UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Danielle Giaritelli

FUNDAMENTAL PATIENT ASSESSMENT TOOL . Assignment Date: 6/25/2014

Agency: FHT/SUMMER 2014

1 PATIENT INFORMATION
Patient Initials:
WS
Gender:

Male

Age: 72

Admission Date: 6/23/14

Marital Status: Divorced

Primary Medical Diagnosis with ICD-10 code:

Primary Language: english

Bacterial Infection (Organism Unidentified)

Level of Education: 10th grade in high school

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Patient owns a mobile home

company and runs his own business
Number/ages children/siblings: patient is an only child; patient has
a daughter but did not disclose her age

Leukocytosis

Served/Veteran: served in army for two years

Code Status: full reccesitation

Living Arrangements: Patient owns a one story home where he

lives with his daughter

Advanced Directives: yes

If no, do they want to fill them out?
Surgery Date: N/A
Procedure: N/A

Dyslipidemia

Culture/ Ethnicity /Nationality: I am American.

Religion: not religious

Type of Insurance: United Way

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 1 CHIEF COMPLAINT: Patient was admitted to hospital with complaint of weakness. He also felt so cold
he was shaking and could not get warm. Patient states, I was on my way to the doctor and was shaking so bad
my daughter drove me straight to the emergency room. I couldnt get myself warm and my chills would not go
away.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The 72-year-old male patient woke up the morning of June 23, 2014 feeling very weak. He also noticed that he was
shaking because he was cold and could not warm himself up. After deciding to go to the doctor, his daughter was
driving him there and saw him shaking so severely she took him straight to the emergency room instead. I interviewed
the patient when he was alone, two days after admission, and he currently feels fine with pain being a 0 out of 10. He
also has equal strength bilaterally of 5 in both right and left upper and lower extremities. Patient can ambulate and has a
smooth gait. He can also reposition himself. He does not have chills anymore and temperature 97.8 degrees Fahrenheit
taken orally. He tested positive for a gram-negative bacteria, but the identification of the organism is still pending as of
June 25, 2014. The patient said he had gone to a barbeque on Saturday and may have eaten undercooked/raw chicken.
He has had no other contact with any sick persons or any recent travels. Patient had a central PICC line inserted on his
left arm in his bacillic vein. Patient had a CT for his abdomen and pelvis because of elevated lactic acid and the gramnegative bacteria with results still pending. Patient also had a chest x-ray on June 24, 2014, which shows obstructive
pulmonary physiology; however, there is no acute chronic pulmonary disease.

Patient also has Pagets disease, an upper respiratory infection, and hyperlipidemia (goal is to keep LDL<130)

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

Operation or Illness

Mid 90s

Cosmetic Surgery for Eyes-My eyes were baggy

March 2013

Tubular Adenoma Polyp Removed

January 2013

Transient Ischemic Attack- The doctor told me I had a slight stroke, but I think I was fine.

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2
FAMILY
MEDICA
L
HISTOR
Y

Ag
e
(in
ye
ars
)

Cause
of
Death
(if
applicable
)

Father

85

Heart
Attack

Mother

74

Stroke

Brother

N/A

Sister

N/A

Al
co
hol
is
m

Env
iron
men
tal
Alle
rgie
s

A
ne Art As
m hri th
ia tis ma

Bl
ee
ds
Ea
sil
y

Ca
nc
er

Di
ab
ete
s

Hea
rt
H
Tro
yp
Gl
G
uble
er
au
ou
(angi
te
co
t
na,
ns
ma
MI,
io
DVT
n

Kid
ney
Pro
ble
ms

etc.)

Me
nta
l
Sto
He
ma
alt Sei ch Stro Tu
zur Ul ke
h
mor
Pr es cer
obl
s
em
s

relationship
relationship
relationship

Comments: Include date of onset

Patient is an only child. Patient also stated , My mom was a diabetic all of her life. My dad always had respiratory problems. He
was smoke since I was a kid. I knew it would catch up to him soon enough.

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)- Unknown
Adult Tetanus (Date) Patient said yes, but date was Unknown
Influenza (flu) (Date) I get it down every year
Pneumococcal (pneumonia) (Date) Patient said yes, but date was
Unknown

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Have you had any other vaccines given for international travel or
occupational purposes? Ive traveled, but not to Africa where I would
need a vaccine.
1 ALLERGIES

OR ADVERSE
REACTIONS

NAME of
Causative Agent
N/A

Type of Reaction (describe explicitly)

PATIENT HAS NO KNOWN ALLERGIES

Medications

N/A
Other (food, tape,
latex, dye, etc.)

