UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kayleigh Shelton

PATIENT ASSESSMENT TOOL .

Assignment Date: 02/28/15

Agency: VA

1 PATIENT INFORMATION
Patient Initials:

W.A

Age: 63

Admission Date: 02/09/15

Gender:

Male

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

ETOH dependence

Level of Education: BA in computer science and business

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Postal Service

N/A

Number/ages children/siblings: Two brothers and one sister

One daughter (34) two sons (32,38)
Served/Veteran: 20 years in army as a secretary
Living Arrangements: Lives at home with wife

Code Status: Full

Advanced Directives:
If no, do they want to fill them out? NO/NO
Surgery Date: n/a
Procedure:n/a

Culture/ Ethnicity /Nationality: white non Hispanic

Religion: none

Type of Insurance: VA

1 CHIEF COMPLAINT: I was heavily intoxicated. I dont know why I am in here.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
This 63-year-old male was brought in after being baker acted for being violent at home towards his wife. His wife states
that he walks around drunken all day defecating all over the house, and talks about dying all the time. Wife claims that he
has been throwing all of his medications away since December. He claims that he does not have a plan to kill himself, and
he gets his alcohol by calling a taxi. The sister of the wife corroborates the wifes claims. The patient also presents with
ataxia, delirium tremors, neurogenic bladder, and cerebella calcification.

University of South Florida College of Nursing Revision August 2013

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Operation or Illness

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

n/a

Bleeds Easily

87

Asthma

Mother

Arthritis

88

Anemia

Father

Cause
of
Death
(if
applicable
)
n/a

Environmental
Allergies

Neurogenic Bladder
Seborrheic dermatitis
Alcohol abuse
Ataxia
Cerebella calcification
Retained dental root

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Date
09/2013
Not documented
Not documented
Not documented
Not documented
Not documented

X
X

Brother
Sister
relationship
relationship
relationship

Comments: Include date of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
UNKNOWN
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
UNKNOWN
Adult Tetanus (Date) (over due)
Influenza (flu) (Date) (over due)
Pneumococcal (pneumonia) (Date) (over due)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

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NO

X
X
X
X
X

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKA
Medications

NKA
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)
This patient has come in with a primary DX of ETOH dependence. Alcohol dependence is usually cause by a major life
problem or traumatic event that triggers the constant use of alcohol, or a long term inability to cope with stressful
situations (Nursing , 2014). Alcohol dependence usually begins in early adulthood followed by periods of
exacerbation and remission. (Nursing , 2014) Alcoholism shortens your life expectancy by an average of ten
years, but 2/3 of patients are usually successful in obtaining abstinence (Nursing , 2014). Risk factors are any

type of unhappiness associated with their job, social life, marriage, money, legal issues, or even things like
exposure at a young age (Nursing , 2014). Alcohol in the body depresses the CNS while acting on the GABA
receptor (Nursing , 2014). One or two drinks cause a blood alcohol level of 0.02-0.03 g/dL. At that level changes
are already being made behaviorally, cognitively, and psychomotor (Nursing , 2014). The legal intoxication
amount is 0.08 g/dL. Signs of alcohol abuse can be deficiencies in folic acid, mild anemia, thrombocytopenia,
and hyperuricemia (Nursing , 2014). Treatment includes vitamins such as thiamine, fluid and electrolytes,
benzodiazepams, and counseling (Nursing , 2014).

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name Lorazepam

Concentration (mg/ml) 0.5 mg

Route PO

Dosage Amount (mg) 0.5mg

Frequency Q12H

Pharmaceutical class benzodiazepam

Home

Hospital

Indication Helps with symptoms of alcohol detoxification and anxiety

Side effects/Nursing considerations can not drink alcohol with this medication
Name Amlodipine

Concentration 10mg

Dosage Amount10mg

University of South Florida College of Nursing Revision August 2013

Route PO

Frequency Qdaily

Pharmaceutical class calcium channel blockers

Both

Indication antihypertensive
Side effects/Nursing considerations Do not drink a lot of grapefruit juice and do not take if BP is less than 50bpm
Name

Enoxaparin

Concentration 40mg/0.4ml

Route SQ

Dosage Amount 0.4ml

Frequency Q daily

Pharmaceutical class antithrombotics

Home

Hospital

Indication Anticoagulant
Side effects/Nursing considerations Do not take aspirin or ibuprofen while on this medication. Report any dizziness or bruising to doctor.
Name Acetaminophen

