UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Kristina I. Maldonado
Assignment Date: 10/21/2016
.
 1 PATIENT INFORMATION Agency: Sarasota Memorial Hospital
Patient Initials: I.G.N Age: 68 years old Admission Date: 10/18/2016
Gender: Female Marital Status: Widowed Primary Medical Diagnosis: Right rotator cuff
tear
Primary Language: English
Level of Education: BSN -CNOR Other Medical Diagnoses: (new on this
admission)
The patient did not have new medical
diagnoses upon admission.
Occupation (if retired, what from?): Patient is a registered nurse who
works in the operating room in the cardiac unit
Number/ages children/siblings: Patient has two children
including a 45-year-old son and a daughter. Patient has three
sisters and two brothers.

Served/Veteran: Army Veteran. Served for 12 years. Code Status: Full code.
If yes: Ever deployed? No.
Living Arrangements: Lives alone. Advanced Directives:
If no, do they want to fill them out?
Chart stated “will bring if able to fin.”
Surgery Date: 10/18/2016 Procedure:
Reverse total shoulder arthroplasty
Culture/ Ethnicity /Nationality: Mexican/Hispanic/American
Religion: Baptist Type of Insurance: Webtpa

 1 CHIEF COMPLAINT:
Patient’s chief complaint is shoulder discomfort and pain.

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) Patient is a 68 year old female who tore her right rotator cuff upon sitting down on a chair. She accidently kicked the
wheels of the chair and hit the ground. She received a right reverse total athroplasty on 10/18/2016. Patient tolerated
surgery well and will be discharged home.

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 O: Patient received rotator cuff surgery on 10/18/2016
L: right rotator cuff
D: Patient states a history of shoulder pain but fall occurred on 10/9/2016.
C: Patient reports sharp and acute pain. Patient reports hot and cold sensations on right shoulder.
A: moving her arm
R: not moving her arm
T: Patient underwent surgery and is recovering
S: Pain is currently 6 out of 10.

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
1975 Right lower lobectomy
1980’s Hysterectomy
2004 Right hemicolectomy
2004 Right neck node
2004 Non Hodgkin’s lymphoma
2015 Cataracts removal

Hypertension
Diverticulitis
Pneumonia
Bronchitis
Chronic kidney disease
Age (in years)

2

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause
etc.)

FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma

of
Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT

MEDICAL
Gout

Death

Mental
Heart

HISTORY (if
(angina,

applicable
)
Father X

Mother X X
X
Brother
Sister X
relationship

relationship

relationship

Comments: Include age of onset

 1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO

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 Routine childhood vaccinations U
Routine adult vaccinations for military or federal service U
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? X
Influenza (flu) (Date) Is within 1 years? X
Pneumococcal (pneumonia) (Date) Is within 5 years? U
Have you had any other vaccines given for international travel or
occupational purposes? Please List U
If yes: give date, can state “U” for the patient not knowing date received

 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Epinephrine Tachycardia/jittery
Phernergan Dystonic reaction in hands and feet
Medications

Insect bites/bee
Anaphylaxis
stings
Other (food, tape,
latex, dye, 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)
            Three bones make up the shoulder. The bones include the humerus, the scapula, and the clavicle. The 

shoulder is a ball­and­socket­joint where the head of the humerus fits into the glenoid cavity of the scapula. The

rotator cuff keeps the shoulder joint in place by attaching the humerus to the shoulder blade through four 

muscles that come together as tendons to make a protective covering around the humerus. The rotator cuff gives

individuals the ability to lift and rotate the arm. Underneath the acromion (part of the scapula), lies a sac called 

a bursa. This sac provides lubrication within the shoulder joint. Without this bursa, the rotator cuff tendons 

would not be able to glide, and therefore, impede your arm from freely moving. The bursa can become inflamed

when the rotator cuff tendons are damaged, which contributes to pain. Upon rotator cuff tendon breakage, the 

tendon is no longer attached to the head of the humerus. The supraspinatus muscle and tendon is most 

commonly the muscle and tendon torn. Many tendon tears are due to tendon fraying. After progressive fraying, 

the tendon can completely tear after a high impact movement, such as, lifting and moving heavy objects or 

falling. The rotator cuff can be severed via a partial tear or a full­thickness tear. Full­thickness tears are 

complete tears where the tendon is no longer connected, but rather split in two. The two main causes of rotator 

cuff tears are injury and degeneration. Tears can be acute or degenerative (Armstong, n.d.).