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)
Bacterial infections can be caused by a variety of different reasons. The process of pathogenesis of a bacterial infection
includes the initiation of the infection and the mechanisms that lead to signs and symptoms. The result of contact
between bacteria and a susceptible host depends on the invasiveness and bacterias ability to invade the hosts immune
system. After a bacteria invades tissues it has the possibility to produce toxins releasing exotoxins or endotoxins.
Endoxtoxins are present in gram-negative bacteria and can be released in growing bacterial cells. They then can be
transported by blood and lymph causing more invasion and growth. There are many risk factors for bacterial infections
that put some at greater risk than others. A weakened immune system is a vital factor that would allow a bacterial
infection to enter a human body more easily. Other risk factors include age, nutritional status and genetic
predispositions. This patient recently suffered from an upper respiratory infection, which could be a reason behind the
development of his bacterial infection that brought him into the hospital. The patient also had undercooked chicken at a
barbeque he attended a few days before his onset of symptoms. The patient could potentially have Salmonella due to
eating contaminated food. Diagnosing for bacterial infections can be done through a complete blood count, a urine
culture, or a culture of fluid to test the patient for presence of bacteria. This patient tested positive for gram-negative
bacteria. Taking an antibacterial antibiotic is a crucial part of treating bacterial infections. Making sure the entire
prescription of antibiotics is taken will help get rid of the infection. Also, effective hand washing can help with treating
an infection and also prevention of a new one. Bacterial infections can be treated, but if not monitored closely, it can
turn into a bacterial disease.

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

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Name aspirin

Concentration (mg/ml)

Route PO

Dosage Amount (mg) 81mg

Frequency daily

Pharmaceutical class: class antipyretic and nonopioid analgesic

Home

Hospital

or

Both

Indication: prevention of stroke, coronary heart disease, and management of primary hypercholesterolemia
Side effects/Nursing considerations: amnesia, abdominal cramps, constipation, diarrhea, hyperglycemia, dizziness, headache

Name enoxaparin (Lovenox)

Concentration 5mg of enoxaparin sodium and

5000 IU per .01 mL of water for Injection

Route ING-subcut

Dosage Amount 40mg

Frequency daily

Pharmaceutical class anticoagulant

Home

Hospital

or

Both

Indication: prevention of ischemic complications (with aspirin) and venous thromboembolism

Side effects/Nursing considerations: dizziness, headache, edema, nausea, vomiting

Name heparin flush (Heparin Lock Flush)

Concentration

Route INJ-IV

Dosage Amount 50 units

Frequency Q8H-every 8 hours

Pharmaceutical class antithrombotic

Home

Hospital

or

Both

Indication prophylaxis and treatment of various thromboembolic disorders; used in low doses to maintain patency of IV (heparin flush)
Side effects/Nursing considerations rashes, uticartia, bleeding, fever, sensitivity, heparin-induced thrombocytopenia
Name piperacillin-tazobactam (Zosyn)

Concentration 25mL/hr

Route IVPB

Dosage Amount 3.375 GM

Frequency Q8H at intervals-infuse every 4 hours

Pharmaceutical class extended spectrum penicillins

Home

Hospital

or

Both

Indication skin and skin structure infections; appendicitis and peritonitis

Side effects/Nursing considerations seizures, nephritis, steven-johnson syndrome, rashes, uticartia, bleeding, leukopenia, neutropenia, thrombocytopenia

Name simvastatin (Zocor)

Concentration

Route PO

Dosage Amount 20mg

Frequency QHS-at bedtime

Pharmaceutical class lipid lowering agent

Home

Hospital

or

Both

Indication management of hypercholesterolemia and mixed dyslipidemia; secondary prevention of myocardial infarction and stroke
Side effects/Nursing considerations amnesia, confusion, dizziness, headache, hyperglycemia, insomnia, weakness, nausea, diarrhea

Name sodium chloride (Saline Flush)

Concentration 150 mEq sodium/L

Route iV PUSH

Dosage Amount 10 mL

Frequency Q8H

Pharmaceutical class mineral and electrolyte replacement/

supplement

Home

Hospital

or

Both

Indication hydration, prevention of volume depletion

Side effects/Nursing considerations heart failure, pulmonary edema, hypernatremia, hypervolemia, hypokalemia

Name acetaminophen (Tylenol)

Route liquid PO

Concentration

Dosage Amount 650mg

Frequency PRN

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Pharmaceutical class antipyretic and nonopoid analgesic

Home

Hospital

or

Both

Indication treatment of mild pain or fever

Side effects/Nursing considerations renal failure with chronic use, rash, uticartia, neutropenia

Name

Concentration

Route

Dosage Amount
Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

Name

Concentration

Route

Dosage Amount
Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Concentration

Dosage Amount

Name
Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with
recommendations.