Concentration 650mg

Route PO

Dosage Amount 650mg

Frequency Q6H PRN

Pharmaceutical class Synthetic nonopioid p-aminophenol

derivative
Indication antipyretic, pain

Both

Side effects/Nursing considerations Dont use with other NSAIDS OR Warfarin (INR should not exceed 4). DO NOT USE WITH ALCOHOL. Hepatotoxicity is
a risk.
Name Folic acid

Concentration 1mg

Route PO

Dosage Amount 1mg

Frequency Q daily

Pharmaceutical class water soluble vitamins

Both

Indication restoration of normal hematopoiesis

Side effects/Nursing considerations May make urine more yellow. Inform doctor is rash develops.
Name Thiamine

Concentration 100 mg

Route PO

Dosage Amount 100 mg

Frequency Q daily

Pharmaceutical class water soluble vitamins

Both

Indication dietary supplement with alcoholism

Side effects/Nursing considerations Teach patients about the importance of a healthy diet, and food high in thiamine.
Name Nicotine patch

Concentration 21 mg

Route Transdermal

Dosage Amount 21mg

Frequency change Q 24 H

Pharmaceutical class cholinergic

Both

Indication smoke deterrent

Side effects/Nursing considerations ACETEMINOPHEN may increase effects! Application site may have burning and itching that should go away in an hour.
Should only wear one patch at a time, and apply at same time every day.

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Regular diet
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? Regular diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Two eggs and two pieces of whole wheat toast
Overall the patients diet is pretty good, if he would cut
with butter
out the alcohol and drink more water. Observing the patient
eating in the hospital, I am a little skeptical to the accuracy
of the meal description he gave me for at home. He does
not seem to eat too much here, but that could also be due to
dislike of food or discomfort in the hospital. As far as
grains, he is recommended to eat 6 oz and he eats about 6.5
oz. Vegetables are recommended to eat 2.5 cups, and he
eats about two, so he is a little under. He meets his target of
two cups of fruit. Dairy he suggested eating 3 cups, but he
does not report having any dairy in a typical meal. Protein
is suggested to have about 5.5 oz and he gets about 6, so he
is in range for protein. Finally he is taking in about 3030
calories compared to the suggested 2000. The calories can
be managed easily by cutting out the beer. I also would
suggest more dairy.
Lunch: Egg salad sandwich with chips
Dinner: Hamburger with potatoes
Snacks: chips, fruit, apple sauce
Liquids (include alcohol): 8 beers a night, one or two
glasses of 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 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? I get drunk or smoke.

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Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Same. I am in pain and dealing with life like everyone else.

+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?_____Yes, my wife does all of the time.__________ Have you ever been hit
punched or slapped? No_________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_________No_________________________________ If yes, have you sought help for this?
______________________n/a
Are you currently in a safe relationship? Yes.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

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

Industry 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:

My patient is currently in the stage of stagnation. In this phase a person looking back feels a lack of contributions to
society (Eriksons, 2011). This phase occurs between the ages of 40 and 65 (Eriksons, 2011). My patient doesnt
seem to feel like he contributed much, or is important to the world. He reports asking why am I still here and why
hasnt God taken me yet. He describes his contribution in the service as being a pencil pusher. When I inquired on
what that meant he said, I was just a secretary. My patient also told me he is not close with any of his children. He
seems a little depressed and expresses feelings of worthlessness.

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

ETOH dependence is usually influenced by depression or inefficient coping ability. My patients stagnation phase
may be a direct influence of his alcohol dependence. The feeling worthlessness and depression can easily cause someone
to be stuck in this phase, and keep them from generatively.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? Life.

University of South Florida College of Nursing Revision August 2013

What does your illness mean to you? It means I will be in pain for a very long time.

+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_____________________________________________
Have you or a partner ever had an abnormal pap smear?_I dont
know_______________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? I dont
know.________________________________
Are you currently sexually active? No________________________When sexually active, what measures do you take
to prevent acquiring a sexually transmitted disease or an unintended pregnancy?
___________________n/a_______________
How long have you been with your current partner? 17
years__________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? I am
incontinent___________________
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 August 2013

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

What importance does religion or spirituality have in your life?
I dont know.____________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition? No.
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)
Cigarettes
2 packs a day

Yes
No
For how many years? 50 years
(age

13

thru

63

If applicable, when did the

patient quit? n/a

Pack Years: 100

Does anyone in the patients household smoke tobacco? If
so, what, and how much?

