UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kacy McMurry

PATIENT ASSESSMENT TOOL .

Assignment Date: 10/15/2014

Agency: TGH UD

1 PATIENT INFORMATION
Patient Initials: M.D.

Age: 39

Admission Date: 10/9/14

Gender: Male

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Acute back pain 724.5

Level of Education: Bachelor's Degree

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Businessman

C4 Cervical Fracture, Closed Lumbar Vertebral

Number/ages children/siblings: 2 children ages 7 and 10

Fracture

Served/Veteran: N/A

Code Status: Full

Living Arrangements: Lives with wife and 2 daughters

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

Culture/ Ethnicity /Nationality: Caucasian

Religion: Atheism

Type of Insurance: Blue Cross

1 CHIEF COMPLAINT:
Patient complains of neck pain, back pain, and right wrist pain.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient was in a motorcycle accident and thrown over the handle bars. Patient does not remember the location and does
not know if he lost concisouness. C-collar was applied on scene by the paramedics and so was a splint for his right
wrist. The accident occurred on 10/9/14 at about 12:30 am, right when the accident occurred. The patient states the pain
came on abruptly and is severe, sharp, and stabbing. The pain in his back is aggravated by movement. Patient states that
the only thing that helps his pain is Dilaudid. Patient is still in cervical collar, but does not have the wrist splint anymore.
He received an X-ray for all of his extremities and the only fracture found was in his C4. The patient is only at the
hospital now for pain treatment, and is expected to be discharged today due to the change from IV medication
to oral medication for pain.

University of South Florida College of Nursing Revision August 2013

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

Operation or Illness

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

None

Father
Mother
Brother
Sister
relationship
relationship
relationship

Comments: Include date of onset

Patient was adopted and does not know family history.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (2009)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

University of South Florida College of Nursing Revision August 2013

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

No known allergies

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)
A fracture is defined as a break in the continuity of any bone. These breaks occur when forced is applied to the bone
that exceeds the overall strength of the bone. The occurrence of certain types of fractures often depends on the age
and gender of a person. Young people tend to break longer bones more often, whereas older people tend to break the
upper leg and hip bones. Fractures have many different factors that classify them. Fractures can be open or closed
depending if the bone is sticking out of the skin and the fracture themselves can be differently shaped and that classifies
it. Fracture healing happens in two ways, direct and indirect. Indirect healing involves the formation of a callus where as
direct healing is when the bone cortices are in contact with each other. Clinical manifestations of a fracture include
deformity, swelling, impaired sensation, pain, and decreased mobility. Treatment usually includes realigning the bone
and casting the broken bone so that it is immobile. Sometimes surgery is needed to fix the fracture. X-rays are used
to diagnose fractures and they can show what kind of fracture it is as well (Huether, 2008, p.979).

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

Concentration (mg/ml)

Route Oral

Dosage Amount (mg) 100 mg

Frequency once daily

Pharmaceutical class stool softener

Home

Hospital

or

Both

Indication Constipation
Side effects/Nursing considerations opioids can cause constipation, throat irritation, cramps, diarrhea, rash
Name famotidine (Pepcid)

Concentration

Dosage Amount 20 mg

Route oral

Frequency once daily

Pharmaceutical class histamine h2 antagonist

Home

Hospital

or

Both

Indication prevention of stomach ulcers

Side effects/Nursing considerations dizziness, arrhythmias, constipation, erectile dysfunction, drowsiness
Name tramadol (Ultram)

Concentration

Dosage Amount 50 mg

Route oral

Frequency Every 4 hours PRN

Pharmaceutical class analgesic

Home

Hospital

or

Both

Indication moderately severe pain

Side effects/Nursing considerations dizziness, headache, constipation, nausea, sweating, urinary retention
Name hydrocodone-acetaminophen (NORCO)

Concentration

Dosage Amount 325 mg

University of South Florida College of Nursing Revision August 2013

Route oral

Frequency Every 6 hours PRN

Pharmaceutical class opioid agonists nonopioid analgesic comboniation

Home

Hospital

or

Both

Indication Severe constant pain

Side effects/Nursing considerations confusion, dizziness, hypotension, constipation, dyspepsia
Name hydromorphone (Dilaudid)