Diet ordered in hospital?

Heart Healthy Cardiac

Analysis of home diet (Compare to My Plate and

Diet patient follows at home? No specific, but tries to Consider co-morbidities and cultural considerations):
follow a healthy eating pattern
24 HR average home diet:
Breakfast: 1 cup of cheerios with 1 cup 2% milk, a banana, Patient does not have any cultural considerations for his
and 8 oz glass of Orange juice
eating pattern. He does however have hyperlipidemia and
said, I watch what I eat and what goes in my mouth. I try
and stick to a schedule and mostly whole foods. When
evaluating the patients diet, he does appear to have a good
grasp on a healthy lifestyle diet. He understands it is
essential to maintain stable blood glucose levels by having
5-6 small meals a day. The patient tries to eat at least two
snacks and 3 meals a day. The patient had a total daily
amount of 1,265 calories. He was under his limit of 22g of
saturated fat by only consuming 14g. Patient consumed
34g of carbs extra than the daily allowance and could
reduce that by substituting a vegetable like kale at dinner
for the baked potatoes. Patient was well under his daily
allowance of cholesterol by over 100mg. The patient had a
good understanding that he has high cholesterol and tries
to follow a heart healthy diet at home as well as during his
hospital stay. Patient had an adequate intake minerals and
vitamins with consuming more Calcium and Vitamin C
than his target goal. Patient was over the daily allowance
of sodium by 31mg. He could eliminate this problem by
substituting sliced turkey on his sandwich instead of ham.
Turkey has adequate nutritional value and can contain less
sodium in certain brands. The patient understands the
importance of water and tries to drink a minimum of 5-6,
8oz glasses a day. Instead of having both orange juice and
milk in one sitting, he could drink the orange juice with his
snack or dinner. The patient exhibits a desire to maintain a
healthy diet after he is discharged.

Lunch: Approximately 4 slices of Ham and 1 slice of Swiss

Cheese sandwich on Wheat bread with no additional
toppings

Dinner: 1 serving of chicken with baked potatoes (no salt,

butter, or sourcream added)

Snacks: medium size apple at 10 am and a single serve

plain yogurt at 3pm

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Liquids (include alcohol): 8 oz of orange juice, five to six,

eight oz glasses of water, 8oz cup of 2% milk

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? I drink more water than I already do when I am sick to flush out my body. I also take
an aspirin to help.
How do you generally cope with stress? or What do you do when you are upset? I cope by not putting stress on myself.
I try not to worry about things I cant control that way I dont get stressed or upset.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient has no current feelings of depression, anxiety, or being overwhelmed. Patient is happy with relationships and
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? _____no___________________________

Have you ever been talked down to?_Im sure. ____ Have you ever been hit punched or slapped? __yes___

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
__________I have not been physically harmed.___If yes, have you sought help for this?
____no__________________

Are you currently in a safe relationship? Patient is not in current relationship.

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

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Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for
your
patients age group: Older adults must come to view their lives as meaningful to face death without worries and regrets (Sigelman,
p. 36)
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 was in a very good mood and exhibited emotions and gestures that led me to
believe he has lived a meaningful life. The patient worked hard to own his own company and still enjoys working there
and running it. The patient doesnt like to think about negative things and prefers not to add stress to himself by
worrying about things he cant control. Although patient didnt reveal much information about his divorce, he seemed to
feel he has a successful life and is happy with where he is at in this time of his life. He was very pleasant to talk to and
seemed very relaxed. He did not show signs of regret or despair, but more emotions of happiness and seemed to be
younger than 72.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? There isnt a cause. Things happen that I cant control and this is one
of them. I think I ate raw chicken though, so that could have caused it.
What does your illness mean to you? It doesnt mean anything to me. I feel back to normal now and dont let these
types of things bother me.

