UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Christina Weyant

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 3/20/15

Agency: MPM

Patient Initials:

Age:

Admission Date:

Gender:

Marital Status:

Primary Medical Diagnosis:

Urinary Tract Infection

male

Primary Language: English

Level of Education:

Other Medical Diagnoses: (new on this admission)

Renal Calculi

Occupation:
Number/ages children/siblings:

Served/Veteran: No

Code Status: Full Code

Living Arrangements: Patient lives in a condo with his wife and

children. They also have one dog.

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: Procedure: Cystoscopy, left
ureteroscopy, holmium laser fragmentation and
ureteral stent replacement

Culture/ Ethnicity /Nationality:

Religion:

Type of Insurance:

1 CHIEF COMPLAINT: I had fever, chills, nausea, and vomiting. I just felt really sick.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The patient was experiencing fever, chills, nausea, and vomiting for a day and a half before coming into the Emergency
Department on . A urine analysis revealed a urinary tract infection with Enterococcus faecalis and was started on IV
Vancomycin. A cystoscopy performed on revealed renal calculi, a holmium laser fragmentation was performed to break
up the renal calculi, and a ureteral stent was placed. The patient is experiencing pain of 5 out of 10 that began after the
cystoscopy. The pain is in the left side of a groin area that radiates around to the left lower back. The pain is intermittent,
and dull. It is aggravated by voiding, and is relieved by pain medication, laying still, and using heating pads. The only
treatments that have been tried are pain medications and heating pads.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
University of South Florida College of Nursing Revision August 2013

Father

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

Cause
of
Death
(if
applicable)
Myocardial
infarction

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Alcoholism

Operation or Illness
Cystoscopy, left ureteroscopy, holmium laser fragmentation of ureteral stent, basketing of the stone,
and ureteral stent replacement
Cystoscopy, left ureteral stent placement, and retrograde pyelogram
Replacement of automatic cardiovertor and defibrillator pulse generator
Replacement of pacemaker device with dual chamber device
Knee surgery
cholecystectomy
Pacemaker defibrillator placement
vasectomy

Mother
Sister

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 (2010)
Adult Tetanus (2010)
Influenza (flu)
Pneumococcal (pneumonia)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Penicillin

YES

NO

Type of Reaction
Patients parents told him he had hives after taking penicillin as a child.

Medications

Other (food, tape,

latex, dye, etc.)

none

University of South Florida College of Nursing Revision August 2013

 5 PATHOPHYSIOLOGY:
A urinary tract infection occurs when a microorganism enters the urinary tract, which includes the urethra, bladder,
ureters, and kidneys. The infection will lead to symptoms such as urinary urgency, pain or burning while urinating,
urinating frequent, but small amounts, hematuria, flank or lower abdominal pain, and cloudy, foul smelling urine (CarsonDeWitt, 2011). Risk factors include sexual intercourse, taking antibiotics for another infection, having a medical
procedure which involves the urinary tract, and using a urinary catheter. Certain comorbid conditions such as diabetes,
neurogenic bladder, paralysis, kidney stones, and benign prostatic hyperplasia will increase the likelihood of getting a
urinary tract infection. Older adults and women are at a higher risk for developing urinary tract infections than other
populations (Carson-DeWitt, 2011). Diagnosis will require the patient to provide a sterile urine sample. A urinalysis, and
culture and sensitivity can then be performed. These tests can determine if there are bacteria in the urine. The culture and
sensitivity can determine what type of bacteria it is, and what antibiotic will be effective in treating it (Carson-DeWitt,
2011). Treatment for urinary tract infections includes antibiotic therapy, and patient education on how to avoid getting a
urinary tract infection in the future. Some of the teaching may include urinating after intercourse, drinking increased
amounts of water, drinking cranberry juice or using cranberry supplements, avoiding baths, wearing cotton underwear and
wiping front to back (Carson-DeWitt, 2011). Some research suggests that women who had mothers with frequent urinary
tract infections may be more likely to have frequent urinary tract infections themselves, but otherwise there does not
appear to be much of a genetic component (Carson-DeWitt, 2011).