Has the patient ever tried to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)
8 beers a day and whiskey
8 beers
A small glass of whiskey
If applicable, when did the patient quit?
n/a

For how many years?

(age

18

thru

now

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
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.

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 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
X Changes in appearance of skin
X Problems with nails
X Dandruff
X Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: Qdaily with help
Other:

HEENT
X Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
X Dental problems
Routine brushing of teeth
1/day
Routine dentist visits
0 /year
Vision screening No, cant remember
last one
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
X Last colonoscopy? 7-8 years
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
X Bleeds easily
X Bruises easily
Cancer
Blood Transfusions
Blood type if known: unknown

X nocturia
dysuria
hematuria
X polyuria
kidney stones
Normal frequency of urination:
/day
Bladder or kidney infections
On External Catheter

n/a

Hematologic/Oncologic

Other:

Metabolic/Endocrine
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
X Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
X last CXR? About two years ago
Other:

Cardiovascular
X Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
X Frequency of prostate exam?
Date of last prostate exam? 1 year
ago
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
X Seizures
X Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
X Depression
Schizophrenia
X Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
X Weakness
X Pain
Gout
Osteomyelitis

Childhood Diseases
X Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision August 2013

X Last EKG screening, when? (On

telemetry ) 02/14/15
Other:

X Arthritis
Other:

Chicken Pox
Other:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No

Any other questions or comments that your patient would like you to know?
No

University of South Florida College of Nursing Revision August 2013

10

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: Alert, calm,
cooperative
Temperature: (route taken?)
Oral 98.8F

Height: 68 in

Weight: not documented(not

taken)
BMI: 18.6
Blood
Pressure: 137/82 Right arm

Pulse: 91
Respirations: 18

Pain: (include rating & location)

No pain

(include location)

SpO2 96%
Is the patient on Room Air or O2: RA
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
X clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
X awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
X clear, crisp diction
Mood and Affect:X pleasant X cooperative
cheerful
X talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
X Skin is warm, dry, and intact
X Skin turgor elastic
No rashes, lesions, or deformities
X Nails without clubbing
X Capillary refill < 3 seconds
X Hair evenly distributed, clean, without vermin

X Peripheral IV site Type:

Heplock
X no redness, edema, or discharge
Fluids infusing? X no
yes - what?
Peripheral IV site Type:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Fluids infusing?
no
yes - what?

Location:
Location:
Location:

Left arm

flat
loud

Date inserted: 02/15/2015

Date inserted:
Date inserted:

HEENT:X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ X Trachea midline
X Thyroid not enlarged X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge
X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
X PERRLA pupil size 3 / mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmus
X Ears symmetric without lesions or discharge X Whisper test heard: right ear- 6
inches & left ear- 6
inches
X Nose without lesions or discharge X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

University of South Florida College of Nursing Revision August 2013

11

Pulmonary/Thorax:X Respirations regular and unlabored X Transverse to AP ratio 2:1 X Chest expansion symmetric
X Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
X Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
X Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Cardiovascular: X No lifts, heaves, or thrills PMI felt at: 5TH ICS MCL
Heart sounds: S1 S2 Regular
Irregular
X No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

X No JVD

X Calf pain bilaterally negative X Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
3 Carotid:
3 Brachial: 3
Radial:
3
Femoral: 3
Popliteal: 3
DP:
3
PT: 3
X No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
N/A
pitting
non-pitting
X Extremities warm with capillary refill less than 3 seconds

GI/GU: X Bowel sounds active x 4 quadrants; no bruits auscultated

X No organomegaly
X Percussion dull over liver and spleen and tympanic over stomach and intestine
X Abdomen non-tender to palpation
Urine output: X Clear
Cloudy
Color:
dark yellow
Previous 24 hour output:
800
mLs
N/A
X Catheter (EXTERNAL CATHERTER)
Urinal or Bedpan
Bathroom Privileges without assistance or with
assistance

X CVA punch without rebound tenderness

Last BM: (date 02
/ 16
/ 2015
)
Formed
Semi-formed
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green

Unformed
White

Soft

Coffee Ground

Hard
Maroon

Liquid
Bright Red

Hemoccult positive / negative (leave blank if not done)

Genitalia: X Clean, moist, without discharge, lesions or odor

Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: Full ROM intact in all extremities without crepitus

