UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Ellie Wertheimer

PATIENT ASSESSMENT TOOL .

Agency: VA

1 PATIENT INFORMATION
Patient Initials:
Gender:

J. R.

Male

Assignment Date: 02/28/2015

Age: 24

Admission Date: 02/08/15

Marital Status: Single

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Celllulitis 682.9

Level of Education: High school graduate

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): unemployed

Number/ages children/siblings: Sister 20
No children
Served/Veteran: Persian Gulf War

Code Status: Full Code

Living Arrangements: Lives with girlfriend, she helps drive him

places and provides income. Can take own medication and no
problems with mobility

Advanced Directives: yes

If no, do they want to fill them out?
Surgery Date: 02/09/15
right leg

Procedure: biopsy on

Culture/ Ethnicity /Nationality: White

Religion: N/A

Type of Insurance: none

1 CHIEF COMPLAINT: Cellulitis

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
0-pain
When having pain from his cellulitis
O: started two weeks ago and was the size of a quarter
L: Left calf
D: would be at a constant 4 but would increase to 15 every 5-10 minutes
C: hot burning pain
A: pressure, touch
R: no relief
T: antibiotics

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
Aug 13, 2013

Father
Mother

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

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Substance abuse
Alcohol abuse
Major depression
Chronic back pain
Insomnia

In
50
s
47

Brother
Sister

20

relationship
relationship
relationship

Comments: Include date of onset

Mother has schizophrenia and is bipolar

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 (Date): 4 years ago since last shot
Influenza (flu) (Date): 2 years since last shot
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or

YES

University of South Florida College of Nursing Revision August 2013

NO

occupational purposes? Please List

1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
vancomycin

Type of Reaction (describe explicitly)

Rash and prutis

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)
Cellulitis is a non-necrotizing inflammation of the skin and subcutaneous tissues, usually caused by staphylococcus or
streptococcus infections that does not involve the fascia or muscles (Osborn et al., 2014). The border to cellulites is nondefinable, has edema and is eurythmic. The patient also may have fever, chills, headache, and vomiting. WBC would be
increased and would have a skin biopsy on or near the area. A patient is more likely to have cellulitis if there is an open
wound, there is not much know about the causes of cellulitis. Treatment is taking antibiotics and elevation to the area. If it
is left alone, the cellulitis might spread to the bloodstream and cause septicemia.

University of South Florida College of Nursing Revision August 2013

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

Concentration (mg/ml)

Route: IV piggyback infusion

Dosage Amount (mg): 1.5 GM in normal saline

Frequency: Q4

Pharmaceutical class: anti-infectives

Home

Hospital

or

Both

Indication: skin and skin structure infections, soft-tissue infections

Side effects/Nursing considerations: seizures, pseudomembranous colitis, diarrhea, nausea, vomiting, rashes, urticarial, blood dyscrasias, pain at IM site, pain
at IV site, allergic reactions. Nursing considerations: check the IV site frequently, make sure there is a toilet nearby for easy access. Talk to the doctor about
giving anti-nausea medication.
Name: Enoxaparin Inj.

Concentration

Dosage Amount: 40mg

Route: Subcutaneous injection

Frequency: Once a day

Pharmaceutical class: antithrombotics

Home

Hospital

or

Both

Indication: prevention of VTE, DVT or PE

Side effects/Nursing considerations: dizziness, headache, insomnia, edema, constipation ,increase liver enzymes, nausea, vomiting, alopecia, ecchymosis,
pruritus, rash, urticarial, hyperkalemia, bleeding anemia, eosinophilia, thrombocytopenia, erythema at injection site, hematoma, irritation, pain, osteoporosis,
fever. Nursing considerations: check temperature, check injections site and body for edema, have the patient report any headaches dizziness or nausea.
Name: Acetaminophen/Hydrocodone

Concentration

Dosage Amount: 5mg

Route: Oral

Frequency: PRN

Pharmaceutical class: opioid agonists nonopioid analgesic

combinations
Indication: management of moderate to severe pain

Home

Hospital

or

Both

Side effects/Nursing considerations: confusion, dizziness, sedation, euphoria, hallucinations, headache, unusual dreams, blurred vision, diplopia, miosis,
respiratory depression, hypotension, bradycardia, constipation, dyspepsia, nausea, vomiting, urinary retention, sweating, physical dependence, psychological
dependence, tolerance. Nursing considerations: check for any confusion and the rating of pain every 2 hours.

