UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Gianna Constantine

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION

Assignment Date: July 2nd

Agency: SJH

Patient Initials: HR

Age: 93

Admission Date: June 30th

Gender: Female

Marital Status: Widow

Primary Medical Diagnosis Risk for falls

Primary Language: English

Level of Education: Bachelors Degree
Occupation (if retired, what from?): Retired teacher

Other Medical Diagnoses: (new on this admission)

Risk for infections/pressure ulcers, activity
intolerance, hypertension.

Number/ages children/siblings: No children/ 7 siblings- all

deceased
Served/Veteran: No
If yes: Ever deployed? Yes or No N/A

Code Status: DNR

Living Arrangements: Lives alone. Has 3 small steps that she has to
climb to her deck. Does not need help taking medicines.
Pt will need rehabilitation after discharge.

Advanced Directives:
If no, do they want to fill them out? No
Surgery Date:
Procedure:
NONE

Culture/ Ethnicity /Nationality: Cuban, Spanish

Religion: Methodist

Type of Insurance: Medicare

1 CHIEF COMPLAINT:
I didnt know that I was acting differently then I fell, but I dont know who called.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Pain and weakness regarding her fall. Onset was at the time of her incident prior to admission; location is in her back,
neck, shoulder, and bladder; duration is about a day; characteristics is acute pain, some aching pain; aggravators are lifting
things past the midline of her body; relief to her pain occurs with therapy and exercising; treatments she has been trying
are therapy and exercising.
Patient also records being a little weak prior to her fall. This includes weakness in her bladder, as she is incontinent.
Patient reports pain being a 10/10 in her shoulders and hips.
Patient has been receiving therapy and medication while at the hospital for her fall. She has been ordered a CT scan and
has had a consult with neuro. The pt has been ordered rehab after discharge.

University of South Florida College of Nursing Revision September 2014

Mother

10
1
87

Brother

93

Sister

85

Father

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

Gout

Glaucoma

Diabetes

Cancer

Cause
of
Death
(if
applicable
)

Bleeds Easily

2
FAMILY
MEDICAL
HISTORY

Asthma

Arthritis; unresolved

Arthritis

Since mid-1950s

Anemia

Hypertension: Lopressor; Cardiac diet- Resolved

Environmental
Allergies

Unknown

Alcoholism

Operation or Illness
Surgery for carcinoma of left breast. Onset 11/2010

Age (in years)

Date
12/2010

(angina,
MI, DVT
etc.)
Heart
Trouble

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

Old age
Unknown
Parkinson
s
Blood
disorder

Brother

U
nk
Unknown
no
w
n
Brother
U
nk
no Unknown
w
n
Sister
U
nk
no Unknown
w
n
Comments: Patient was having a very hard time talking about her family history. It seems that it has to due with some memory loss, but
the conversation took almost an hour to discuss only 3 family members. She states she does not remember why her mother died, or her
other siblings.

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?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Penicillin
Sulfa

Patient says she does not remember because when she was exposed as
a little girl, she was not given it again.

Pollen

Aggressive sneezing

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)
My patient came into the hospital due to a fall. Her CT scan revealed a minor subdural hematoma. Subdural hematomas
are typically caused by a high-speed impact to the skull (Medscape, 2015). Because my patients hematoma was acute, it
was caused by a tearing of blood vessels. It is more common that the torn blood vessel is actually a vein, and that vein
connects the cortical surface of the brain to a bridging vein. Because my patient is 93, it is likely that her bridging veins
might already be stretched due to brain atrophy (Medscape, 2015). Due to the acute subdural hematoma, my patient is
now at risk for several other injuries, such as brain hematomas, contusions, diffuse axonal injury, or secondary injuries
such as edema, brain herniation, secondary hemorrhage, and infarction. Acute subdural hematomas can only be treated in
an operating room, and since my patients was so minor and her brain did not suffer any edema, I do not believe they will
operate (Healthline, 2012). The prognosis for my patients current standing is very good, considering it was such a minor
injury and she did not suffer any complications because of the hematoma. My patients sister had anemia, so that is a
genetic factor that may impact the prognosis, because it may be a more serious illness if the patient has problems with
bleeding, but she does not.