X Strength bilaterally equal at ____3___ RUE __3_____ LUE _4______ RLE & ___4____ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

X vertebral column without kyphosis or scoliosis

X Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias

Neurological:X Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
X CN 2-12 grossly intact
X Sensation intact to touch, pain, and vibration
Rombergs Negative (not done
due to impaired gait)
X Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

Biceps:

Brachioradial: 2

Patellar: 2

Achilles:

Ankle clonus: positive negative Babinski: positive

negative

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
BUN

Dates
8

(02/09/2015)

11

(02/15/2015)

Normal: 6-20
Creatinine
0.3 L
0.3 L

(02/09/2015)
(02/15/2015)

Trend
BUN has increased since
patient had been admitted
(detoxed), but has
remained in normal
range.
Creatinine was low upon
admission, and remained
the same.

Normal: 0.6-1.3

Albumin

(02/09/2015)

4.0
4.1
Normal: 4-6

(02/15/2015)

RBC

02/09/2015)
3.71 L
3.68 L

(02/15/2015)

Albumin remained in a
normal range.

The patients RBC count

upon admission was low,
and has decreased since
his admission (detox).

Normal: 4.6 - 6.2

HBG

02/09/2015)
12 L
12.1 L

(02/15/2015)

Hemoglobin upon
admission was low and
remained low after
admission (detox).

Normal: 13.5-18

HCT

02/09/2015)
37 L
36.8 L

Normal: 40-54%

(02/15/2015)

Hematocrit remained low

throughout admission.

Analysis
BUN is the result of
protein breakdown.
Usually BUN and
creatinine increase
together. When they dont
a cause can be
dehydration.
Creatinine is the result of
muscle breakdown.
Usually creatinine and
BUN rise together. When
BUN increases and
creatinine stays the same
it a common result of
dehydration. Low
creatinine can be
something as simple as
decreased muscle mass.
Albumin is a protein
made by the liver. We
look at this to evaluate
liver function. Since the
albumin level remains
normal, I would suspect
the liver is still healthy.
RBCs are the blood cells
that carry oxygen. When
excessive drinking
occurs, RBC decreases
due to toxic abuse on
bone marrow and
nutritional deficiencies.
Hemoglobin is a protein
that helps oxygen bind to
RBCs. Excessive alcohol
is a big factor in low
hemoglobin because it
causes toxic abuse on
bone marrow and
nutritional deficiencies.
Hematocrit is the percent
of blood that is actually
composed of RBCs. This
too is affected by
alcohols toxic abuse on
bone marrow and
nutritional deficiencies.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient is on a telemetry monitor because he is tachycardic.
Patient is also a 1:1 because he has been baker acted and is a high fall risk.
Patient is not able to ambulate out of the room because he is a high fall risk and baker acted.

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

1. Activity intolerance r/t generalized weakness AEB verbal report of weakness and unstable gait.
2. Risk of impaired liver function r/t verbal report of ETOH dependence and use of acetaminophen.
3. Urge urinary incontinence r/t neurologic disorders AEB polyuria and inability to make it to the bathroom.
4.
5.

 15 CARE PLAN
Nursing Diagnosis: Activity intolerance r/t generalized weakness AEB verbal report of weakness and unstable gait.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Minimize cardiovascular
Positioning the client in an upper
Deconditioning of the
Patient remained in an upright
deconditioning progressively over
right position several times daily.
cardiovascular system occurs
position the entire time I was there.
the time of his stay and have no
within days and sitting up the client He functions very well in that
signs of cardiac deconditioning
can prevent deconditioning such as position and was able to switch
(such as developed orthostatic
fluid shifts, fluid loss, decreased
positions fairly easily with no
hypotension) by the time of
cardiac output, and increased
complaint of orthostatic
discharge.
resting heart rate.
hypotension or SOB.
Decrease the patients fall risk,
prevent risk of impaired skin
integrity, and improve
cardiovascular function as well as
muscle and joint strength.

Mobilize the client at least 3 times

a day, increasingly until discharge.

Moving the patient keeps the

muscles and joints from
decomposing and losing strength. It
also keeps the cardiovascular
health healthy by increasing HR
and decreases risk of impaired skin
integrity by not sitting in one spot
too long.

The patient was unable to get up

while I was there and the time
before my shift. He already has a
pressure ulcer on his foot, and is
very tachycardic when sitting up.
Patient is also on a 1:1 and strict
fall risk precautions.