Concentration

Dosage Amount 2 mg

Route oral

Frequency Every 4 hours PRN

Pharmaceutical class opiod agonist

Home

Hospital

or

Both

Indication Moderate to severe pain

Side effects/Nursing considerations sedation, hypotension, dry mouth, nausea, vomiting, blurred vision
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

University of South Florida College of Nursing Revision August 2013

 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 pt follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patient's diet is not that far off from the "My Plate"
Breakfast: 2 eggs scrambled, bacon, grapefruit
diet. He eats at least one fruit or vegetable with each meal
and even his snacks have healthy qualities to them.
Lunch: Meatball sub with a side salad
Something that could be improved upon though is adding
whole grains into the diet, such as the bread of his sandwich
Dinner: Steak, green beans, mashed potatoes
being whole grain, or having oatmeal for breakfast instead
of bacon. More water could be included into his diet as
Snacks: Banana, granola bar
well.
Liquids (include alcohol): 6 glasses of water, can of coke,
1 can of beer
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 reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? "I take care of myself usually. If I get in really bad shape, my wife will take care of me."
How do you generally cope with stress? or What do you do when you are upset?
"I don't typically get stressed, but I guess when I do I go out and ride my motorcycle, take a break from everything."

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
"I haven't had any of those feelings lately. Just want to get out of the hospital and be with my family."

+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

University of South Florida College of Nursing Revision August 2013

 4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Intimacy vs. Isolation

Autonomy vs. Doubt & Shame

Initiative vs. Guilt
Industry
Generativity vs. Self absorption/Stagnation
Ego Integrity vs.

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: Erikson believed it was important for people to develop close, committed relationships with other people. Success

leads to strong relationships or intimacy, while failure leads to loneliness and isolation. (McLeod, 2008)
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 intimacy stage of life where you choose to be in close, committed relationships with other people.
My patient was married with 2 daughters, so you can tell he chose to be committed to his relationship and marriage.
He is not by himself at home, he has a support team. His family comes to visit him at the hospital, so he is not isolated.

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

Being the in hospital, although he's not sick, has probably made him appreciate his family more and he says he hates that
he can't see them more while he is in the hospital, so it makes him desire intimacy more than before.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
"Well I'm not really sick, so I don't think it really means anything. I just need to be safer on my motercycle."
What does your illness mean to you?
"I just need to be safer."

+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? _I'm not sure________________________________
Are you currently sexually active? 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? 15 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

University of South Florida College of Nursing Revision August 2013

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

What importance does religion or spirituality have in your life?
I'm atheist, so it doesn't really affect my life.
Do your religious beliefs influence your current condition?
No it doesn't influence it.

+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)
Smokes cigarettes
1/2 a pack a day

Yes
No
For how many years? 15 years
(age 24

thru

39

If applicable, when did the

patient quit?

Pack Years: 8 years

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

Has the patient ever tried to quit? No

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Beer
How much? (give specific volume)
3 cans of beer a week

For how many years? 18

(age 21

thru

39

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?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: 1 time daily
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
3/day
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? 8/17/2011
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

4/day

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
2/year

Type:

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 10/9/2014
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 10/9/14
Other:

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam? N/A
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision August 2013

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 August 2013

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: Well
Height: 6"
Weight:164llbs BMI:22.2
Pain: (include rating & location)
7/10 in neck and back
developed and well nourished Pulse: 79
Blood
Pressure: 118/76 R arm
Temperature: (route taken?)
Respirations: 16
(include location)
96.6 oral
SpO2: 98
Is the patient on Room Air or O2: Room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin

Peripheral IV site Type: IV

no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Fluids infusing?
no
yes - what?

talkative
withdrawn

Location: Right forearm

Location:
Location:

quiet
boisterous
aggressive
hostile

flat
loud

Date inserted: 10/13/14

Date inserted:
Date inserted:

HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 12 inches & left ear- 12
inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: In good repair, without cracks and cavities
Comments:
Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red

University of South Florida College of Nursing Revision August 2013

RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: apex
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3
Femoral: 3
Popliteal:3
DP: 3
PT: 3
No temporal or carotid bruits
Edema:
0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color:
Previous 24 hour output:
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 10 /8 /14
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: X Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __5___ RUE ____5___ LUE ____5___ RLE & ___5____ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias

