UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Kristina Nealy

Assignment Date: June 26, 2015
.
1 PATIENT INFORMATION Agency: Sarasota Memorial Hospital
Patient Initials: M.N. Age: 64 Admission Date: June 24, 2015
Gender: Female Marital Status: Married Primary Medical Diagnosis: Right hip replacement,
osteoarthritis
Primary Language: English
Level of Education: Received education from the UK (Britain), pt Other Medical Diagnoses: (new on this admission):
stated it is different from the US None
Occupation (if retired, what from?): Restaurant Owner
Number/ages children/siblings: 2 children (ages 32 & 35), 1 brother
(age 60)

Served/Veteran: No Code Status: Full code

If yes: Ever deployed? Yes or No
Living Arrangements: Pt lives with her husband and daughter, she Advanced Directives: Yes
is able to take care of herself. No stairs. If no, do they want to fill them out?
Surgery Date: 6/24/15
Procedure: Right hip replacement
Culture/ Ethnicity /Nationality: British
Religion: Not religious Type of Insurance: PCHS

1 CHIEF COMPLAINT: Right hip pain/right hip replacement

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
M.N. presents herself at Sarasota Memorial hospital on 6/24/2015; pt states she has experienced continuous,
sharp/stabbing pain for approximately 3 years in the groin region and right hip. It hurts the most while performing any
weight-bearing activities and she states she can only walk short distances. Resting provides minimal improvement and pt
has tried physical therapy, home exercise, and anti-inflammatory medications for at least three months with no relief. Pt
requests surgical intervention to replace her right hip. Pt was admitted on 6/24/2015 for right hip surgery, she was placed
on orthopedics 9 courtyard for post-op observation and is to be discharged home on 6/26/2015 if everything goes as
planned.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
Diagnosed as a child Asthma
1990 Hypothyroidism; medication killed off thyroid
2001 Hypertension; treated with anti-hypertensive
2010 Liver disease; Imuran 50mg
2011 Avascular necrosis
02/2015 Osteoarthritis; anti-inflammatory drug therapy, physical therapy, exercise
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma
of

Cancer

Problems

Tumor
Stroke
Allergies

MI, DVT
Gout
MEDICAL Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Father 92
Mother 52 Overdose
Brother 60
N/
Grandmother N/A
A
Comments: Include age of onset
Paternal Grandmother died of cancer, pt did not specify what kind of cancer or age
Mother passed at age of 52

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) 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? 10/2014
Pneumococcal (pneumonia) (Date) Is within 5 years? Date U
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Medications NKA NO KNOWN MED ALLERGIES
Other (food, tape, Environmental
Breaks out in hives, itchy and red
latex, dye, etc.) (pollen, etc.)

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 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)
Osteoarthritis (OA), also termed degenerative joint disease, is a localized disorder that affects synovial joints indicated by
erosion and destruction of articular cartilage. OA is primarily seen in the elderly population after many years of use and
weight bearing activities on specific joints; women usually have more severe cases than men. According to Huether and
McCance (2012) the primary cause of OA has not been determined but it is said to begin with degeneration of articular
cartilage through enzymatic processes which results in many other defects such as dense, hard subchondral bone leading
to development of cysts within those spaces. Bone spurs (osteophytes) begin to develop, break off into the synovial cavity
and eventually aggravate the synovial membrane, which causes synovitis (pp. 997-998). All of these progressive
deformities in the bone basically causes the bones to rub together; resulting in extreme pain, joint stiffness and sometimes
immobility.
Risk factors for osteoarthritis include old age, obesity, genetic alterations, long-term mechanical stress from sports and
repetitive physical tasks, neurological disorders, congenital or acquired skeletal deformities, hematologic or endocrine
disorders, and certain medications. Diagnosing OA does not usually require extensive, expensive studies. Clinical
assessment and radiologic studies can usually show if OA is present but in rare cases the patient may need to have a CT
scan, arthroscopy, and MRI. There is not a cure to OA however, there is treatment to relieve pain for short periods of time
(conservative) or surgical treatment. It is recommended that the patient uses a can, walker or crutches to minimize the
weight and stress on joints. Range of motion may help with the pain and if the patient is obese, it is highly recommended
that they lose weight. The patient should take anti-inflammatory medications and analgesics to control inflammation and
pain. If the pain from OA is unbearable, the ideal treatment would be surgical (hip replacement, knee replacement, etc.)
which is very common (Huether et al. 2015).

