UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Garrett Mongelluzzo

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION

Assignment Date: 11/7/15

Agency: MPM

Patient Initials: PH

Age: 69

Admission Date: 10/24/15

Gender: Male

Marital Status: Married

Primary Medical Diagnosis

Primary Language: English

Cellulitis Rt. Knee

Level of Education: High School Diploma

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired, previously salesman

MSSA Bacteremia / Sepsis

Number/ages children/siblings:

Pyogenic Arthritis

Brother (82 years old) , Sister (74 years old)

Acute confusion/ Feve

Served/Veteran:
If yes: Ever deployed? Yes, deployed in Vietnam

Code Status: Full

Living Arrangements:

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

Lives with wife, not a caretaker. No stairs in home, no help with

medications.
Culture/ Ethnicity /Nationality: Western / Non - Hispanic / American

Religion: Protestant

10/26/15, Total Knee Arthroplasty revision (Rt.)

Type of Insurance: Medicare

1 CHIEF COMPLAINT:
I started having pain in my knee grocery shopping (10/22/15) and when I got home a had a 103 degree fever.
Wife also states that he became very confused.

3 HISTORY OF PRESENT ILLNESS:

Onset: Acute
Location: Rt. Knee
Duration: 7 days
Characteristics: Sharp, burning pain
Aggravating: Anytime he ambulates and has to move Rt. knee.
Relieving: Keeping the knee still and elevated.
Treatments: Took 2 Tylenol (325 mg tablets)
Severity: Pain was a 9 on a 0-10 scale.
On 10/22/15, he was shopping with his wife and began having pain in his Rt. knee. When he returned home the pain
intensified and he began exhibiting acute confusion. His wife became very concerned and took his temperature with
revealed a fever of 103 degrees F. His wife then drove him to the Morton Plant Mease ER. A knee x-ray revealed small
bone effusion, unremarkable R total knee replacement, and no fracture. A blood and culture showed a Staphylococcus
Aureus infection of the right knee. A total knee arthroplasty revision (Rt. knee) was performed and a wound culture was
performed revealing a Staphylococcus aureus infection in the right knee.

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

relationship
relationship

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

74

Glaucoma

Sister

Diabetes

82

Cancer

Brother

Bleeds Easily

Diabetes

Asthma

78

Arthritis

Mother

Anemia

82

Environmental
Allergies

Father

Cause
of
Death
(if
applicable
)
Stroke

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Diagnosed with hypertension / Prescribed Losartan 100 mg Daily & Verpamil 240 mg Daily
Diagnosed with Diabetes Mellitus (Type 2) / Dapagliflozin
Left Knee Arthroplasty
Right Knee Arthroplasty
Gout : Prescribed Allopurinol 300 mg Daily

Age (in years)

Date
July 2002
September 2004
December 2006
April 2015
July 2015

Breast
Cancer
N/A
N/A

relationship

N/A
Father died from stroke at 82. He stated that his mother was diagnosed with Diabetes Mellitus when she was in her 50s. Sister
diagnosed with breast cancer when she was 71. Brothers diagnosed with CAD but he did not know his brothers age at time of
diagnosis. He also stated that his brother was diagnosed with Diabetes Mellitus in his 40s.

1 IMMUNIZATION HISTORY
YES

NO

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
If yes: give date, can state U for the patient not knowing date received
University of South Florida College of Nursing Revision September 2014

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

No known allergies

N/A

No known allergies

N/A

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)
Cellulitis is an infection of the dermis and subcutaneous tissue usually caused by Staphylococcus Aureus. Cellulitis can
occur as an extension of a skin wound, as an ulcer, or from furuncles or carbuncles. The infected area is warm,
erythematous, swollen, and painful. The infection is usually in the lower extremities and responds to systemic antibiotics,
as well as therapy to relieve pain (Huether & McCance, 2012). Risk factors for cellulitis are any injury (cut, fracture,
burn, or scrape) that provides bacteria and entry point, conditions that weaken the immune system (diabetis, HIV,
leukemia), chromic swelling of the arms and legs (lymphadema), obesity, and a histroy of cellulitis (Mayo Clinic, 2015).
Cellulitis can be diagnosed by skin assessments, a CBC, and lab cultures or the wound, blood, and sputum. To treat
cellulitis, an antibiotic should be prescribed for 10-14 days. The most commly used antbiotics for cellulitis are pennicillin,
flucloxacillin, docloxacillin, and erythromyin. For instance, the patient in this case was prescried nafcillin, which is in the
class of penicillins. In most cases cellulitis will be resolved as long as the antibiotic schedule is adhered to.