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: amLODIPine (Norvasc)

Concentration: 5 mg

Route PO

Dosage Amount: 1 tablet

Frequency 1x daily

Pharmaceutical class: calcium channel blocker

Home

Hospital

or

Both

Indication: Hypertension
Adverse/ Side effects: Dizziness, fatigue, peripheral edema, angina, hypotension, palpitations, nausea, flushing
Nursing considerations/ Patient Teaching: Avoid large amounts of grapefruit juice while on this medication; instruct patient on correct technique for monitoring
pulse, and tell patient to contact a health care professional if heart rate is less than 50 bpm. Advise patient to avoid driving while on this medication as it can

University of South Florida College of Nursing Revision September 2014

cause dizziness. Instruct patient on the importance of maintaining good dental hygiene.
Name: furosemide (Lasix)

Concentration 20 mg

Route PO

Dosage Amount: 1 tablet

Frequency 1x daily

Pharmaceutical class: loop diuretics

Home

Hospital

or

Both

Indication: Hypertension
Adverse/ Side effects: Stevens-Johnson syndrome, aplastic anemia, Agranulocytosis, erythema multiforme, toxic epidermal necrolysis, dehydration,
hyponatremia, hypokalemia, hyperuricemia, metabolic alkalosis
Nursing considerations/ Patient Teaching: Instruct patient to take Lasix as directed and to take missed doses as soon as possible and not to double dose. Advise
patient to change positions slowly to minimize orthostatic hypotension. Advise patient to contact health care professional if she notices weight gain of more than
3 lbs in one day. Also advise patient to consume a diet high in potassium. It is important for patient to contact health care professional immediately if rash,
muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs.
Name: prednisone

Concentration 1 mg

Route PO

Dosage Amount: 1 tablet

Frequency 4x daily

Pharmaceutical class: anti-inflammatory

Home

Hospital

or

Both

Indication: Patient has inflammation in the brain minor subdural hematoma

Adverse/ Side effects: peptic ulceration, depression, cataracts, thromboembolism, osteoporosis
Nursing considerations/ Patient Teaching: take meds as directed, do not double dose, inform doctor immediately if abdominal pain/ tarry stools occur
Name: .45% sodium chloride

Concentration 1000mL

Route IV

Dosage Amount 75mL/hour

Frequency: continuously

Pharmaceutical class: mineral and electrolyte replacement

Home

Hospital

or

Both

Indication NS being used to keep patient hydrated.

Adverse/ Side effects: heart failure, pulmonary edema, hypernatremia, irritation at IV site
Nursing considerations/ Patient Teaching: have the pt explain purpose of why they are taking the drug.
Name cloNIDine (Catapres)

Concentration .1mg

Route PO

Dosage Amount 1 tablet

Frequency q6 hours

Pharmaceutical class: adrenergic (central acting)

Home

Hospital

or

Both

Indication: Patient has high blood pressure, and this medication is an antihypertensive.
Adverse/ Side effects: drowsiness, dry mouth, dry eyes, constipation, nausea
Nursing considerations/ Patient Teaching: Take at same time every day; avoid sudden changes in position to decrease orthostatic hypotension; frequent mouth
rinses and good oral hygiene will decrease dry mouth effect; avoid concurrent use of alcohol or CNS depressants; notify health care professional of all Rx or
OTC medications, vitamins, or herbal products.
Name olmesartan (Benicar)

Concentration 40 mg

Route: Oral

Dosage Amount: 1 tablet

Frequency: 1x daily

Pharmaceutical class: Angiotensin II Receptor Blocker (ARB)

Home

Hospital

or

Both

Indication: Hypertension
Adverse/ Side effects: Angioedema; dizziness; hypotension; hyperkalemia; impaired renal function
Nursing considerations/ Patient Teaching: Notify health care professional if swelling of face, eyes, lips, or tongue if difficulty swallowing or breathing occurs;
avoid salt substitutes; emphasize the importance of taking the medication as directed, even if the patient begins to feel well. Take medication at same time each
day.
Name meloxicam (Mobic)