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: apixaban (Eliquis) Concentration: mg (tablet) Dosage Amount: 2.5mg
Route: PO (by mouth) Frequency: Q 12h (twice daily)
Pharmaceutical class: Factor xa inhibitors Home Hospital or Both
Indication: Decreases risk of stroke/systemic embolism associated w/ nonvalvular atrial fibrillation; Serum creatinine level
>1.5
Adverse/ Side effects: Bleeding, anaphylaxis
Nursing considerations/ Patient Teaching: Inform pt that they may bleed or bruise more easily or longer than usual. Call
health care provider immediately if any unusual signs of bleeding occur.

Name: atorvastatin (Lipitor) Concentration: mg (tablet) Dosage Amount: 20mg

Route: PO Frequency: Q.h.s. (every night at bedtime)
Pharmaceutical class: hmg coa reductase inhibitor Home Hospital or Both
*Lipitor is a sub for pravastatin which pt takes at home
Indication: Primary prevention of coronary heart disease
Adverse/ Side effects: Rhabdomyolysis, arthritis, hyperglycemia, bronchitis, chest pain, angioneurotic edema
Nursing considerations/ Patient Teaching: Instruct pt to contact health care provider if unexplained muscle pain,
tenderness, or weakness occurs, especially if accompanied by fever or malaise.

Name: azaTHIOprine (Imuran) Concentration: mg (tablet) Dosage Amount: 50mg

Route: PO Frequency: Once a day
Pharmaceutical class: Purine antagonist Home Hospital or Both
Indication: Taken for liver disease
Adverse/ Side effects: retinopathy, pulmonary edema, anorexia, hepatotoxicity, nausea, vomiting, anemia, leukopenia,
pancytopenia, thrombocytopenia, malignancy, serum sickness

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Nursing considerations/ Patient Teaching: Take as directed, if a dose is missed on once-daily regimen, omit dose.
Reinforce need for lifelong therapy, emphasize importance of follow-up exams and lab tests

Name: oxycodone (Percocet) Concentration: mg (tablet) Dosage Amount: 325mg

Route: PO Frequency: Q 4h PRN
Pharmaceutical class: opioid agonist Home Hospital or Both
Indication: moderate to severe pain
Adverse/ Side effects: Confusion, sedation, respiratory depression, orthostatic hypotension, constipation, nausea, vomiting
Nursing considerations/ Patient Teaching: Advise pt to rise slowly to minimize orthostatic hypotension, encourage pt to
turn, cough and deep breath every 2 hrs to prevent atelectasis, avoid alcohol or other CNS depressants, advise pt to call for
assistance when ambulating

Name: levothyroxine (Synthroid) Concentration: mcg (tablet) Dosage Amount: 200mcg

Route: PO Frequency: Q.A.C. (every morning before breakfast)
Pharmaceutical class: thyroid preparations Home Hospital or Both
Indication: Thyroid supplementation in hypothyroidism
Adverse/ Side effects: *usually only seen when excessive doses cause iatrogenic hyperthyroidism
Nursing considerations/ Patient Teaching: Take medication as directed at same time each day, explain that the med does
not cure hypothyroidism, therapy is lifelong, advise pt to notify healthcare provider if headache, nervousness, diarrhea,
excessive sweating, weight loss, increased pulse rate, palpitations, or any other unusual symptoms occur.

Name: omeprazole (Prilosec) Concentration: mg (capsule) Dosage Amount: 20mg

Route: PO Frequency: once a day
Pharmaceutical class: proton pump inhibitor Home Hospital or Both
Indication: Gastroesophageal reflux (GERD)
Adverse/ Side effects: pseudomembranous colitis, abdominal pain, hypomagnesemia
Nursing considerations/ Patient Teaching: Instruct pt to notify healthcare provider if onset of black, tarry stools; diarrhea;
abd. pain; or persistent headache occurs or if fever develops especially if stool contains blood, pus or mucus. Advise pt not
to treat diarrhea without consulting health care professional.

