UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: ASHLEY KAVUMKAL

FUNDAMENTAL PATIENT ASSESSMENT TOOL .

Agency: SMH

1 PATIENT INFORMATION
Patient Initials:
Gender:

LL

Assignment Date: 6/20/2014

Age: 67

Admission Date: 6/18/2014

Marital Status: WIDOW

Primary Medical Diagnosis with ICD-10 code:

LEFT KNEE OSTEOARTHRITIS (M17. 12)

Primary Language: ENGLISH

Level of Education: DOCTRATE IN CHILD/YOUTH
EDUCATION
Occupation (if retired, what from?): RETIRED SCHOOL
ADMNISTRATOR
Number/ages children/siblings: A BROTHER (71)

Other Medical Diagnoses: (new on this admission)

Served/Veteran: N/A

Code Status:

Living Arrangements: LIVING IN A HOUSE IN PUNTA GORDA

WITH FATHER

Advanced Directives:
If no, do they want to fill them out? NO
Surgery Date: 6/18/2014 Procedure: LEFT KNEE
ARTHROPLASTY

Culture/ Ethnicity /Nationality: HEBREW

Religion: JEWISH

Type of Insurance: MEDICARE, FLORIDA BLUE

1 CHIEF COMPLAINT: Patient states I have pain in the left knee and I am feeling nauseous.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The patient reports strong pain in the left knee that is continuous. She rates the pain as 6 on a scale from 0 to 10. The
patient indicates that the pain decreases an hour or two after she receives the medication (every 4 hours) which then
comes down to a 3 to 4 on a scale from 0 to 10 and makes her sleep well.

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

Father

99

Mother

92

Brother

71

Operation or Illness
Diagnosed with Bilateral breast cancer
Mastectomy (Bilateral)

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

Cause
of
Death
(if
applicable
)

Anemia

Breast Reconstruction (Bilateral,done within the same year after mastectomy)

Environmental
Allergies

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Date
2010 (patient does
not know exact
date)
2010(patient does
not know exact
date)
2010(patient does
not know exact
date)

Anurism

Sister
relationship
relationship
relationship

Comments: Include date of onset

Patient does not know

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)

YES

University of South Florida College of Nursing Revision August 2013

NO
2

Routine childhood vaccinations

Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

X
X
X
X
X
X
X

Type of Reaction (describe explicitly)

Penicillin
Sulfa

Fever/spike
Fever/spike

Shell fish
Insect bites/bee
stings

Itching/rash

Medications

Other (food, tape,

latex, dye, etc.)

Anaphylaxis

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Osteoarthritis (OA) is the gradual failure of joints which is related to aging more commonly in women. Risk factors
include vulnerability and loading of joints, obesity, previous damage, trauma to joints, nutritional factors, proprioceptive
deficiency. OA is initially noticed by changes in cartilage by the depletion of type 2 collagen that provides strength. This
eventually leads to increased vulnerability. OA is most common in knees, hip and spine which are weight-bearing.
Symptoms include use related pain, stiffness after rest, limited joint function etc. Laboratory tests, radiographic features,
synovial fluid findings etc can help in diagnosis. To reduce pain-Acetaminophen, NSAIDS,salicytes, COX-2 inhibitors,
Tramadol etc. can be administered. Non-pharmacotherapy includes exercising and weight reduction, using cane for
ambulation etc.
References:
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software]. Retrieved from
http://www.unboundmedicine.com/products/nursing_central

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

University of South Florida College of Nursing Revision August 2013

Name- Anastrozole

Concentration (mg/ml)

Route: oral

Dosage Amount (mg)

Frequency :once everyday

Pharmaceutical class: Aromatase inhibitor

Both Home and Hospital

Indication: Adjuvant treatment in early breast cancer, initial therapy for locally advanced or metastatic breat cancer, Advanced postmenopausal breast cancer
in women with disease progression
Side effects/Nursing considerations : headache, weakness, MI, allergic reactions such as angioedema, hot flashes, pain
Name- cetrizine

Concentration

Dosage Amount: 10mg

Route: oral

Frequency:

Pharmaceutical class: antihistamine

Hospital

Indication: treatment for seasonal or perennial allergies and hives

Side effects/Nursing considerations: sleepiness in some patients, nausea, headache, fatigue, sore throat, dry mouth
Name- Alendronate

Concentration

Dosage Amount

Route : oral

Frequency : once every week

Pharmaceutical class: bisphosphonate

Both -Home & Hospital

Indication: Treatment and prevention of postmenopausal osteoporosis

Side effects/Nursing considerations: blurred vision, eye pain, abdominal distention, acid regurgitation, erythema, musculoskeletal pain
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

University of South Florida College of Nursing Revision August 2013

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?
Analysis of home diet (Compare to My Plate and
Diet patient follows at home?
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids (include alcohol):
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?
How do you generally cope with stress? or What do you do when you are upset?

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, 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? _______________________________________________________
Have you ever been talked down to?_______________ Have you ever been hit punched or slapped? ______________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
__________________________________________ If yes, have you sought help for this? ______________________
Are you currently in a safe relationship?

University of South Florida College of Nursing Revision August 2013

 4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
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 patients developmental stage of life:

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

What does your illness mean to you?

+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?____________________________________________________________________
Do you prefer women, men or both genders? _____________________________________________________________
Are you aware of ever having a sexually transmitted infection? _______________________________________________
Have you or a partner ever had an abnormal pap smear?_____________________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___________________________________________
Are you currently sexually active? ___________________________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?________________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ___________________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?

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?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

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

Has the patient ever tried to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)

For how many years?

(age

thru

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
-None

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
Pts perception of health:

Integumentary:
HEENT:
Pulmonary:
Cardiovascular:
GI:
GU:
Women/Men Only:
Musculoskeletal:
Immunologic:
Hematologic/Oncologic:
Metabolic/Endocrine:
Central Nervous System:
Mental Illness:
Childhood Diseases:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?

Any other questions or comments that your patient would like you to know?

University of South Florida College of Nursing Revision August 2013

10 PHYSICAL EXAMINATION:
General survey _____________________________________________________________________________________
Height ____________Weight__________ BMI ___________ Pain (include rating and location)___________________
Pulse_______ Blood Pressure (include location)_____________________Temperature (route taken)____________
Respirations____________ SpO2 _________________ Room Air or O2___________________________
Overall Appearance________________________________________________________________________________
Overall Behavior__________________________________________________________________________________
Speech___________________________________________________________________________________________
Mood and Affect___________________________________________________________________________________
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
WBC

Dates
6.9

19.8 H
Normal (4.5-11)

(03/18/2013)
(03/22/2013)

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

Analysis
Number of infection
fighting cells. High WBC
indicates the presence of
an infection or
inflammation. High WBC
is often indicated in an
exacerbation of ulcerative
colitis.

This should represent the

patients trend of the
exacerbation, such as
after surgery, with new
meds added, or since
admission.

University of South Florida College of Nursing Revision August 2013

10

+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.
2.
3.
4.
5.

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 15 CARE PLAN
Nursing Diagnosis: (Which nursing diagnosis you are doing your care plan on goes here.)
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided

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

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