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: nafcillin

Concentration

Dosage Amount: 2 g

Route: IVPB

Frequency: q4hr (interval)

Pharmaceutical class: Penicillins

Home

Hospital

or

Both

Indication: Highly effective against penicillin G-resistant Staphylococcus Aureus.

Adverse/ Side effects: Severe/bloody diarrhea, allergic reaction (itching, hives, swelling, trouble breathing), sores or white patches on lips, mouth, and throat.
Nursing considerations/ Patient Teaching: Finish the prescription out to clear up infection, even if feeling better after a few doeses.
Name: Enoxoparin sodium (Lovenox)

Concentration

Dosage Amount: 40 mg

Route: SubQ

Frequency q24hr

Pharmaceutical class: Low- Molecular Weight Heparins

Home

Hospital

or

Both

Indication: For thromboembolism, Prevents and treats DVT and pulmonary embolism.
Adverse/ Side effects: Bleeding, blood in urine, bloody or black, tarry stools, patches on skin (large, flat, blue/purplish), uneven heartbeat
Nursing considerations/ Patient Teaching: Must monitor CBC
Name: Sodium Chloride 0.9% 1000mL

Concentration: 0.9% N/S

Route: IV

Dosage Amount 1000 (75mL/Hr)

Frequency: Continuous

Pharmaceutical class: mineral and electrolyte replacement

Home

Hospital

or

Both

Indication: Loss of body water, excessive sweating due to fever.

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects: Heart failure, pulmonary edema, edema, hypernatremia, hypovolemia, hypokalemia, irritation at IV site
Nursing considerations/ Patient Teaching: Explain purpose of IV therapy to patient.
Name: Allopurinol (Aloprim)

Concentration: Tablet

Route Oral

Dosage Amount: 300 mg

Frequency: Once daily

Pharmaceutical class: Xanthine oxidase inhibitor

Home

Hospital

or

Both

Indication: to treat gout by lowering the amount of uric acid in the blood.
Adverse/ Side effects: skin rash, painful urination, blood in the urine, loss of appetite, unexpected weight loss, fever, sore throa, chills, itching
Nursing considerations/ Patient Teaching: Educate patient that he should be drinking at least eight glasses of water or other fluids each day while taking med.
Name: Meloxicam (Mobic)

Concentration: Tablet

Route: Oral

Dosage Amount: 15 mg
Frequency: Once daily

Pharmaceutical class: NSAID

Home

Hospital

or

Both

Indication: reduce inflammation

Adverse/ Side effects: blistering, red skin rash, trouble breathing, coughing up blood, loss of appetite, numbness or weakness, vision, speech, and walking
problems, unusual bleeding, bruising,
Nursing considerations/ Patient Teaching: Teach that medicine can increase risk of clots, MI, and stroke. Can cause high blood pressure as well.
Name: Verapamil (Calan)

Concentration: Tablet

Route: Oral

Dosage Amount: 240 mg

Frequency: Once daily

Pharmaceutical class: Calcium channel blocker

Home

Hospital

or

Both

Indication: Treats high blood pressure

Adverse/ Side effects: Chest pain, dark urine, (fast, slow, uneven, pounding heartbeat), rapid weight gain, swelling (hands, legs, feet), trouble breathing,
weakness, tiredness, rapid weight gain, loss of appetite
Nursing considerations/ Patient Teaching: Blood pressure may go up if he stops taking medication. Do not stop taking without asking doctor, even if feeling well
because high blood pressure usually does not have symptoms.
Name: Losartan (Cozaar)

Concentration: Tablet

Route: Oral

Dosage Amount: 100 mg

Frequency: once daily

Pharmaceutical class: Angiotensin receptor blocker

Home

Hospital

or

Both

Indication: treats high blood pressure and reduces risk of stroke.

Adverse/ Side effects: change in how often you urinate confusion, weakness, uneven heartbeat, trouble breathing, and numbness/tingling in hands, ankles, or
feet. diarrhea, tiredness, fainting
Nursing considerations/ Patient Teaching: Medication can lower BP too much if patient is dehydrated so be sure to monitor hydration level.
Name: Insulin aspart (NovoLog)

Concentration

Dosage Amount: unknown

Route: SubQ

Frequency: 3x daily ac & once daily hr

Pharmaceutical class: Insulin

Home

Hospital

or

Both

Indication: To treat diabetes mellitus

Adverse/ Side effects: dry mouth, increased thirst, cramps, N&V, uneven heartbeat, rapid weight gain, swelling in your hands, feet, ankles, trouble breathing,
cold sweat, bluish skin, trembling, fast or pounding heartbeat.
Nursing considerations/ Patient Teaching: Educate patient to not share pens or cartridges with anyone, shared needles can pass Hepititus, HIV, and other
illnesses. This medication can also cause heart failure with used with thiazolidinediones.
Name: Dapagliflozin (Farxiga)