Name: losartan (Cozaar) Concentration: mg (tablet) Dosage Amount: 100mg (2 tabs)

Route: PO Frequency: once a day
Pharmaceutical class: angiotensin II receptor
Home Hospital or Both
antagoinst
Indication: alone or with other agents in the management of hypertension
Adverse/ Side effects: diarrhea, hyperkalemia, impaired renal function, angioedema, fever
Nursing considerations/ Patient Teaching: Instruct pt to notify healthcare provider if swelling of face, eyes, lips or tongue
or if difficulty swallowing or breathing occur. Instruct pt and family on proper technique for monitoring BP; check BP at
least weekly to report significant changes. Encourage pt to comply with additional interventions for hypertension.
Encourage pt to avoid salt substitutes containing potassium. Advise pt to take medication as directed, even if feeling well.

Name: triamterene (Dyrenium) Concentration: mg Dosage Amount: 25mg

Route: PO Frequency: once a day
Pharmaceutical class: Diuretic (potassium-sparing) Home Hospital or Both
Indication: Used with other agents to treat edema or hypertension
Adverse/ Side effects: hyperkalemia, photosensitivity, muscle cramps, nausea, vomiting, arrhythmias, bluish urine
Nursing considerations/ Patient Teaching: Reinforce need to continue additional therapies for hypertension, teach pt and
family correct technique for checking BP weekly, emphasize importance of continuing mediacation as directed even if
feeling well.
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Name: celecoxib (CeleBREX) Concentration: mg (capsule) Dosage Amount: 200mg
Route: PO Frequency: once a day
Pharmaceutical class: cox 2 inhibitor Home Hospital or Both
Indication: Relief of signs and symptoms of osteoarthritis
Adverse/ Side effects: myocardial infarction, stroke, thrombosis, edema, GI bleeding, exfoliative dermatitis, stevens-
johnson syndrome, toxic epidermal necrolysis, rash
Nursing considerations/ Patient Teaching: Advise pt to notify healthcare provider promptly if signs or symptoms of GI
toxicity (abd pain, black stools), skin rash, unexplained weight gain, edema or chest pain occurs. Instruct pt to take exactly
as directed

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: Pt admits to not eating much MyPlate suggests that the patient should eat 5 oz of grains,
due to being busy, when she eats she tries to eat healthy 2 cups of vegetables, 1.5 cup of fruits, 3 cups of dairy, and
but it does not always work out that way. She does not 5 oz of protein daily.
use salt substitutes.
Breakfast: Toast (wheat) with butter and/or cheese No fruits are consumed on a daily basis, pt should eat more
fruits

Lunch: Sausage or a small salad with dressing

Dinner: Salad, vegetables, baked potato with sour Pt should include protein and vegetables in every meal
cream, cheese, butter which she does not do.
Pt states I try to eat lighter foods
Snacks: I dont really eat snacks, too busy

Liquids (include alcohol): Club soda, wine, any type of Pt should consume more water as she hardly drinks any.
juice Soda and juice contain a lot of sugar and sodium so pt
should cut down on those.

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? Husband

How do you generally cope with stress? or What do you do when you are upset? I dont get stressed often, if I am
feeling a bit stressed I will have a drink or two.

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Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life): None

+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?
Are you currently in a safe relationship? Yes. Married for 30 years

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame
Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role Confusion/Diffusion 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: The generativity vs stagnation stage is said to be experienced by individuals
between the ages of 40 and 65 years old. The goal of this stage is to be creative and productive. Often this is
accomplished through work or relationships. The person who fails to achieve generativity may manifest stagnation
in the form of superficial relationships and self-absorption (Treas, Wilkinson, 2014).
Generativity- The desire and motivation to guide the next generation (Treas et al. 2014)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
My patient is 64 years old and I believe she is in the generativity stage because she is a restaurant owner with two
grown children. She made it very evident that she spends most of her time at her restaurant working and taking
care of her 35 year old daughter who has many medical needs. She seemed to me as the type of person who always
puts others needs before her own so she definitely is not self-absorbed. She wanted to heal and get out of the
hospital as soon as possible to be able to get back to her activities of daily life as she is a very busy, productive,
pleasant woman.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
My patients hospitalization has a positive impact on her developmental stage of life because her hip replacement is
going to allow her to be able to perform her ADLs without pain and discomfort. Before her hospitalization she said
the pain was getting in the way of life and that it was annoying, She couldnt hardly walk a few feet without
having so much unbearable pain that she would have to rest. She said she couldnt wait to get healed up and be
able to get back up on the barstool at work as well as live her life!