            Repetitive shoulder motions associated with certain sports and jobs can add stress to the rotator cuff 

muscles and tendons and can put individuals at risk for an overuse tear. Baseball players, tennis players, and 

weight lifters are some athletes at risk for a rotator cuff overuse tear. Traumatic falls and jobs that require 

overhead work can also put people at risk for tears. Another risk factor includes aging. Due to the fact that many

rotator cuff tears are attributed to degenerative tendon changes, people over the age of 40 at are risk. In addition,

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as people age, the body’s blood supply lessens.  The diminished blood supply impedes the body’s ability to 

repair any tendon damage. Continued damage with no repair can lead to a tendon tear. Bone spurs that occur on 

the acromion can lead to shoulder impingement, which can weaken tendons (Armstong, n.d.).

            The doctor will conduct a physical examination of the shoulder and assess for tenderness, deformity, 

range of motion, arm strength and pain. Pain presents itself uniquely in that the patient may experience pain 

when moving their shoulder in a particular motion, experiencing pain when resting upon the affected shoulder 

and at night, and crepitus upon shoulder movements. The patient may experience weakness when lifting as well 

and can experience pain when lifting the arm out to the side. Overhead movements can cause discomfort and 

pain. Routine activities can become difficult. In the event of a traumatic fall, the patient could have heard a clear

snapping sound or sensation. To confirm the diagnosis imaging is necessary. X­rays are first used and are then 

followed by MRI’s. Plain X­ray’s are usually a normal finding and will only reveal bone spur if present. The 

MRI will reveal the actual rotator cuff tear on the tendon. The MRI will reveal the gravity and size of the tear 

(Armstong, n.d.).

            There are nonsurgical treatment options and surgery available as treatment. In order to restore rotator 

cuff function (before a tear occurs), patients are recommended to rest, to discontinue or limit jobs, activities, 

and sports that aggravate the shoulder. Patients may also incorporate strengthening exercises to strengthen the 

muscles that make up the shoulder joint. Patients can also use NSAIDS to alleviate pain. If nonsurgical 

treatments are ineffective, surgery may be necessary. Persistent pain over 6­12 months is indicative of surgery. 

Clear tear is indicative of surgery. Surgery usually entails reattaching the tendon to the humerus. There are 

major risks associated with undergoing rotator cuff surgery that include, infection, permanent stiffness, and a 

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lengthy recovery (Armstong, n.d.).

 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: amlodipine (Norvasc) Concentration Dosage Amount 2.5 mg

Route: oral administration Frequency: once daily

Pharmaceutical class: calcium channel blocker Home☐ Hospital ☐ or Both
Indication: Hypertension
Adverse/ Side effects: dizziness, fatigue, peripheral edema, angina, hypotension, palpitations, flushing
Nursing considerations/ Patient Teaching: Take medication as directed. Take missed doses within 12 hours, and if more than
12 hours pass, skip the dose and take the next prescribed dose at the scheduled hour. Do not double dose. Arise
slowly to avoid orthostatic hypotension. Patients should report irregular heart rates, dyspnea, and swelling of the
hands and feet.

Name: aspirin (Ecotrin) Concentration Dosage Amount: 325 mg (1 enteric

coated tablet)
Route: oral administration Frequency: once daily
Pharmaceutical class: salicylates Home☐ Hospital ☐ or Both 
Indication: analgesic, anti-inflammatory, antipyretic, antiplatelet
Adverse/ Side effects: gastrointestinal bleeding, dyspepsia, epigastric distress, nausea, abdominal pain, anemia,
hemolysis, tinnitus, hepatotoxicity, Reye’s syndrome (in children).
Nursing considerations/ Patient Teaching: Instruct the patient to report tinnitus, bleeding gums, tarry stools, and bruising.
Instruct patient to not use alcohol while taking aspirin as this can increase the risk for gastrointestinal bleeds. The
nurse should also instruct the patient to avoid taking NSAIDS and acetaminophen with aspirin concurrently for a
few days, unless physician states otherwise.