+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? __N/A-did not feel comfortable asking patient____
Have you or a partner ever had an abnormal pap smear?_N/A-patient is no longer married and I did not feel comfortable
asking
Have you or your partner received the Gardasil (HPV) vaccination? Patient has not-did not ask about ex wife

Are you currently sexually active? _ N/A-did not feel comfortable asking patient When sexually active, what measures
do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? N/A-did not feel
comfortable asking patient

How long have you been with your current partner? I am no longer with them. Patient wasnt happy about this
question

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?
N/A-did not feel comfortable or reason for asking patient

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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?
Religion is not important to me, personally.
Do your religious beliefs influence your current condition?
___Once again, I am not religious, so not to me personally.

+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?

Yes

No

How much?(specify daily amount)

For how many years? 25 years

1 pack per every 2 days

(age

15 thru

35

Cigarettes
If applicable, when did the
patient quit? Age 35

Pack Years: 4,562 packs per 25 years

Does anyone in the patients household smoke tobacco? If

Has the patient ever tried to quit? Yes, he successfully
so, what, and how much? Patients daughter lives with home
quit 37 years ago
and smokes cigarettes; she smokes a pack a day

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? Beer

Yes

No

How much? (give specific volume)

For how many years? all my

life

6-8 beers a week; approximately 96

oz a week

(age

18

thru 72

If applicable, when did the patient quit?

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?

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4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks

No. Patient owns a mobile home business where he works inside an office with air conditioning.

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
Pts perception of health: I think I am doing great for 72. I feel good and watch what I eat.

Integumentary: patient denies problems with nails, dandruff, psoriasis, hives or rashes, skin infections. Patient
has noticed changes in appearance of skin because he bruises easily and there are spots on his skin. Patient
also uses sunscreen but denied knowing the SPF amount. Patient states he bathes and brushes his teeth at
least two times a day.
HEENT: patient glaucoma, sinus pain or infections, nosebleeds, post-nasal drip, oral infection, dental
problems. Patient visits the dentist once a year and routinely brushes his teeth and flosses everyday. Patient
denied difficulty hearing, but asked multiple times for me to repeat a question. Patient has difficulty seeing,
but used glasses as an assisted device. He had had ear infections in the past-I had them as a child. Patient
had his left cataract done and is getting his right next week.
Pulmonary: Patient denies difficulty breathing, cough, asthma, bronchitis, emphysema, pneumonia,
tuberculosis, and environmental allergies. Although patient denied cough, he did have a small dry cough due
to upper respiratory infection. Patient had chest xray on June 24, 2014.
Cardiovascular: Patient denies coronary artery stenosis, chest pain, myocardial infarction, CHF, murmur,
thrombus, rheumatic fever, myocarditis, and arrhythmias. Patient has hypertension and hyperlipidemia.
Patient also has on cardiac monitor strips since 6/24/2014 to current date. Patient had an electrocardiogram on
6/23/2014 and it says in process.
GI: Patient denies nausea, vomiting, diarrhea, constipation, GERD, indigestion, hemorrhoids, jaundice,
pancreatitis, colitis, diverticulitis, appendicitis, abdominal abscess, irritable bowel, cholecystitis, gastritis,
ulcers, blood in the stool and hepatitis. Patient has had a few colonoscopies and his most recent was in 2012.
GU: Patient denies dysuria, hematuria, and bladder and kidney infections. Patient has nocturia and polyuria.
Patient voids 3-4 times a day. 300 mL output on June 24, 2014.
Women/Men Only: Patient denies BPH and urinary retention. Patient has had infection of his genitalia, but
would not go into detail. Patient also was unsure about his last prostate exam.
Musculoskeletal: Patient has had injuries and fractures when he fractured his foot and dislocated his thumb.
Patient denies weakness, pain, osteomyelitis, and arthritis. Although patient denied weakness, it was his
admitting complaint, but he states feeling is no longer there.
Immunologic: Patient denies night sweats, fever, HIV or AIDS, lupus, rheumatoid arthritis, sarcoidosis, tumor,
life threatening allergic reaction, and enlarged lymph nodes. Patient says the only time he had severe chills
with severe shaking was on his admission date, 6/23/2014.
Hematologic/Oncologic: Patient denies anemia and blood transfusion. Patients bleeds easily-Yeah, I bleed
easily because of the baby aspirin I take. Patient bruises easily and has had skin cancer in the past. Patients
blood type is O positive.
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Metabolic/Endocrine: Patient denies diabetes, hypothyroid, hyperthyroid, intolerance to hot and cold, and
osteoporosis.
Central Nervous System: Patient denies dizziness, severe headaches, migraines, seizures, ticks or tremors,
encephalitis, and meningitis. Patient had a mini stroke in January 2012.
Mental Illness: Patient denies depression, schizophrenia, anxiety, and bipolar.
Childhood Diseases: Patient had measles, mumps, and chicken pox. Patient denies having polio and 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