Concentration: Tablet

Route: Oral

Dosage Amount: 10 mg
Frequency: once daily

Pharmaceutical class: Gliflozin

Home

Hospital

or

Both

Indication: to treat type 2 diabetes mellitus in combination with diet and exercise
Adverse/ Side effects: Anxiety, bladder pain, bloody urine, chills, cold sweats, coma, confusion, depression, decreased frequency or amount of urine, difficulty
urinating, painful urination, dizziness, fast heartbeat, increased thirst and hunger, trouble breathing, swelling of face, fingers, or lower legs.
Nursing considerations/ Patient Teaching: Take in morning with or without food. For maximum benefit, take at same time each day. Important to follow diet
and exercise plan with medication.

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?
Consistent Carb Diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? low carb
Consider co-morbidities and cultural considerations): Type
2 Diabetes and Hypertension.
24 HR average home diet:
When comparing the my plate recommendations to the
patients diet, the patient is lacking essential food groups
and nutrients and is in excess in terms of dairy, meats,
saturated fats, cholesterol, and sodium. The patient is
lacking any fruits and whole grains in his diet. There are
also only 2 to 3 servings of vegetables in his diet each day.
Breakfast: Two eggs and two slices of bacon.
There is not enough variety in this diet to get the total
compliment of nutrients required for healthy living.
Considering the clients comorbidities, this diet is clearly
not beneficial to his health considering the amount of
sodium and cholesterol in his diet. I would recommend the
client receive a proper nutritional consultation by a
nutritionist before being discharged. The patient would
benefit from education on the importance of a balanced diet
and the difference between the types of carbohydrates and
how they specifically impact his diabetes.
Lunch: Chicken with green beans
Dinner: Cheeseburger with ketchup, bacon slices, onions,
with grilled cauliflower.
Snacks: almonds, a couple pepperoni slices, a couple
cheese slices
Liquids (include alcohol): water, coffee (cream and
splenda) 1-2 alcoholic beverages
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?
His wife takes care of him when he is ill.
How do you generally cope with stress? or What do you do when you are upset?
He tries to not let anything upset him but claims that he ignores the things that stress him out.

University of South Florida College of Nursing Revision September 2014

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
He experiences anxiety related to his health and fears losing his autonomy as he ages.

+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?
___________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
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:

Trust- The child develops a sense of trust in himself and the external world as a result of his needs being consistently
met (Treas, 2014, pp. 163-164).
Autonomy- The goal is for the child to develop self-control and independence while maintaining self-esteem. This
requires an ability to cooperate and express feelings and thoughts (Treas, 2014, pp. 163-164).
Initiative- The focus of this stage is to develop initiative by gradually assuming responsibility and developing selfdiscipline (Treas, 2014, pp. 163-164).
Industry- In this stage, the child learns that recognition comes through achievement and completion of tasks (Treas,
2014, pp. 163-164).
Identity- The adolescent develops a sense of self and begins to make decisions about the future. Healthy role models
facilitate the development of identity (Treas, 2014, pp. 163-164).
Intimacy- The capacity to commit himself to concrete affiliations and partnerships and develop the ethical strength to
abide by such commitments (Treas, 2014, pp. 163-164).
Generativity- The goal of this stage is to be creative and productive. Often this is accomplished through work or
relationships, such as raising healthy, functional children or contributing to society by developing a distinguishing career
(Treas, 2014, pp. 163-164).
Ego- This stage reflects satisfaction with life and an understanding of ones place in the life cycle (Treas, 2014, pp. 163164).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is in the Ego integrity stage. He exhibits a great deal of satisfaction with his life and family. The patient has
accepted his role in the life cycle.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

Being hospitalized can cause people a great deal of stress and self doubt in their life but my patient seems very content
and happy with his life and the choices hes made. I would say that his condition has had minimal impact on his
developmental stages of life.

University of South Florida College of Nursing Revision September 2014

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
He believes that being overweight caused the diabetes, hypertension, and gave him bad knees.
What does your illness mean to you?
His illness has prevented him from doing things he loves such as home improvements and being active.