Concentration: 15 mg

Route PO

Dosage Amount: 1 tablet

Frequency 1x daily

Pharmaceutical class: NSAID

Home

Hospital

or

Both

Indication: Used to treat symptoms of patients arthritis

Adverse/ Side effects: GI bleeding; exfoliative dermatitis; Stevens-Johnson Syndrome; toxic epidermal necrolysis; pruritus; anemia; increased liver enzymes;
diarrhea; dyspepsia; nausea
Nursing considerations/ Patient Teaching: Caution patient to avoid the concurrent use of alcohol, aspirin, Tylenol, or other OTC medications without consulting
health care professional; advise health care professional if rash, itching, visual disturbances, weight gain, edema, black stools, or signs of hepatotoxicity (such as

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jaundice and nausea) occur; advise patient that meloxicam may increase the risk for heart attack and stroke and the risk increases with longer use or in patients
with heart disease.

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Eggs, cereal, or cornflakes with milk
Patient is very good with making sure she gets all the right
kinds of food.
Patient makes sure that she is using whole wheat bread.
Lunch: Small sandwich with lettuce and cheese (whole
However, it seems that the patient is not eating enough
wheat bread) with fruit
proteins. She says she has some beef at dinner, but she does
not put any protein on her sandwiches at lunchtime.
Dinner: Beef (some Spanish dish usually), bean soup with
potatoes, peas, and carrots

Patient loves to eat her fruits and veggies. She does a great
job at varying her vegetables and eating the right amount of
fruit for her age (1 cups per day), and the right amount of
vegetables for her age (2 cups per day)

Snacks: Late in evening, cookies or crackers

Patients cultural stance does not seem to affect her

nutrition status.

Liquids (include alcohol): No alcohol; coffee (no creamer),

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? Nieces and nephews
How do you generally cope with stress? or What do you do when you are upset?
I sit quietly to myself or talk to someone who doesnt make too many waves
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Her brother passed away two weeks ago, so she said she felt a little sad about it, but she was just happy that he was no
longer in any pain.
+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

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Have you ever been talked down to? No

Have you ever been hit punched or slapped? No

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? No
If yes, have you sought help for this? N/A
Are you currently in a safe relationship? No because she is widowed

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: Integrity versus despair is the eighth and final stage of Erik Erikson's theory of psychosocial development.
This stage occurs during late adulthood from age 65 through the end of life. During this period of time, people reflect back on
the life they have lived and come away with either a sense of fulfillment from a life well lived or a sense of regret and despair
over a life misspent (psychology.about.com).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The basic virtue for this stage is wisdom. My patient is in the integrity stage because she feels a sense of fulfillment about
how she lived her life. She always seemed to reflect back and tell me about all these fun things she did and all the great
things she has seen and always seemed so happy. She is very proud of her accomplishments. This means, even when she
is confronting death, she will attain wisdom.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

I believe that my patients illness did not set her back and make her lose her sense of accomplishment. As she suffered a
minor injury, and she feels that she is just getting old. She is so happy about the life she has lived, and her illness is not
making her regret anything.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Old age
What does your illness mean to you?
Just that I have lived too long. Im pretty healthy. Just old.

+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, when married
Do you prefer women, men or both genders? Men
Are you aware of ever having a sexually transmitted infection? No
Have you or a partner ever had an abnormal pap smear? No
Have you or your partner received the Gardasil (HPV) vaccination? No. (Too old to receive it).
Are you currently sexually active? No
If yes, are you in a monogamous relationship? When married, it was monogamous.
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended

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pregnancy? Condoms
How long have you been with your current partner? He is deceased
Have any medical or surgical conditions changed your ability to have sexual activity? No
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

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

What importance does religion or spirituality have in your life?
It has always been important. Patient has always been in church and has even gone on mission studies.
Do your religious beliefs influence your current condition?
No, they do not. I just did what I had to do and went to the hospital.

+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)
N/A
N/A

Yes
No
For how many years? N/A
(age

thru

If applicable, when did the

patient quit?

Pack Years: N/A

Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? N/A

If yes, what did they use to try to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? N/A
How much? N/A
Volume:
Frequency:
If applicable, when did the patient quit?

Yes

No
For how many years? N/A
(age

thru

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

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health? Patient says she views her overall health as not as good as it used to be, but pretty good
considering she is 93 and doesnt have half the problems she expected to have. She says she has lost a few pounds over the past year
because she does not eat as much and does not exercise as much.