Name: acetaminophen Concentration Dosage Amount: 325mg per tablet

Route: oral administration Frequency: 2 tablets as needed
Pharmaceutical class: nonopioid analgesic/antipyretic Home ☐ Hospital  or Both ☐
Indication: mild pain and pyrexia
Adverse/ Side effects: hepatotoxicity, increased liver enzymes, neutropenia, renal failure, acute exanthematous
pustulosis, Steven-Johnson syndrome, toxic epidermal necrolysis
Nursing considerations/ Patient Teaching: The nurse should advise the patient to only take one drug with aceptaminophen at a
time, to avoid alcohol because this increases your risk for hepatotoxity, and to contact health provider if fever is
not reduced in three days.

Name: hydromorphone (Dilaudid) Concentration Dosage Amount: 4mg per tablet

Route: oral administration Frequency: Every three hours as needed.

Pharmaceutical class: opioid agonist Home ☐ Hospital  or Both ☐
Indication: Moderate to severe pain, antitussive
Adverse/ Side effects: constipation, respiratory depression, confusion, sedation, euphoria, hallucinations, hypotension,
bradycardia
Nursing considerations/ Patient Teaching: Taper drug after repeated use to avoid withdrawal symptoms. The nurse should
advise the patient to call for ambulation assistance. The patient should not operate any machinery or vehicles. The
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patient should not ingest alcohol or other central nervous system depressants. The nurse should teach the patient
deep breathing techniques to avoid atelectasis.

Name: candesartan (Atacand) Concentration Dosage Amount: 32 mg per tablet

Route: oral administration Frequency: once daily

Pharmaceutical class: antihypertensive Home ☐ Hospital ☐ or Both 
Indication: alone or with drug agents to treat hypertension
Adverse/ Side effects: hypotension, angioedema, dizziness, headache, fatigue, impaired renal function, back pain,
hyperkalemia
Nursing considerations/ Patient Teaching: Instruct patient to not discontinue drug therapy. The patient should avoid salt
substitutes that contain potassium. Caution patient on orthostatic hypotension and dizziness. Instruct patient to
notify their physician upon signs of facial swelling. African Americans may not respond effectively to this
medication.

Name: omega-3-acid ethyl esters Concentration Dosage Amount: 1g per tablet

(Lovaza)
Route: oral administration Frequency: Four times daily
Pharmaceutical class: fatty acids Home ☐ Hospital ☐ or Both
Indication: Hypertriglyceridemia
Adverse/ Side effects: altered taste, eructation, increased liver enzyme, rash
Nursing considerations/ Patient Teaching: Medication does not cure elevated serum triglyceride levels, but does help manage
triglyceride levels. Medication should be used in combination with non-pharmacological low-fat, low-
carbohydrate, low-cholesterol diet and exercise management.

Name: hydrochlorothiazide Concentration Dosage Amount: 12.5 mg per tablet

Route: oral administration Frequency: once daily at 0300 hours
Pharmaceutical class: thiazide diuretics Home ☐ Hospital ☐ or Both 
Indication: mild to moderate hypertension, treatment of edema associated with heart failure, renal dysfunction,
cirrhosis, glucocorticoid therapy, estrogen therapy
Adverse/ Side effects: hypokalemia, dehydration, hypercalcemia, hyponatremia, hypomagnesemia, hypovolemia,
hypophosphatemia, muscle cramps, hyperuricemia, hypercholesterolemia, pancreatitis, Stevens Johnson
syndrome
Nursing considerations/ Patient Teaching

Name: Turmeric Concentration Dosage Amount: 2.5 mg per tablet

Route: oral administration Frequency: once daily
Pharmaceutical class: antifungals/anti-invectives Home ☐ Hospital ☐ or Both 
Indication: bacterial and viral infection prevention
Adverse/ Side effects: kernicterus (in newborns)
Nursing considerations/ Patient Teaching: Instruct patient not to take this herb without seeking the opinion of a health care
professional first. Patient must be aware of OTC medications that are contraindicated with turmeric use.

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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? Normal diet Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Not specific. Patient states Consider co-morbidities and cultural considerations):
she eats mainly vegetables and fruits. Patient is not a
vegetarian but does not eat animal protein frequently.
24 HR average home diet:
Breakfast: Usually eats eggs or oatmeal.

Lunch: Salad with fruit. Patient usually has peaches or

apples.