+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?_No_________________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? _No_______________________________
Are you currently sexually active? _Yes__________________________ 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? __None _______________________________
How long have you been with your current partner?__45 Years________________________________
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 concerns

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?
______________________________________________________________________________________________________
__Patient believes that there is a god but claims that he is not over spiritual or religious.
____________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
___No, life choices are to blame for his current and past health
conditions.___________________________________________________________________________________________________
______________________________________________________________________________________________________

+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
1 pack per day

Yes
No
For how many years? 20 years
(age 20

thru 40

If applicable, when did the

patient quit? 1986

Pack Years: 20
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? Yes

If yes, what did they use to try to quit? Quit cold turkey

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? Beer
How much?
Volume: 24 oz.
Frequency: everyday
If applicable, when did the patient quit?
N/A

Yes

No
For how many years?
(age 18

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?
For how many years?
(age N/A thru
N/A
Is the patient currently using these drugs?
Yes No
N/A

69

If not, when did he/she quit?

N/A

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Herbicide Orange
5. For Veterans: Have you had any kind of service related exposure?
Herbicide Orange in Vietnam

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: Believes his skin is healthy considering his age. Patient is concerned about the knee infection
in his knee but is relieved that is not MRSA.
HEENT: Patient says hes blind and needs glasses to read due to his diabetes.
Pulmonary: Stated that his lungs are healthy.
Cardiovascular: Says his heart is healthy despite his high blood pressure.
GI: States he does not have stomach problem and no issues with bowel movements.
GU: Patient does not have any problems urinating or with incontinence.
Women/Men Only: N/A
Musculoskeletal: He says his knees suck and that he experiences back pain from time to time.
Immunologic: Reported no issues.
Hematologic/Oncologic: Reported no issues.
Metabolic/Endocrine: Reported being a diabetic and that he has a need for insulin and blood glucose monitoring.
Central Nervous System: No issues.
Mental Illness: States that he gets anxiety from time but is not depressed and happy with his life.
Childhood Diseases: States he did not have any childhood diseases.

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 September 2014

10 PHYSICAL EXAMINATION:
General survey _69 year old Caucasian male___Oriented X 3 ______
Height _178 cm___Weight__126 kg__ BMI _40.1___ Pain (include rating and location)_6/10 in Rt. Knee_________
Pulse_63_ Blood Pressure (include location)__143/80 Rt. Arm__Temperature (route taken)_97.9 oral_____
Respirations__16__________ SpO2 __96_______________ Room Air or O2_____RA
Overall Appearance: Awake, alert, engaged, symmetrical, no signs of distress
Overall Behavior: Pleasant. Positive, calm
Speech: Used appropriate speech and no issues with verbal communication.
Mood and Affect: Mood and affect are appropriate for age and situation.
Integumentary: Skin pink warm, and dry. No lesions and skin turgor present. Skin intact except for incision on Rt. knee
from surgery. __
IV Access: Right hand, SCDs present
HEENT: Pupils Round Reactive to Light and Accommodation, Conjunctiva are pink, Sclera is white.
Pulmonary/Thorax:_Lungs clear to bases, no accessory muscle use, O2 96% on RA.
Cardiovascular: S1/S2 present w/no additional heart sounds, Regular rate/rhythm. RUE, LUE, RLE, LLE all 2+. Cap
Refill less than 3 seconds in all extremities.
GI: Abdomen round, soft, Normoactive bowel sounds, No tenderness or rebound tenderness present. No masses, with last
bowel movement taking place the night before (10/28/15) and it was normal. Patient reports no nausea or vomiting.
GU: Patient last voided this morning (10/29/15) and reported that is was normal.
Musculoskeletal: Patient tested 5/5 in lift and hold in RUE, LUE, LLE. Did not test RLE. Grip Strength 5/5 in RUE and
LUE. ROM 100% in RUE, LUE, LLE. Did not test RLE.
______________________________________________________

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
8.5

(10/29/15)

11.4 H
Normal (4.5-11)

(11/5/15)

Hgb
11.9 L
12.7 L
Normal (13.5-17.5)

(10/29/15)

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

(11/5/15)

BUN
20

(10/29/15)

27 H
(8-20)

(11/5/15)

When admitted BUN was

in normal range but
trending upward.

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.
The numbers indicate
blood loss most likely
from the recent surgery
and are starting to
produce more red blood
cells.
The elevated BUN
indicates the kidneys are
not functioning well. This
could be from GI
bleeding, a urinary tract
obstruction, dehydration,
medications, or high
protein diet.