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? Healthy tray
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? Heart Healthy
Consider co-morbidities and cultural considerations):
24 HR average home diet:
He did not have many calories, he needs to have better
nourishment for
Breakfast: eggs, grape juice
dinner, the main problem is that he does not like the food
at the hospital. More calories would help with the healing
Lunch: Boar head turkey sandwich, green fruit snacks
process. Despite not having enough calories his diet did
include protein, which helps with healing.
Dinner: ate nothing for dinner
Snacks: fruit snacks
Liquids (include alcohol): water
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? girlfriend
How do you generally cope with stress? or What do you do when you are upset?
OK get angry or frustrated, will walk away and come back to later.

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

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? __no_____________________________________________________
Have you ever been talked down to?____no___________ Have you ever been hit punched or slapped? __no_________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
__________no________________________________ If yes, have you sought help for this? ______________________

University of South Florida College of Nursing Revision August 2013

Are you currently in a safe relationship? Yes

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:

He is in the intimacy stage because he is happy with his girlfriend, and having good relations with her. Intimacy is the
patient making a future for themselves and making good connections with people as friends or as a couple.
He seems to have many different friends and would also like to get married one day, however states that he is not ready
for marriage currently.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The condition that he is in has affected the patient. He wants to go home to see his dog and his girlfriend. He misses them
and feels useless in the hospital.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
no idea size of a quarter than blew up
What does your illness mean to you?
Sucks, I hate sitting around

+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? _____no__________________________________
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? ___the pill____________
How long have you been with your current partner? ______known for 20, 2 years as a couple____________________
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?
___none___________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
____none__________________________________________________________________________________________________
______________________________________________________________________________________________________

+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)
New Ports
pack 1 pack

Yes
No
For how many years? 4 years
(age 19

thru

23

If applicable, when did the

patient quit?
Yes, put them down and walked
away

Pack Years: 4

Does anyone in the patients household smoke tobacco? If

so, what, and how much?
Yes, girlfriend pack-1 pack

Has the patient ever tried to quit? yes

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)
too much would not give specific
Beer
volume

For how many years? -1 year

(age

19 thru

20

If applicable, when did the patient quit?

When I ended up in the hospital
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
marijuana
How much?
For how many years?
2 4 grams
Is the patient currently using these drugs?
Yes No

(age 15
currently)

thru

18

) (22 -

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: N/A
Bathing routine: once a day
Other: Cellulitis

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
Once
every other day
Routine dentist visits last one was
years ago
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
GERD
Indigestion
Hemorrhoids
Yellow jaundice
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

Irritable Bowel
Cholecystitis
Gastritis / Ulcers
Blood in the stool
Hepatitis

Genitourinary
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 2 - 4/day
Bladder or kidney infections

Chills with severe shaking (at night

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

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

Metabolic/Endocrine
Diabetes

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? 02/08/15
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias

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? N/A
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

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision August 2013

Last EKG screening, when? N/A

Other:

Arthritis
Other:

Chicken Pox
Other:

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

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:
Height: 72 in
Weight: 217
BMI: 30
Pain: (include rating & location)
0- No pain
Patient is a 24 year old male Pulse: 73
Blood
who is alert and orientated x3
Pressure: 121/65
(include location)
and no signs of distress
Temperature: (route taken?)
Respirations: 20
97.7 oral route
SpO2: 97
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

talkative
withdrawn

Peripheral IV site Type:

Location: Left forearm
no redness, edema, or discharge
Fluids infusing?
no
yes - what? Normal Saline 10 mL
Peripheral IV site Type:
Location:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Fluids infusing?
no
yes - what?

quiet
boisterous
aggressive
hostile

Date inserted:

flat
loud

02/09/15

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 /3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without
nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 16 inches & left ear14 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

University of South Florida College of Nursing Revision August 2013

10

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
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at:
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

N/A had no ECG tape

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:
+1
[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: amber
Previous 24 hour output: 720
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 02 / 10 / 15 )
Color: Light brown
Medum Brown