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10 PHYSICAL EXAMINATION:
General survey: 72 year old male. Alert, awake, and oriented to person, place, and time.
Height __180cm__Weight_83kg__ BMI ___________ Pain (include rating and location)___0 ____________
Pulse__76__ Blood Pressure (include location)_left arm-136/79 _______Temperature (route taken)oral-97.8 __
Respirations_18____ SpO2 _98%_____ Room Air or O2__Room Air-21%________
Overall Appearance: patient is clean, hair combed, dress appropriate for setting and temperature, maintains eye
contact, and no obvious handicaps.
Overall Behavior: patient is awake, calm, relaxed, interacts well with others, and judgment is intact
Speech: patients speech is clear, crisp diction, and well-spoken
Mood and Affect: patient is pleasant, cooperative, cheerful, and talkative
Integumentary: patient exhibits warm, dry, intact skin, elastic skin turgor, no rashes, lesions, or deformities, nails
without clubbing, capillary refill is less than 3 seconds, and hair is clean and evenly distributed with the exception
of slight balding.
IV Access: patient has a central line device in his left bacillic vein. It was inserted on 6/24/2014 at 17:00. Patient
tolerated it and was compliant with procedure. It is used for injection of medications.
HEENT: patient has symmetric facial features, no pain in sinus region, no pain or clicking of TMJ, trachea
midline, thyroid isnt enlarged, no palpable lymph nodes, sclera is white and conjunctiva is clear without
discharge, eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands are symmetric without edema or
tenderness, PERRLA, pupils are 3mm on right and left, peripheral vision intact, EOM through 6 cardinal fields
without nystagmus, ears are symmetric without lesions or discharge, patient did not respond to whisper test for
either ear, nose without lesions or discharge, and lips, bucal mucosa, floor of mouth, and tongue are pink and
moist without lesions. Patient wears glasses and has 20/20 vision corrected.
Pulmonary/Thorax: patients respirations are regular and unlabored, transverse to AP ratio 2:1, chest expansions
symmetric, percussion resonant throughout all lung fields, dull towards posterior bases. Patient denies sputum
production, but does have dry cough.
Cardiovascular: patient has no lifts, heaves, or thrills, PMI is felt at 5th intercostal space, midclavicular line,
sounds S1 and S2 are regular, no murmurs, clicks, or adventitious sounds, no JVD, calf pain negative bilaterally,
pulses bilaterally equal-apical +2, carotid +2, brachial +2, radial +2, femoral +2, popliteal +2, no temporal or
carotid bruits, 0 edema, extremities warm with capillary refill less than 3 seconds
GI/GU: : patients bowel sounds are normoactive in 4 quadrants, no bruits auscultated, no oranomegaly,
percussion is dull over liver and spleen and tympanic over stomach and intestine, abdomen was soft and round,
urine output is clear and yellow with 300 mL output in the last 24 hours, no rebound tenderness on CVA punch,
last bowel movement was on June 24, 2014 with patient not wanting to describe it. Patients genitalia was not
assessed, but patient said he had infections in the past, but currently denies having any problems.
Musculoskeletal: patient has full ROM intact in all extremities without crepitus, strength bilaterally equal at 5
RUE, 5 LUE, 5 RLE, AND 5 LLE, vertebral column without kyphosis or scoliosis, peripheral pulses palpable, no
pain, no pallor, no paralysis or parathesias
Neurological: patient is awake, alert, oriented to person, place, time, and date, not confused, CN 2-12 is intact,
sensation intact to touch, pain, and vibration, patient is +2 with deep tendon reflexes. Patient would not allow me
to test sterognosis, graphesthesia, and proprioception. Did not test patient for Romberg because he did not want
to get out of bed. Did not evaluate patients gait, but was told in rapport he can move without assistance.

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.