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

What does your illness mean to you? Mean to me? It is annoying and getting in the way of life. It means that I am
University of South Florida College of Nursing Revision September 2014 6
getting 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

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
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? I think I am a bit old for that.

How long have you been with your current partner? 30 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

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life? Im not religious but, I do believe in God.

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? Yes No
If so, what? How much?(specify daily amount) For how many years? X years
(age thru )

If applicable, when did the

Pack Years:
patient quit?

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? No If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes
What? Martinis, wine How much? 1-2 glasses
Volume: 8-16 oz
Frequency: Daily
If applicable, when did the patient quit?
No
For how many years? 48 years
(age: 16 thru: Current)

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 thru )

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No

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?

University of South Florida College of Nursing Revision September 2014 8

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? Pretty good

Integumentary: Pt denies changes in appearance of skin, problems with nails, dandruff, psoriasis,
hives/rashes, or skin infections. Pt uses sunscreen SPF 8 and bathes daily.
HEENT: Pt has difficulty seeing and wears glasses and contacts. No glaucoma or cataracts, no difficulty
hearing, no ear infections, no sinus pain or infections, no nose bleeds, no post-nasal drip, no
oral/pharyngeal infection, and no dental problems. Pt brushes teeth 2x/day, routine dentist visits 4x/year,
vision screening ever couple of years.
Pulmonary: Pt has asthma, hx of bronchitis and pneumonia (as a child), and environmental allergies. Pt
denies difficulty breathing, cough, emphysema, tuberculosis. Pt has not had a recent CXR.
Cardiovascular: Pt has hypertension; last EKG screening was last week; pt denies hyperlipidemia, chest
pain/angina, myocardial infection, CAD/PAD, CHF, murmur, thrombus, rheumatic fever, myocarditis,
arrhythmias
GI: Pt has autoimmune hepatitis; last colonoscopy 2010; pt denies nausea, vomiting, diarrhea,
constipation, GERD, indigestion, hemorrhoids, yellow jaundice, pancreatitis, colitis, diverticulitis,
appendicitis, abd. abscess, IBD, cholecystitis, gastritis/ulcers, or blood in the stool.
GU: Pt urinates 3-4x/day; pt denies nocturia, dysuria, hematuria, polyuria, kidney stones, and bladder or
kidney infections.
Women/Men Only: Pt admits to not giving herself monthy self breast exams; pt has had pap/pelvic exams
every couple of years; last gyn exam was 2-3 years ago; menopause at 52; last mammogram was 2013
(result was negative); DEXA bone density test was April 2015 & result showed light density
Musculoskeletal: Pt has had pain in her hip, feet, & hands for about 3 years from arthritis; pt denies
injuries or fractures, weakness, gout, or osteomyelitis
Immunologic: Pt denies any immunologic disoraders/diseases
Hematologic/Oncologic: Blood type O+; Pt has anemia, bleeds & bruises easily, she had her first blood
transfusion during this hospitalization; Pt does not have cancer
Metabolic/Endocrine: Pt has hypothyroidism & osteoarthritis; pt denies diabetes, osteoporosis, &
interolerance to hot or cold
Central Nervous System: Pt denies any central nervous system disorders/diseases
Mental Illness: Pt denies any mental illnesses
Childhood Diseases: Pt had measles and chicken pox; denies mumps, polio, scarlet fever