University of South Florida College of Nursing Revision September 2014

10

Glucose
158 H
127 H
Normal (60 - 100)

(10/29/15)
(11/5/15)

Calcium
8.4L
10.1
Normal (8.5 - 10.2)

(10/29/15)
(11/5/15)

Albumin
2.6 L

(10/29/15)

3.4
Normal (3.4 - 5.4)

(11/5/15)

Culture - Body Fluid

(Synovial Joint)
Culture - Blood (Venous)

10/25/15

Culture - Wound (Rt.

Knee)
X-Ray (Rt. Knee 3V)

10/26/15

X-Ray (Chest 1V)

10/24/15

10/25/15

10/24/15

The blood glucose is

slightly lower than it was
upon admittance but has
remained high.

There are high levels of

glucose in the patients
blood. This is a result of
the patients type 2
diabetes and his bodys
ability to metabolize
sugar. The body is either
not producing enough
insulin or is resisting the
effects of insulin.
Upon admittance,
The slightly low calcium
calcium levels were low
level could have been a
and are now trending up
result of his diet, meds, or
into normal range.
kidneys not functioning
properly. Low calcium
can cause confusion,
muscle cramps, and
tingling in extremities.
Albumin levels were low Low albumin can be seen
upon admittance and have in inflammation and with
trended up but still are in conditions where protein
the low normal range.
is not absorbed in the
intestines or not properly
digested.
N/A
Positive for light growth
Staphylococcus Aureus.
N/A
Positive for light growth
Staphylococcus Aureus.
N/A
Positive for light growth
Staphylococcus Aureus.
N/A
Small bone effusion,
unremarkable Rt. total
knee replacement, no
fracture.
N/A
Atherosclerotic changes
of Aorta and degenerative
changes of spine.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Diet - Consistent carb diet
University of South Florida College of Nursing Revision September 2014

11

Vitals - every 4 Hr.

Ambulate with assistance
Accuchecks every 4 Hr.
Physical Therapy Consult
Home Health Consult
Orthopedics Consult
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Acute pain r/t inflammatory changes in tissues by infection as evidenced by pain and discomfort when moving
2. Impaired mobility r/t loss of integrity of bone structures as evidenced by total Rt. knee arthroplasty revision.
3. Risk of falls r/t impaired physical mobility.

University of South Florida College of Nursing Revision September 2014

12

 15 CARE PLAN
Nursing Diagnosis: Impaired physical mobility r/t loss of integrity of bone structures as evidenced by total rt. knee arthroplasty revision.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will demonstrate use of
Teach patient how to properly use
Having a patient demonstrate a
Goal was met; patient was taught
adaptive equipment and mobility
walker and apply leg brace before
skill allows both the nurse and
how to properly use walker and leg
devices to increase mobility by end ambulating and have them
patient to be confident that the
brace and showed competence in
of shift.
demonstrate to you.
patient knows how to use the
using them both.
equipment and can ambulate safely.
Patient will ambulate 250 feet
Help client achieve mobility and
Early mobilization of orthopedic
Goal was met; patient ambulated
down hallway by end of shift.
start walking as soon as possible if clients generally prevents medical
250 feet down hallway before end
not contraindicated.
complications such as DVTs and
of shift.
Apply any ordered brace before
allows client time to practice using
moving client.
assistive devices or changes in
weight bearing status, and
promotes improved function,
reduces pain, and facilitates earlier
returns to independence.
Braces support and stabilize a body
part, allowing increased mobility
(Ackley & Ladwig, 2014).
Increase exercise to 20 minutes per
day for those who were previously
sedentary and keep a log of
activities preformed each day for 2
months.

Consult with physical therapist for

further evaluation, strength
training, and development of a
mobility plan.

Prescribing a regimen of physical

activity that includes both aerobic
exercise and muscle strengthening
activities is beneficial to
minimizing impaired mobility; use
exercise or log to improve
adherence to mobility enhancement
recommendations (Ackley &
Ladwig, 2014).

Unknown if goal was met. Would

follow up with patient to measure
progress.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
University of South Florida College of Nursing Revision September 2014

13

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

14

References
Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook. Maryland Heights, Missouri: Mosby Elsevier.
Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology. St. Louis: Elsevier Mosby.
Mayo Clinic. (2015, February 11). Diseases and Conditions. Retrieved November 7, 2015, from Mayo Clinic:
www.mayoclinic.org/diseases-conditions/cellulitis/basics/risk-factors/con-20023471
Treas, L. S., & Wilkinson, J. M. (2014). Philadelphia, Pennsylvania: F.A Davis Company.
USDA. (2015). Retrieved November 7, 2015, from ChooseMyPlate: www.choosemyplate.gov

University of South Florida College of Nursing Revision September 2014

15

University of South Florida College of Nursing Revision September 2014

16