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Lab Dates Trend Analysis

WBCNormal-(4.5-11)
2.5
2.7
6/23/14
6/24/14
Patients white blood cell count was low on admission, and trended up a little bit probably
indicating a bacterial infection.
Patient has low white blood cell count and is probably
immunosuppressed. Patient was positive for gram negative bacteria showing the possible cause for a low
count.
RBCNormal (4.7-6.1-male)
4.59
3.68
6/23/2014
6/24/2014
Patients red blood cell count was low upon admission and has trended downwards possibly
because of medications.
Patient is on aspirin and enoxaparin, which are both anticoagulants. Patient
denied having anemia, but said he bled easily because of medications that could result in a lower than normal
RBC.
Neutrophils
Normal-(1.5-8.0)
2.18
5.57
6/23/2014
6/24/2014
Patients neutrophil count trended upward since admission indicating a bacterial infection.
Neutrophils are a type of white blood cell that help to fight infection. Alike with the white blood cell
count that trended upward, it was originally low due to a gram negative bacteria. It is trending upwards
because they are treating him.
Lymph
Normal(.08-4.8)
.20
1.20
6/23/2014
6/24/2014
Patients lymph is trending upward upon admission that is another factor indicative of a
bacterial infection because of the low amount that was originally present. Patient had a low amount of lymph
because he was probably immunosuppressed but after taking Zosyn, active against susceptible bacteria, the
lymph has gone up.
Hematocrit
Normal (37-51%)
43.6%
36.6%
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+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
A CT on the abdomen and pelvis was performed after the patient exhibited elevated lactic acid and
tested positive for gram-negative bacteria.
Patient has had cardiac monitoring strips placed on him on 6/24/2014 at 04:11 and 6/25/2014 at 09:54
to assess rate and rhythm of patients heart. Electrocardiogram reads In Process.
Patient is having his vitals evaluated every 4 hours.
Patient had a CBC and basic metabolic pane done on 6/24/14 to look at his cell counts after diagnosing
him with a bacterial infection (organism identity still pending).
Patient is on a heart healthy cardiac diet during hospital stay because of his hyperlipidemia and
dyslipidemia.
Patient had a chest X-ray done on 6/23/14 to evaluate his heart after complaints of weakness and chills.

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

1. Ineffective protection r/t abnormal blood profiles a/b decrease in white blood cells

2. Infection related to microorganism invasion into the body

3. Risk for vascular trauma r/t infusion of antibiotics

4.

5.

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 15 CARE PLAN
Nursing Diagnosis: Ineffective protection r/t abnormal blood profiles a/b decrease in white blood cells
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal

Rationale for
Interventions
Provide References

Evaluation of Goal on
Day Care is Provided

Patients white blood cell

count will continue to
trend upward and be
maintained between
normal limits

Note, document, and

report laboratory values
including white blood
cells and absolute
neutrophils

The white blood cell

count and the automated
absolute neutrophil count
are a better diagnostic
tests for adults and most
children

The patient will have an

elevated white blood cell
count by time of
discharge. The patient had
a slight trend upward in
his white blood cell count
in a 24 hours time span.

Patient will demonstrate

appropriate hygienic
measures such as hand
washing, oral care, and
perineal care

Educate the patient on the

importance of hand
washing and using
alcohol-based hand rubs.
Also, assisting the patient
with oral or perineal care
if necessary or educating
the patient on the
importance of doing so
himself.

Meticulous infection
prevention precautions
are required to prevent
health care-associated
infection, with particular
attention to hand hygiene
and standard precautions.

Patient will have

demonstrated adequate
hand washing technique
as well as oral and
perineal care. Patient will
be well educated on how
to perform all of these
skills properly to prevent
worsening infection.

(Ackley and Ladwig,

2014).

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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

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References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
(9th ed., pp. 61, 491-495). United States: Mosby, an imprint of Elsevier Inc.
Peterson, J. (0096, January 17). Bacterial Pathogenesis. Bacterial Pathogenesis. Retrieved June 26, 2014, from
http://www.ncbi.nlm.nih.gov/books/NBK8526/
Sigelman, C. K., & Rider, E. A. (2009). Life-span human development (6th ed., pp. 36, 332-334). Australia:
Wadsworth Cengage Learning.
SuperTracker - MyPlate. Retrieved June 26, 2014, from http://www.choosemyplate.gov/supertrackertools/supertracker.html
Vallerand, A. H., & Sanoski, C. A. (2014). 2014 drug information update for Davis's drug guide for nurses,
thirteenth edition and Nurses med deck, thirteenth edition. Philadelphia: F.A. Davis Company.

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