Integumentary: Patient has some redness on her back from a heating pad. She does not believe this to be a
problem; however, it can lead to a pressure ulcer due to her lack of mobility because of her weakness. Patient
has no skin infections, hives, rashes, or dandruff.
HEENT: Patient does have difficulty hearing, but she only thinks this is because of her old age. Patient has no
nosebleeds, post-nasal drip, sinus pain or infections. It does not seem that she has an ear infection, but I believe
the damage she suffered from her fall may have something to do with her hearing deficit. Patient has a very
good routine of brushing her teeth two times a day and visiting the dentist once a year.
Pulmonary: Patient has no difficulty breathing, no cough, asthma, or bronchitis. She has not been diagnosed
with pneumonia, emphysema, or tuberculosis. She does have environmental allergies to pollen, and exposure
leads to aggressive sneezing, but she does not believe it to be a huge problem because she has had the allergies
for so long.
Cardiovascular: Patient has no abnormalities in her heart. No murmurs, myocarditis, hypertension, or
hyperlipidemia. Apparently when patient came in she was having mild chest pain, but today she denied any type
of chest pain.
GI: Patient has no nausea, vomiting, or diarrhea. She does not have any abdominal pain. She states that she has
no problems with bowel movements and no problems with her abdomen.
GU: Patient is getting frustrated due to incontinence. She urinates once every hour, and is frustrated that she
does not have the strength to get herself to the bathroom. She believes that the incontinence is temporary and not
a serious problem to worry about. Patient reports no kidney stones or nocturia.
Women/Men Only: Last gynecologic exam was years ago, does not go anymore. Patient is post-menopausal.
Reached menopause at age 55. Does not report monthly self breast examination.
Musculoskeletal: Patient says she has weakness and pain in shoulders and hips. Says it is because of the fall.
Patient also has had arthritis for a very long time and is aware of it because she is currently taking medication at
home for it.
Immunologic: Patient says she has no problems with her immune system. She does not get any life threatening
allergic reactions, night sweats, or chills with severe shaking. Patient does not report HIV or AIDS, tumors,
enlarged lymph nodes, or lupus.
Hematologic/Oncologic: Patient does not report any oncologic problems. No cancer. She also says she is not
anemic and has no problems with bleeding. Although, patient did come into the hospital with minor bleeding of
the brain, and she does have a family history of anemia. Patient denies that the family history has anything to do
with her minor subdural hematoma.
Metabolic/Endocrine: Patient denies any sort of problem with her endocrine system. No diabetes, no hypo or
hyperthyroid, and no osteoporosis.
Central Nervous System: Patient claims she suffered a severe headache once she fell, but she does not
experience these on a regular basis. Currently, patient gets dizzy when she stands up. These problems conclude
that her fall did affect her CNS, but there were no past issues with the central nervous system.
Mental Illness: Patient believes she does not have any type of altered mental status, although having a
conversation with the patient can be quite difficult as she can be forgetful.
Childhood Diseases: No childhood diseases.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No

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10

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

10 PHYSICAL EXAMINATION:
General survey Alert and Oriented x3, no signs of distress
Height 52 Weight 150.9 lbs BMI 27.4 Pain (include rating and location) 10/10 Hips and shoulders Pulse 61
Blood Pressure (include location) 158/72 Upper arm Temperature (route taken) 97.5 oral
Respirations 18
SpO2 97%
Room Air or O2 Room air
Overall Appearance Clean, combed hair; teeth brushed; face washed; appears pleasant.
Overall Behavior Awake, very kind. Seems confused as to how she got to the hospital and why she is there.
Speech Normal, audible, and clear speech
Mood and Affect Pleasant and positive mood, normal affect.
Integumentary No edema, skin warm, dry and intact. Has rash on back from heating pad. Possibly stage 1 pressure ulcer?
IV Access No redness, edema, or swelling at site of IV
HEENT Some facial lacerations; hard of hearing; face is symmetric. PERRLA.
Pulmonary/Thorax Clear lung sounds, no labored breathing. Did not hear any crackling or wheezing.
Cardiovascular Normal, S1 and S2 heard. Regular rate and rhythm without distress. Did not hear any murmurs.
GI Soft, non-tender abdomen. Bowel sounds normal. Last bowel movement was yesterday.
GU Incontinent. Constantly urinating (seems to be every hour on the hour).
Musculoskeletal Very weak. Range of motion incomplete. Rates 3/5. Cannot walk on own. Fall risk.
Neurological Seems unfocused. Sometimes will stare off into space and forget what she is talking about. Takes some time
in order to have a conversation with the patient. Seems to have slight altered mental status, but is AO x3