Prevent fall risk during the clients

entire visit.

Assess for signs of intolerance

when the patient tries to get up,
such as, nausea, pallor, dizziness,
visual dimming, impaired
consciousness, and vital signs.

All of these are signs of activity

intolerance and contribute to falls.

Upon sitting up the patient got a

high telemetry reading, in which
the nurse got a call to check on the
patient.

Improve or keep clients ROM

intact.

Perform range of motion exercises

at least twice a day until discharge.

Immobility or lack of ambulation

makes the patients muscle and
joint function decline, as well as
their mobilization.

The patient was able to complete

his ROM exercises with his legs
very well, but he had trouble
moving his arms.

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:
X SS Consult
X Dietary Consult
X PT/ OT
Pastoral Care
X Durable Medical Needs
X F/U appts
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? XYes No
X Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Risk of impaired liver function r/t verbal report of ETOH dependence and use of acetaminophen.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Leave the hospital without any
Watch for signs and symptoms of
Watching for these signs and
During my assessment there was no
signs or symptoms of liver
liver dysfunction such as, jaundice, symptoms are key parts of our
sign of jaundice, pruritus, GI
dysfunction.
pruritus, GI bleeding,
assessment to prevent or identify
bleeding, increasing abdominal
coagulopathy, increasing
liver damage.
growth, fluid overload, SOB,
abdominal growth, fluid overload,
mental status change, or change in
SOB, mental status change, change
color of stool. The patient is
in color of stool, change in urinary
diagnosed with a neurogenic
function, ect.
bladder which seems to be the
cause of his urinary incontinence.
Evaluate liver function through
labs.

Avoid adverse effects on the liver

due to acetaminophen use.

Monitor acetaminophen doses as to

not exceed 650mg Q6H.

Prevent malnutrition in the patient.

Educate the patient on the

importance of nutrition with ETOH
dependency and the increased risks
of liver impairment.

Schedule a consult with a nutrition

specialist.

Watching lab values such as AST,

ALT, and INR can give a good
indication of the function of the
liver. This is important to assess in
patients with alcohol dependence,
because of the excessive toxins
introduced to the liver.
Acetaminophen overdose is the
leading cause of liver failure in the
United States.

The lab values available during my

shift did not express any signs of
liver damage. The only abnormal
lab values were the RBC, HgB,
Hct, and creatinine; which were
more reflective of the toxins in the
bone marrow and malnutrition.
My patient is prescribed 650mg
Q6H PRN, which is something to
be wary of, especially when liver
impairment is possible in these
types of patients.

Patient education is crucial to them

following through with their
nutritional needs when they leave
the hospital. A lot of times they
dont realize the importance of
nutrition, so simply informing them
can be the key to their health.
It is important for this type of
patient to talk with a nutrition
specialist so they can fully

I began patient teaching during my

time with the patient. I explained
the importance of hydration and
how much something as simple as
staying hydrated affects so many of
his lab values which he found
interesting.
I did not do this during my shift,
but I am confident it will be done
upon discharge.

Give patient supplemental vitamins

such as thiamine and folic acid.

understand and come up with a

good plan they can follow at home.
Folic acid stimulates the
production of RBCs which is good
for this patient who has a low RBC
count. Thiamine is a supplement
for dietary deficiencies in
alcoholism and decrease symptoms
of ataxia.

So far, the folic acid has not

brought up the RBC count. The
patient overall GI health is healthy,
and his ataxia is still something he
is struggling with.

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:
X SS Consult
X Dietary Consult
X PT/ OT
Pastoral Care
X Durable Medical Needs
X F/U appts
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
X Rehab/ HH
Palliative Care

References
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
(10th ed., pp. 119-529). United States: Mosby, an imprint of Elsevier Inc.
Choose My Plate. Retrieved February 15, 2015, from
www.choosemyplate.gov
Davis's Drug Guide for Nurses (Thirteenth edition), (2014). F.A. Davis Company
Eriksons Stages of Psychosocial Development. (2011, November 29). Retrieved February 15, 2015, from
http://allpsych.com/psychology101/social_development.html
Nursing Central by Unbound Medicine: Alcohol abuse. (2014). (ver. 1.610.627) [Mobile Application Software]
Retrieved from http://nursing.unboundmedicine.com/nursingcentral/