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 9

10 PHYSICAL EXAMINATION:
General survey: Patient is a well-developed 64 y.o. who is alert & oriented x3
Height: 24 in./61cm Weight: 196.21 lbs/89kg BMI: 39.45 Pain (include rating and location): 5/10 right hip
Pulse: 83 Blood Pressure (include location): 101/52 left arm Temperature (route taken): 97.9 oral
Respirations: 17 SpO2: 95% Room Air or O2: Room air
Overall Appearance: Clean, hair combed, dressed in own clothing (appropriate for setting and temperature), maintain eye
contact, weak gate due to hip replacement
Overall Behavior: Awake, alert, calm, relaxed, judgement intact, interacts well with others
Speech: Clear, crisp diction
Mood and Affect: Pleasant, cooperative, talkative
Integumentary: Surgical incision on right hip with mepilex dressing dry and intact, no seepage or drainage; skin is warm,
dry, and intact; skin turgor elastic; nails without clubbing; capillary refill < 3 seconds; hair evenly distributed, clean, without
vermin
IV Access: Peripheral IV site, 20 gauge, dorsal metacarpal; inserted 6/24/15; blood transfusion infusing; no redness, edema,
or discharge
HEENT: Facial features symmetric; no pain in sinus region; no pain, clicking of TMJ; thyroid not enlarged; no palpable
lymph nodes; sclera white and conjunctiva clear, without discharge; eyebrows, eyelids, eyelashes, orbital, & lacrimal glands
symmetric without edema or tenderness; pupils equal, round, reactive to light and accommodation; peripheral vision intact;
ears symmetric without lesions or discharge; whisper test heard within 6 inches; nose without lesions or discharge; lips,
buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Pulmonary/Thorax: Respirations regular & unlabored; transverse to AP ratio 2:1; chest expansion symmetric; sputum
production not witnessed; lung sounds CL in RUL & LUL bilaterally, CL in RML, D in RLL & LLL bilaterally
Cardiovascular: No lifts, heaves, or thrills; heart sounds regular; s1 & s2 audible; no murmurs, clicks, or adventitious heart
sounds; no JVD; calf pain negative bilaterally; apical pulse +2, carotid +2, brachial +2 bilaterally, radial +2 bilaterally, DP
+1 right, +2 right; no temporal or carotid bruits; non-pitting edema +1 on right hip; extremities warm with capillary refill <
3 seconds
GI: Bowel sounds normoactive x4 quadrants; no bruits auscultated; no organomegaly; percussion dull over liver & spleen
& tympanic over stomach & intestine; abdomen non-tender to palpation; last BM 06/23/2015 before admission, pt states it
was normal; pt denies nausea.
Genitalia was not assessed, pt alert, oriented, denies problems.
GU: Urine output clear, normal. Pt has bathroom privileges with assistance
Musculoskeletal: Strength bilaterally equal at 5 RUE, 5 LUE. Strength unequal bilaterally in lower extremities: 2 RLE & 3
LLE; vertebral column without kyphosis or scoliosis; neurovascular status intact w/ pain: peripheral pulses palpable, no
pallor, paralysis, or paresthesia
Neurological: Pt awake, alert, oriented to person, place, time & date; CN 2-12 grossly intact; sensation to touch, pain, &
vibration; stereognosis, graphesthesia, & proprioception intact; Rombergs negative; weak gait; DTR: triceps +2, biceps +2,
brachioradial +2, patellar +2, Achilles +2, Babinski 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
University of South Florida College of Nursing Revision September 2014 10
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 Dates Trend Analysis

WBC WBC levels have stayed There is no indication of
4.6 06/17/2015 (Before within normal ranges infection.
surgery) upon admission and after
surgery.
8.5 06/25/2015 (After
surgery)

5.9 (06/26/2015)
Normal (4.5-11)
RBC Upon admit, the patients The patient is anemic due
3.37 L 06/17/2015 RBC were low but closer to Imuran (medication for
to the normal range. liver disease) and also
2.46 L 06/25/2015 However, the RBC are lost blood during surgery.
trending downwards.
2.26 L 06/26/2015
Normal (4-5.2)
HGB HGB was low upon admit RBC and platelets are low
11.7 L 06/17/2015 and began trending so it HGB is going to be
downwards even more low also.
8.4 L 06/25/2015 after surgery.

7.9 L 06/26/2015
Normal (12.3-15.3)
HCT HCT were in the low Low HCT indicates
35.1 06/17/2015 normal range prior to anemia which pt has been
admission. However HCT diagnosed with. HCT
25.6 L 06/25/2015 are trending downwards levels trend along with
since surgery. RBC, HCB and platelets.
23.5 L 06/26/2015
Normal (35-47%)
Platelet Platelets were within Imuran causes anemia
203 06/17/2015 normal range prior to and thrombocytopenia.
admission but began Platelets may also be low
145 L 06/25/2015 trending downward after due to surgery as it is
surgery. only post op day 2.
124 L 06/26/2015

Normal (150-400)
Glucose Glucose is within normal Pt does not have anything
101 06/17/2015 range that would alter glucose
levels.
151 06/25/2015

109 06/26/2015

University of South Florida College of Nursing Revision September 2014 11

 Normal (80-200)
Potassium is within Pt is on a lifelong
Potassium normal range potassium sparing
3.7 06/17/2015 diuretic which is
effectively keeping
4.1 06/25/2015 potassium levels normal.