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):
Lab
WBC

Dates
07/02/2015

Trend
No trend. Only taken 1
time

Analysis
Number of infection
6.6
fighting cells. Patient has
Normal (4.5-11)
normal WBC counts,
indicating no infection,
inflammation or
ulcerative colitis present.
Mono
07/02/2015
No trend. Only taken 1
Looks for antibodies to
6.1
time.
the Epstein-Barr virus.
Normal (0.0-10.0)
The patient has a normal
Mono test, which means
that mononucleosis is not
present.
RBC
07/02/2015
No trend. Only taken 1
Number of red blood
4.09
time
cells. Patient has normal
Normal (3.60-5.40)
RBC counts, indicating
no bone marrow disorder
or white blood cell
cancer.
HCT
07/02/2015
No trend. Only taken 1
Proportion of total blood
L 36.0
time.
volume composed of red
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11

Normal (37.0-47.6)

Sodium

07/02/2015

No trend. Only taken 1

time.

07/02/2015

No trend. Only taken 1

time.

07/02/2015

No trend. Only taken 1

time.

07/02/2015

No trend. Only taken 1

time.

07/02/2015

No trend. Only taken 1

time.

07/02/2015

No trend. Only taken 1

time.

140
Normal (135-145)

Potassium
4.6
Normal (3.5-5.1)

Lymphs
L 15.7
Normal (24.0-44.0)

Glucose
H 103
Normal (70-99)

Creatinine
L 0.65
Normal (0.7-1.3)

Albumin
L 3.1
Normal (3.4-5.0)

blood cells. Patients

levels were low,
indicating anemia,
decreased production of
RBCs, or nutritional
problems.
Tests for how much
sodium is in the blood.
Patient has a normal
sodium value, which
indicates that there is not
a high blood pressure, or
no signs of nausea or
vomiting.
Tests how much
potassium is in the serum
part of the blood.
Patients levels are
normal, which indicates
no diabetes, renal failure,
hyperaldosterone, or
addisons disease
White blood cells
manufactured in the bone
marrow. Patient has a low
lymph count, which
means the body is is low
on infection resistance,
and at an increased risk
for cancer.
Blood sugar. Patients
glucose is high, indicating
patient might have
diabetes, or stress from an
illness such as the cold or
flu.
Level of waste product in
your blood and urine.
Low levels are a cause for
concern, and usually
indicate some sort of
condition with decreased
muscle mass.
Protein found in the
blood. Low albumin can
indicate poor nutritional
status, a heart condition, a
liver disease, or stomach
problems.

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12

T Protein

07/02/2015

No trend. Only taken 1

time.

Carbon Dioxide
26
Normal (21-32)

07/02/2015

No trend. Only taken 1

time.

CT Scan

07/02/2015

No trend. Only taken 1

time.

EKG

07/02/2015

No trend. Only taken 1

time.

L 6.2
Normal (6.4-8.2)

Total protein in fluid

portion of the blood. Low
levels may indicate
bleeding (hemorrhage),
liver disease,
malabsorption, or
malnutrition.
Carbon Dioxide in the
blood. Normal levels
indicate that the patient
has a good amount of
CO2 in the blood, and
there are no signs of
hyperventilation,
hyperthyroidism, or
COPD.
Taken to see patients
head after fall. Minor
subdural hematoma
found, which indicates
tearing of the blood
vessels in the brain.
Ordered if there are signs
and symptoms of a heart
problem. In this case, it
was ordered due to the
initial chest pain of the
patient after she fell. EKG
came back normal.