Formed
Dark Brown

Semi-formed
Yellow

Unformed
Green

White

Soft

Hard

Coffee Ground

Liquid
Maroon

Watery
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:
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

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

positive

negative

Biceps: +2

Brachioradial:

+2

Patellar:

+2

Achilles:

+2

Ankle clonus: positive negative Babinski:

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
AST

Dates
(02/08/15)
32
Normal: 16-43

(02/08/15)

ALT
62
Normal: 11-44

Trend
Normal range throughout
the hospital stay

(02/08/15)

Sharp increase since the

day before admission

(02/08/15)
HCT
38.0
Normal: 39-49

(02/08/15)
(02/08/15)

RDW-SP
35.8
Normal: 38-50

(02/08/15)
(02/08/15)

MPV
9.0
Normal: 9.4-12.8

(02/08/15)
(02/08/15)

A decrease at the
beginning of the hospital
visit, then after being
admitted there was an
increase
A decrease at the
beginning of the hospital
visit, then after being
admitted there was an
increase
A decrease at the
beginning of the hospital
visit, then after being
admitted there was an
increase

Analysis
It is strange that his levels
are normal as an increae
in ALT will increase AST
Has had alcohol
dependence for several
years which affects the
AST, because the liver
has to process the alcohol.
Low from the long term
effects of alcohol, since
the liver helps produce
the erythropoietin
Normally low because of
the liver difficulties.
Almost in normal range
Slightly below the
number, could show that
he has liver difficulties.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Heart healthy tray for diet for after discharge, follow up with primary care provider and dermatologist
02/09/15 biopsy on right leg
Up with assistance and progress to independence activity as tolerated.
Anticipated discharge on Feb 11, 2015

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

1.Activity intolerance
R/t generalized weakness aeb skin color and walking distance
2. Infection potential
r/t smoking aeb smoking 2-4 grams of marijuana
3. Fluid volume excess
r/t compromised regulatory mechanism aeb peripheral edema
4.
5.

 15 CARE PLAN
Nursing Diagnosis: Fluid volume excess r/t compromised regulatory mechanism aeb peripheral edema
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Maintain clear lung sounds; no
Monitor vital signs; note
His vital signs were normal,
Keep vital signs at a normal level.
evidence of dyspnea or orthopnea
decreasing blood pressure,
however later in the day they were Give medication to help with any
tachycardia, and tachypnea
elevated. It is important that his
heart difficulties and have
cellulites is not having any other
education on normal vital signs.
negative effects.
Remain free of jugular vein
Maintain the rate of all IV
This is done to prevent inadvertent Important since he became allergic
distention, positive hepatojugular
infusions, carefully utilizing an IV exacerbation of excess fluid
to vancomycin. Also to make sure
reflex, and gallop heart rhythm
pump
volume.
that his IV medication is not given
too quickly and is check frequently.
Remain free of edema, effusion,
Monitor for the development of
He shows signs of having
Teach about different medications
anasarca
conditions that increase the clients difficulties with his liver and needs he is taking and talk about how
risk for excess fluid volume,
to make sure that it is not affecting fluid excess can affect his liver.
including heart failure, renal
his liver further with medication
failure, and liver failure.

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: Infection potential r/t smoking aeb smoking 2-4 grams of marijuana
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Remain free from symptoms of
Recommend responsible use of
Use and misuse of antibiotics
Have education on the signs and
infection
antibiotics; use antibiotics
results in several problems, the
symptoms of cellulitis and have
sparingly
most significant of which are
him repeat back about what his
increases in resistance.
medications do.
Demonstrate appropriate care of
Observe and report signs of
Change in mental status, fever,
Should be able to demonstrate how
infection-prone site
infection such as redness, warmth, shaking, chills, and hypotension
to clean the site, and to report any
discharge, and increased body
are indicators of sepsis
changes in the cellulitis.
temperature
Demonstrate appropriate hygienic
Use appropriate hand hygiene
Precautions are required to prevent Make sure that the patient can
measures such as hand washing,
(i.e. hand washing or sue of
health care-associated infection
demonstrate hygienic measures and
oral care, and perineal care
alcohol-based hand rubs)
the importance of performing them.
Patient Goals/Outcomes

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
Ackley, B.J. Ladwig, G.B. (2014). Nursing Diagnosis Handbook. Missouri: Elsevier.
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