Dinner: Quinoa, walnuts, pistachios, rice

Snacks: hummus, carrots, chips

Liquids (include alcohol): Mainly drinks water with the

occasional glass of wine once a month. Patient does not
have more than 2 alcoholic beverages.

Analysis: Although patient reports eating quite adequately she is

not receiving 2,000 calories a day. She consumes 1,100-1,300
calories a day putting her under the MyPlate recommendation.
Patient does not eat animal protein but is receiving adequate
amount of protein. Patient is not taking in enough calcium or
vitamin D. Due to her insufficient dairy consumption, and her
postmenopausal age, she is at a greater risk for osteoporosis. To
increase healing and bone maintenance the patient should
increase her dairy consumption. Patient can also take calcium
supplement.

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Patient states her friends and family take care of her when she is ill. Patient did not
mention specific individuals or give any names.

How do you generally cope with stress? or What do you do when you are upset?
Patient copes with stress by praying. Patient expresses that her faith is extremely important to her. When the patient is
upset she analyses the situation and tries to analyze if she is mad due to her own fault.

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Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient shares that she is overwhelmed with surgery and is praying for the best outcome.

+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? Patient states “not really.”

Have you ever been talked down to? Patient verbalizes that she has but she also expressed that everyone has been. Have
you ever been hit punched or slapped? Patient denies being punched or slapped.

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Patient verbalizes that she has not been emotionally or physically harmed in a way that she should be actually concerned .
If yes, have you sought help for this? ______________________

Are you currently in a safe relationship? Patient states that all her relationships are safe. She verbalizes that she does not
socialize or hang around negative people.

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s 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 Erickson’s developmental stage for your
patient’s age group:

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

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

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?” Patient states that the cause of her illness was her fall. She expresses
having a rush of thoughts on what she should do in regards to her state.

What does your illness mean to you? Patient states, “it is too early to tell.” Patient hopes to recover fully and hopes to
regain the abilities to perform daily activities. She doesn’t know what the future holds.

+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
University of South Florida College of Nursing – Revision September 2014 9
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? Patient has been sexually active in the past.
Do you prefer women, men or both genders? Patient prefers men.
Are you aware of ever having a sexually transmitted infection? N/A.
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? __No._________________________ If yes, are you in a monogamous relationship?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? __________________________________

How long have you been with your current partner? Patient is widowed but was married to her husband for 32 years.

Have any medical or surgical conditions changed your ability to have sexual activity? Patient’s cancer decreased her
libido.

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?
Impacts the patent’s life on every level.
Do your religious beliefs influence your current condition?
Patient states her religious beliefs help her cope with her condition.
+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? 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 patient’s household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? Never. 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? Wine. How much? 1-2 glasses. For how many years? Whole life.
Volume: (age thru )
Frequency: 1-2 times a month
If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? 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
Patient is a nurse and states that her job puts her at a greater risk for infection.

5. For Veterans: Have you had any kind of service related exposure?
Patient has served in the Army for 12 years. Patient states that some bases she worked on were not in the best conditons.

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? Patient believes she is in good health overall.

Integumentary: Brittle nails. Occasionally uses sunscreen.

HEENT: She underwent cataract surgery in 2015. Brushes teeth 2-3 times day. Patient goes to the dentist twice a
year. Patient’s last eye exam was 1 and half years ago.
Pulmonary: History of bronchitis and pneumonia.
Cardiovascular: History of hypertension. Last EKG was before her shoulder surgery.
GI: Diverticulitis
GU: Urinates 8-10 times a day with no difficulty.
Women/Men Only: Patient self examines her breasts every month. Menopause. Hysterectomy.
Musculoskeletal: Rotator cuff tear.
Immunologic:
Hematologic/Oncologic: Non Hodgkins lymophoma
Metabolic/Endocrine: Normal
Central Nervous System: Normal
Mental Illness: No history of mental illness.
Childhood Diseases: Patient had measles, mumps, and chicken pox.