University of South Florida College of Nursing Revision August 2013

Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: +2 Biceps: +2

Brachioradial: +2

Patellar: +2

Achilles: +2

Ankle clonus: positive negative Babinski: positive 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
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
CT of Cervical Spine

Dates

Chest Xray

10/9/14

Trend
10/10/14

Analysis
Nondisplaced fracture of
spinous process of C4
Right upper lobe airspace
disease related to
pneumonia or pulmonary
contustion.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Daily vitals, CT of cervical spine before discharge, patient to do as much ADL's as tolerated, should be
discharged today.

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

1. Acute pain related to C4 fracture as evidenced by patient stating he is in pain 7 out of 10, requesting of pain medication,
and grimacing of the patients face.
2. Constipation related to opioid intake as evidenced by patient not having a bowel movement since 10/9/2014.

University of South Florida College of Nursing Revision August 2013

3. At risk for anxiety of driving related to motorcycle accident that caused his injury.
4.
5.

University of South Florida College of Nursing Revision August 2013

 15 CARE PLAN
Nursing Diagnosis: Acute pain related to C4 fracture as evidenced by patient stating his pain was 7 of 10, requesting pain medication....
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care
Goal
Provide References
is Provided
Perform activities of recovery or
Ask the client to identify a pain
Effective pain relief will allow the
Patient was able to perform all
ADLs easily.
level where they are able to
client to perform desired or
ADLs by himself and identified a
perform desired or necessary
necessary activities within a
comfortable pain level.
activities, so you as the nurse is
tolerable pain level so they can get
able to determine pain management ready for discharge. (NANDA
interventions.
book)
Describe nonpharmacological
Try methods such as imagery,
These can supplement, not replace, No other methods were found.
methods that can be used to help
distraction, application of heat and pharmacological interventions and
achieve comfort-function goal.
cold, and relaxation.
may help relieve pain. (NANDA
book)
Patient will identify a pain level
Use multidimensional pain
Not all pain can be treated the same Pain reached a 3 out of 10 so the
that is tolerable, in this case below treatment to make the patient as
way, using different pain
goal was met.
a 4 out of 10.
comfortable as possible.
medications for example, use
different mechanisms. (NANDA
book)

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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Constipation related to opioid intake as evidenced by patient not having a bowel movement since 10/9/2014.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Maintain passage of soft, formed
Request stool softener since the
Opioids lead to constipation
Patient has not passed stool for 7
stool every 1 to 3 days without
patient is taking opioids and that is because they decrease propulsive
days, and did not pass stool during
straining.
often a cause of constipation. If this movement in the colon and
shift.
does not work request a laxative.
enhance sphincter tone making it
difficult to defecate.
State relief from discomfort of
If the patient is having bowel
There can be multiple causes of
Patient did not state that he was in
constipation.
sounds and fiber, fluid, activity,
constipation, and a certain disorder pain.
and stool softeners do not help,
can be causing the problem.
refer the patient to a physician to
look at their bowel function.
Identify measures that prevent or
Encourage fluid intake, activities
Using multiple methods to reduce
Patient was given stool softeners,
treat constipation.
such as walking, provide stool
constipation may help to start a
drank plenty of fluids, and walked
softeners, laxative, or enemas as
bowel movement. Fluid loosens
off the floor several times with no
needed.
stool and the more movement a
bowel movement.
patient has the more motility there
is in the bowels.
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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

15 CARE PLAN

Patient Goals/Outcomes

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References

Evaluation of Interventions on
Day care is Provided

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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

References
McLeod. S. A. (2008). Erik Erikson. (n.d.). Simply Psychology. Retrieved June 23, 2014, from
http://www.simplypsychology.org/ Erik-Erikson.html
Huether, S. E., & McCance, K. L. (2008). Alterations of Hormonal Regulation.Understanding
Pathophysiology (Fifth Edition ed., ). St. Louis, Mo.: Mosby/Elsevier.
Ackley, B. J. (2010). Nursing diagnosis handbook: an evidence-based guide to planning care (9th ed.).
Maryland Heights, Mo.: Mosby.