3.6 06/26/2015
Normal (3.5-5.3)
BUN BUN was normal prior to Due to increased BUN
20 06/17/2015 admit. However, BUN and creatinine levels the
began trending upwards pt may have some fluid
27 H 06/25/2015 after surgery. retention/decreased renal
output.
27 H 06/26/2015
Normal (8-23)
Creatinine Creatinine level has Due to increased BUN
1.0 06/17/2015 fluctuated between high and creatinine levels the
normal and a little bit pt may have some fluid
1.3 H 06/25/2015 higher than normal range. retention/decreased renal
output.
1.1 06/26/2015
Normal (0.4-1.1)
Calcium Calcium has been on the Pt takes a calcium
10.6 H 06/17/2015 high end of normal and a supplement which
little high prior to explains the slightly high
9.6 06/25/2015 admission and after level.
surgery.
10 H 06/26/2015
Normal (8.3-9.9)

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Check vital signs every 4 hours, get pt up daily for physical therapy while in hospital, pt to be discharged with
home health/PT, schedule two week follow up with the doctor, provide comfort measures and assess pain
frequently.

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

1. Pain related to surgery as evidence by pt stating pain is 5/10 on a scale from 0 to 10.

2. Risk for falls/injury related to impaired physical mobility.

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 15 CARE PLAN
Nursing Diagnosis: Pain related to surgery as evidence by pt stating pain is 5/10 on a scale from 0 to 10.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Pt will have a pain level of 4 or < -Assess pain intensity level in Single dimension pain ratings are The goal was met.
on a scale of 0-10 this shift. client using a valid and reliable valid and reliable as measures of The patients pain was a 5 out of 10
self-report pain tool, such as the 0- pain intensity level (Ackley, during the morning assessment, in
10 numerical pain rating scale. Ladwig, 2014) the reassessment and after
analgesics were administered the pt
-Notify nurse/preceptor when pt is The purpose of the analgesic trial is stated that her pain was a 3 or 4 out
in need for next pain med dose to help confirm the presence of of 10.
pain and provide a basis for the
development of an individualized
pain management plan (Ackley et
al, 2014)

-Monitor V/S, I/Os and labs. Vital signs and labs are viable
resources to show if a client is in
distress

-Reposition patient If a patient is in one position for

long periods of time, they may
become stiff which causes more
pain.

-Provide comfort measures

Pt will be able to perform activities -Encourage ambulation The quicker the patient can become Not met
of recovery and ADLs without mobile again the quicker they will This is a long-term goal.
discomfort within the next few be able to perform ADLs
weeks. comfortably.
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 Pt will be doing physical therapy w/ home health.
Pastoral Care
University of South Florida College of Nursing Revision September 2014 13
Durable Medical Needs
F/U appointments follow up with the orthopedic doctor in 2 weeks.
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH Home health
Palliative Care

The patient is being discharged home with home health. The pt has a well-established support system; the husband and home health nurse
will be providing care for the patient. Financial issues do not seem to be an issue. The patient is going to need to be discharged home with an
ambulating assistance device such as a walker.

University of South Florida College of Nursing Revision September 2014 14

 References

Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care (Tenth ed., pp. 575-582). Maryland Heights, MO: Elsevier Mosby.

Huether, S., & McCance, K. (2012). Understanding pathophysiology (5th ed., pp. 997-999) (V.
Brashers & N. Rote, Eds.). St. Louis, MO: Elsevier Mosby.

Nursing Central. (2015). Unbound Medicine Inc. (Version 1.25) [Mobile application software].
Retrieved from http://www.unboundmedicine.com

Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning (p. 164).
Philadelphia, PA: F.A. Davis Company.

U.S. Department of Agriculture. ChooseMyPlate.gov Website. Washington, DC. Daily Food

Plans. www.choosemyplate.gov/healthy-eating-tips/tips-for-vegetarian.html. Accessed
July, 14 2015.

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