UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Natalie Drass

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION

Assignment Date:
Agency:

Patient Initials: A.T.

Age: 51

Admission Date: 6/28/15

Gender: Female

Marital Status: Married

Primary Medical Diagnosis: Anemia

Primary Language: English

Level of Education: Associates Degree

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): current L.P.N.

Pt doesnt know

Number/ages children/siblings: 1 daughter 31 years old

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

Code Status: Full

Living Arrangements: Two bedroom apartment

Advanced Directives: Yes

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

Culture/ Ethnicity /Nationality: African American

Religion: Muslim

Type of Insurance: No insurance

1 CHIEF COMPLAINT:
Came to the ER on the 28th of June with a severe migraine that lasted over a week and dizziness.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Migraines
O-Migraines started a couple weeks ago
L-Top of head
D-Migraines usually last a few days
C-Constant pain, pt states that pain feels like someone is sitting on my head, acute
A-Migraines more frequent and intense during menses, flashing and bright lights aggravates the pain
R-Sleep and rest lessens pain for a short period of time
T-Tylenol taken at home for migraine pain

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

Father

78

Mother

76

Brother

48

Sister
Daughter

53
31

X
X

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

Environmental
Allergies

Cause
of
Death
(if
applicable
)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Angioedema from allergy to ACE inhibitors

Age (in years)

Date
9/10/14

X
X

relationship
relationship

Comments: Include age of onset

Father-Diabetes age 30, hypertension around age 30, kidney problems(transplant) around age 50
Mother-Arthritis age around 40, easy bleeding around age 50, hypertension around age 50
Brother-Arthritis age around 45
Sister-Hypertension age around 45
Daughter-Anemia age 30

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
X
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria
X
Adult Tetanus-within 10 years
X
Influenza (flu)-within 1 year
Pneumococcal (pneumonia)
Have you had any other vaccines given for international travel or
occupational purposes? Hepatitis B for L.P.N. occupation, U
X
If yes: give date, can state U for the patient not knowing date received
University of South Florida College of Nursing Revision September 2014

NO
X
X

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

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)

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

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name
Route

Concentration

Dosage Amount
Frequency

University of South Florida College of Nursing Revision September 2014

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

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?
Analysis of home diet (Compare to My Plate and
Diet patient follows at home?
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids (include alcohol):
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?
How do you generally cope with stress? or What do you do when you are upset?

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)

+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? _______________________________________________________
Have you ever been talked down to?_______________ Have you ever been hit punched or slapped? ______________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
__________________________________________ If yes, have you sought help for this? ______________________
Are you currently in a safe relationship?

University of South Florida College of Nursing Revision September 2014

 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:

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

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

What does your illness mean to you?

+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?____________________________________________________________________
Do you prefer women, men or both genders? _____________________________________________________________
Are you aware of ever having a sexually transmitted infection? _______________________________________________
Have you or a partner ever had an abnormal pap smear?_____________________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___________________________________________
Are you currently sexually active? ___________________________ If yes, are you in a monogamous relationship?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? __________________________________
How long have you been with your current partner?________________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ___________________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?

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?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

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

Has the patient ever tried to quit?

If yes, what did they use to try to quit?

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

Yes

No
For how many years?
(age

thru

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

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

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?

Integumentary:
HEENT:
Pulmonary:
Cardiovascular:
GI:
GU:
Women/Men Only:
Musculoskeletal:
Immunologic:
Hematologic/Oncologic:
Metabolic/Endocrine:
Central Nervous System:
Mental Illness:
Childhood Diseases:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?

Any other questions or comments that your patient would like you to know?

University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:
General survey _____________________________________________________________________________________
Height ____________Weight__________ BMI ___________ Pain (include rating and location)___________________
Pulse_______ Blood Pressure (include location)_____________________Temperature (route taken)____________
Respirations____________ SpO2 _________________ Room Air or O2___________________________
Overall Appearance________________________________________________________________________________
Overall Behavior__________________________________________________________________________________
Speech___________________________________________________________________________________________
Mood and Affect___________________________________________________________________________________
Integumentary____________________________________________________________________________________
IV Access________________________________________________________________________________________
HEENT___________________________________________________________________________________________
Pulmonary/Thorax________________________________________________________________________________
Cardiovascular____________________________________________________________________________________
GI________________________________________________________________________________________________
GU_______________________________________________________________________________________________
Musculoskeletal_____________________________________________________________________________________
Neurological

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
WBC

Dates
6.9

(03/18/2013)

19.8 H
Normal (4.5-11)

(03/22/2013)

Trend
Upon admit, the patients
WBC were in the low
normal range. However,
WBC are trending
upwards indicating either
an infection or
inflammatory process is
occurring.

Analysis
Number of infection
fighting cells. High WBC
indicates the presence of
an infection or
inflammation. High WBC
is often indicated in an
exacerbation of ulcerative
colitis.

This should represent the

patients trend of the
exacerbation, such as
after surgery, with new
meds added, or since
admission.

University of South Florida College of Nursing Revision September 2014

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

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

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

1.
2.
3.
4.
5.

University of South Florida College of Nursing Revision September 2014

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 15 CARE PLAN
Patient Goals/Outcomes

Nursing Diagnosis: Nursing Diagnosis goes here

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References

Evaluation of Goal on Day Care

is Provided

Include a minimum of one

Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
University of South Florida College of Nursing Revision September 2014

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References

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