seconds, skin is cool, dry and intact, hair is evenly distributed, slight clubbing
IV Access: Clean, not erythemic and no edema, tubes were connected in proper placements, no discharge.
Location: right arm, date inserted: 10/29/2014, 24 gauge
HEENT: had a symmetrical smile and facial features, could feel touch above spinal cord injury, no pain in sinus
region, no pain, clicking of TMJ. The trachea midline with the rest of the neck, the thyroid is not enlarged, with no
palpable lymh nodes, the sclear is white, and conjunctiva clear, small discharge, eyebrows eyelids orbital area,
eyelashes and lacrimal glands symmetric without edema or tenderness. Has PERRLA in both eyes, with peripheral
vision intact, EOM intact though 6 cardinal fields without nystagmus. Ears are symmetric without lesions or
discharge, passed the whisper test in both ears, 4 inches away. There are no lesions or discharge from the nose. The
lips, vuccal mucosa, floor of mouth and tongue are moist with no lesions.
Pulmonary/Thorax: on a respiratory vent, chest was even during inhalation and exhalation. Reported that he was
having some difficulty breathing. Had clear lung sounds in all quadrants when auscultated. Breathing is slightly
labored, had a 2:1 transverse ratio. Percussion resonant throughout all lung fields, dull towards posterior bases.
The sputum production was thick, small amounts, with white color. The lung sounds were clear in all quadrants
(RUL, RML, RLL, LUL, LLL)
Cardiovascular: heart rhythm was normal, no mummer, no carotid bruit or temporal, complained of no chest pain.
S1 and S2 were clear with no regurgitation. No lifts, heaves or thrills, with the S1 and S2 audiable, and no JVD.
There is no calf pain, and pulses are equal bilaterally.
GI: Normal bowel sounds in all four quadrants. Colostomy bag was full, moist stool, has some gas in the colostomy
bag. Dull percussion over the liver and spleem with tympanic over stomach and intestine. Abdomen was slightly
tender but palpable.
GU: Urine output is clear, no sentiment, and was yellow in the folly catheter, had about 135 mL in 5 hours.
Previous 24 hour output: 712. No bathroom privileges, CVA punch without rebound tenderness
Musculoskeletal: Weakness in muscles and bones, paralysis in all four limbs. Able to move both arms in a flexion
and extension. Mostly used his arms to wipe his eyes. Full ROM passively no kyphosis or scoliosis. No pain, slight
pallor, paralysis (quadriplegia)
Neurological: Was alert and awake, was orientated. Able to answer all of the questioned asked. Had feeling above
the injury site on his spine. Stereognosis, graphesthesis and proprioception not intact. Unable to do Rombergs and
unable to check the gait.

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
Whole Blood Glucose

Dates

Sodium

10/31/2014

Potassium
Chloride
CO2

10/31/2014
10/31/2014
10/31/2014

10/30/2014
22:39

Trend
Flag High
187
Normal is between 65 to
110
Flag low
132
3.6 normal
101 normal
19 Flag Low

Analysis
High because of diabetes
type 2
Had less sodium in diet in
the previous day

Has been on the vent,

having difficulty
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breathing.
Urea nitrogen
EGFR
Creatinine

10/31/2014
10/31/2014
10/31/2014

Normal 15
> 60
0.2 Flag low

Anion Gap
Calcium

10/31/2014
10/31/2014

12 normal
9.3 normal

Having difficulty
urinating

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Sacral wound care- irrigate wound and tunnel at 1200 with 20 cc Dakins, dry cut one 6x6 Aquacel Ag inot a
Spiral and pack wound beginning with tunnel at 1200. App.y antifungal powder and daily, change ABD.
Respiratory: Do not inflate cuff until 22:00
Enteral nutrtion: Weigh weekly
Rt ischial wound- Promorgan, Aquacel Ag and mepile x qd
Please change suprapubic cath, Q2 weeks per policy
G-tube flushes- 50 mL nSS every 4 hours
LEP during night shift 6 am and 8 pm
Apply calzyme and micronazole powder to fungal rash on sacrum
Apply powder to neck
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1.Mobility, impaired physical
Related to: neuromuscular impairment
As proved by: paralysis
2.Bowel Incontinence
Related to: perceptual impairment
As proved by: loss of ability to evacuate bowel voluntarily
3.
4.
5.

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 15 CARE PLAN
Patient Goals/Outcomes
To have a solid bowel movement
by the end of the shift

Nursing Diagnosis: Nursing Diagnosis goes here

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Drink a glass of water every hour
A decreaed thirst sensation leads
and half to loosen the stool
to decreased fluid intake, and the
use of narcotics for chronic pain
management leads to slowed
peristalsis. (245)
Increase fiber in the diet, by eating It is even harder this patient
broccoli, raisins, oatmeal, and
because of the inability to
almonds.
ambulate, A low-fiber diet and
sedentary lifestyle contribute to the
occurrence of constipation in
adults. ( 184)
Go to a bowel management
This way, the patient can help
program for a day.
himself with his colostomy bag for
when he returns home, A bowel
training program includes diet,
medicines, and digital stimulation
(touching inside the rectum to help
the bowels move). (685)

Evaluation of Goal on Day Care

is Provided
The goal is to have solid bowel
movement, with a full colostomy
bag (400-500 mL). Initial volume
was 130 mL.
The goal was met; mineral oil
seemed to work very well. Did not
go to bowel management program;
however, will in the future, closer
to discharge day. Filled 410 mL in
6 hours.

Include a minimum of one

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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 Medical Needs *
F/U appointments *
Med Instruction/Prescription *
are any of the patients medications available at a discount pharmacy? Yes
Rehab/ HH
Palliative Care *
The patient will be discharged at home, wife will care for him, and they have the equipment necessary. Will be released home after the pressure ulcer
heals.

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References

McLeod, S. A. (2008). Erik Erikson. Retrieved from Nov. 06 2014 from http://www.simplypsychology.org

Nursing Central. (2013-2014) Ubound medicince (2.3.16m) [Mobile application software]. Retrieved from
httpwww.uboundmedicine.com
Osborn, K. S. Wraa, C.E. Watson, A. B. Holleran, R. (2014). Medical-Surgical Nursing: Preparation for
Practice. Upper Saddle River, New Jersey: Pearson

Super tracker. (n.d.). Retrieved November 09, 2014 from https://www.supertracker.usda.gov/foodtracker.aspx

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