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 Patient was talkative and very pleasant.
Height ______4 feet 9 inches______Weight__136.16 lbs.________ BMI _____29.42______ Pain (include rating and
location)___________________ Pulse_______ Blood Pressure (include location)_____________________Temperature
(route taken)____________
Respirations____________ SpO2 _________________ Room Air or O2___________________________
Overall Appearance________________________________________________________________________________
Overall Behavior__________________________________________________________________________________
Speech________Coherent._____________________________________________________________________________
______
Mood and
Affect______Pleasant_____________________________________________________________________________
Integumentary____________________________________________________________________________________
IV Access________________________________________________________________________________________
HEENT___________________________________________________________________________________________
Pulmonary/Thorax________________________________________________________________________________
Cardiovascular____________________________________________________________________________________
GI________________________________________________________________________________________________
GU_______________________________________________________________________________________________
Musculoskeletal_____________________________________________________________________________________
Neurological

±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis

WBC 8.4 10/12/16 Patient’s WBC count Elevated WBC count
WBC 11.2 10/21/16 have been consistently in could indicate infection.
normal range. This lab value reveals that
the patients shoulder is
Normal (4.5-11) most probably infection
free.
RBC 4.22 10/12/16 Although the patient’s This lab value indicates
RBC 3.84 10/21/16 RBC has decreased, this patient has not lost excess
Normal (4.2-5.4) decrease is insignificant. amount of blood due to
The nurse should the surgical procedure.
continue to monitor this
value.
Hemoglobin 13.0 10/12/16 Patient’s hemoglobin This lab value indicates
Hemoglobin 11.9 10/21/16 values are in normal adequate oxygen and
Normal range: 12.0-15.5 range. tissue perfusion. This is
relevant for post-surgical
patients because the
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 incision needs to be
receiving adequate
oxygen in order to heal.

Creatinine 1.32 10/12/16 Creatinine levels are This lab value is relevant
Creatinine 1.14 10/21/16 minimally elevated. to the patient due to her
Normal range: 0.6­1.2  Patient’s baseline is 1.3- history of CDK.
mg/dL 1.5 mg/dL due to her
CDK.

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

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

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

1. Acute pain as evidence by patient report of 6 out of 10 pain related to surgical intervention.

2. Delayed surgical recovery as evidence by requiring assistance for self-care related to surgical procedure.

3. High risk of injury as evidence by mobility impairment related to post-operative state.

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4. Activity intolerance as evidence by discomfort related to surgical procedure.

5. Altered health maintenance as evidence by deficit knowledge related to lack of material resources.

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± 15 CARE PLAN
Nursing Diagnosis: Acute pain as evidence by patient report of 6 out of 10 pain related to surgical intervention.
Patient Goals/Outcomes
1). Short-term goal is to reduce
pain.
2). Long term goal is to maintain
minimal pain.
Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
1). Administer PRN analgesic 1). Client has the right to maximum 1). Patient reports relieved pain by
(NANDA Nursing Diagnosis List.  pain relief and must be treated f her opioid analgesic.
(n.d.).
2). Evaluate effectiveness of type 2). Each analgesic treats different
of analgesic and dose in a timely types of pain and it is crucial to
manner (NANDA Nursing  evaluate whether or not the patient
Diagnosis List. (n.d.). is receiving the correct type of
analgesic. Given pain alleviation or
continual pain one can tell whether
the dose or administration route
must be changed.
3). Assess subjective pain 3). Pain is a subjective experience,
assessment (NANDA Nursing  and therefore it is what the patient
Diagnosis List. (n.d.). reports. The patient’s description of
their pain will contribute to further
pain interventions.
4). Observe patient and assess for 4). Objective findings are can be
tenderness, guarding, grimacing, indicative to increased or decreased
moaning or any other behavior pain.
indicative of pain. Check vitals
(NANDA Nursing Diagnosis List. 
(n.d.).

±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
University of South Florida College of Nursing – Revision September 2014 16
□Durable Medical Needs
□F/U appointments
□Med Instruction/Prescription
 □ are any of the patient’s 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 evidence­based guide to planning care. Maryland Heights, 

MO: Elsevier.  

Armstrong, A. D., MD. (n.d.). Rotator Cuff Tears­OrthoInfo­ American Academy of Orthopaedic Surgeons. Retrieved November 17, 

2016, from http://orthoinfo.aaos.org/topic.cfm?topic=A00064

DrugGuide.com | Davis's Drug Guide Online Powered by Unbound Medicine. (n.d.). Retrieved November 18, 2016, from 

http://www.drugguide.com/ddo/ 

NANDA Nursing Diagnosis List. (n.d.). Retrieved November 18, 2016, from http://www.nandanursingdiagnosislist.org/ 

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