+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 regular diet. Her orthostatic vital signs needed to be checked every time the patient moves
positions. She was scheduled a neuro consult and a CT scan, which showed a minor subdural hematoma. Accu
checks do not need to be given to this patient. She was ordered a consult with neuro because of the damage to her
head when she fell, and the doctors from neuro need to check to make sure that everything is ok. Once they saw
the patient, and realized that she suffered a minor subdural hematoma, they looked at her brain and realized that
the hematoma was not to be removed because it would cause more harm than good to take it out. It was also very
minor and did not cause any serious cognitive deficits, so they deemed surgery unnecessary.

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

1. Self care deficit
2. Risk for falls

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13

3. Risk for infection

4. Risk for pressure ulcers
5. Risk for activity intolerance

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14

 15 CARE PLAN
Patient Goals/Outcomes
Patient will be able to feed herself
safely this shift.

Patient will remain free of

incontinence this shift.

Patient will bathe with assistance

of caregiver as needed without
exhibiting defensive behaviors.

Patient will be able to dress herself

Patient will be able to perform

activities of daily living with

Nursing Diagnosis: Self care deficit

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Assess for choking and swallowing Ackley, B. & Ladwig, G., (2011).
risk; assure patient is in proper
position for eating; encourage the
patient to feed herself; include
between-meal snacks three times a
day alone if intake is not sufficient.
Assess ability to toilet and clients
Ackley, B. & Ladwig, G., (2011).
usual bowel and bladder toileting
patterns; refer client to OT; provide
privacy; schedule toileting
assistance; make assistance call
button readily available and answer
call light promptly
Consider using prepackaged bath;
Ackley, B. & Ladwig, G., (2011).
develop a bathing care plan based
on the clients own history of
bathing practices that address skin
needs, self-care needs, clients
response to bathing, and equipment
needs; provide privacy; avoid
upsetting factors while bathing;
allow client to participate as able in
bathing
Assess the clients range of motion; Ackley, B. & Ladwig, G., (2011).
select adaptive clothing; use
clothing that fastens in the front
due to limited arm and shoulder
movement.
Assess the clients need for
Ackley, B. & Ladwig, G., (2011).
assistance; encourage the client to
University of South Florida College of Nursing Revision September 2014

Evaluation of Goal on Day Care

is Provided
Patient was able to feed herself this
shift with absolutely no assistance.

Unfortunately, patient was

incontinent for the majority of the
shift.

Patient was given a bath using a

prepackaged bath today and did not
use any defensive or aggressive
behaviors while being given the
bath. Patient is very concerned with
privacy, so it was provided by
closing the curtain and closing the
door.
Patient was not given clothing that
closes in the front this shift,
because her hospital gown closes in
the back. Unfortunately, the patient
was not able to dress herself.
Patient was given a referral for OT.
Nurse and tech encouraged client to
15

limited assistance

be independent; request referral for

occupational therapy

be as independent as possible.

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 Patient needs physical therapy in order to regain her strength so that she is able to walk and take care of other ADLs independently.
Pastoral Care Patient is very religious, and I feel that pastoral care would help the patient with the comfort of her illness.
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH Rehabilitation is necessary for the patient in order for her to gain back her independence, and for her to have the strength to walk by
herself without help from others. Because the patient lived alone before, it seems that autonomy is very important to her.
Palliative Care

University of South Florida College of Nursing Revision September 2014

16

References
Cherry,K.(n.d.).IntegrityvsDespair:PsychosocialDevelopment.RetrievedJuly13,2015,from
http://psychology.about.com/od/psychosocialtheories/a/integrityversusdespair.htm
UnboundMedicine.(2015).NursingCentral.(Version1.25(421).[MobileApplicationSoftware].Retrieved
July14,2015,fromhttp://itunes.apple.com
SubduralHematoma.(2015,January8).RetrievedJuly14,2015,from
http://emedicine.medscape.com/article/1137207overview#a4
Kahn,A.(2012,August20).SubduralHematoma.RetrievedJuly14,2015,from
http://www.healthline.com/health/subduralhematoma#Overview1
Ackley,B.,&Ladwig,G.(2011).NursingDiagnosisHandbook:AnEvidencedBasedGuidetoPlanningCare
(9thed.).St.Louis,Missouri:MosbyElsevier.

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