5 MEDICATIONS:
Name: metoprolol (Lopressor)

Concentration (mg/ml): N/A

Dosage Amount (mg) 25mg

Route: By mouth (PO)

Frequency Twice daily (BID)
Pharmaceutical class: beta blocker
Home
Hospital
or
Both
Indication: Hypertension
Side effects: Fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes,
nervousness, nightmares, blurred vision, stuffy nose, bronchospasm, wheezing, bradycardia, heart failure, pulmonary
edema, hypotension, peripheral vasoconstriction, constipation, diarrhea, drug-induced hepatitis, dry mouth, flatulence,
gastric pain, heartburn, increased liver enzymes, nausea, vomiting, erectile dysfunction, decreased libido, urinary frequency,
rashes, hyperglycemia, hypoglycemia, arthralgia, back pain, joint pain, drug-induced lupus.
Nursing considerations/ Patient teaching: monitor patients heart rate and blood pressure. Hold if the heart rate is less than
50 or systolic blood pressure is less than 100 or diastolic blood pressure is less than 60. Teach the patient to take the
mediation exactly as prescribed, take it at the same time every day, and do not skip doses. Do not abruptly stop metoprolol.
Teach patient how to take their pulse, and blood pressure. Instruct the patient to change positions slowly to reduce
orthostatic hypotension. If diabetic, the patient should carefully monitor blood glucose levels while taking this drug. Tell the
patient to notify the provider if they experience bradycardia, difficulty breathing, wheezing, cold hands and feet, dizziness,
light-headedness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising.
Name: tamsulosin (Flomax)
Route: PO
Pharmaceutical class: peripherally acting

Concentration: N/A

Dosage Amount: 0.4 mg

Frequency: Once daily

Home
Hospital
or
Both

University of South Florida College of Nursing Revision August 2013

antiadrenergics
Indication: management of outflow obstruction in men with benign prostatic hyperplasia
Side effects: dizziness, headache rhinitis, orthostatic hypotension, priapism, retrograde/diminished ejaculation
Nursing considerations/ Patient teaching: monitor the patient for symptoms of prostatic hyperplasia such as urinary
retention, monitor intake and output, assess for orthostatic hypotension. Instruct patient to take this medication at the same
time every day. Instruct patient to change positions slowly, and not to drive or operate heavy machinery until they know
how this medication will affect them. Emphasize importance of follow up appointments to assess the effectiveness of
therapy.
Name: oxycodon-acetaminophen (Norco)

Concentration: N/A

Dosage Amount: 7.5 oxycodon 325

acetaminophen
Frequency: every 4 hours (q4hrs)

Route: PO
Pharmaceutical class: opioid agaonist nonopioid
Home
Hospital
or
Both
analgesic combination
Indication: pain management
Side effects: 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, hepatotoxicity, elevated liver enzymes, renal failure,
neutropenia, pancytopenia, acute generalized exanthematous pustulosis, stevens-johnson syndrome, toxic epidermal
necrolysis, rash, uticaria.
Nursing considerations/Patient teaching: Take the medication as directed, do not exceed 3g of acetaminophen in a 24 hour
period. This drug may cause dependence, do not stop suddenly or withdrawal symptoms can arise. Do not drive while on
this medication. Do not drink alcohol or use other central nervous system depressants while taking this drug, change
positions slowly, this medication is likely to cause constipation. Assess pulse, blood pressure, and respirations frequently
while on this medication. Assess for signs and symptoms of overdose.
Name: simvastatin (Zocor)

Concentration: N/A

Dosage Amount: 10 mg

Route: PO
Frequency: once daily
Pharmaceutical class: hmg coa reductase inhibitor
Home
Hospital
or
Both
Indication: management or primary hypercholesterolemia and mixed dyslipidemias
Side effects: amnesia, confusion, dizziness, headache, insomnia, memory loss, weakness, abdominal cramps, constipation,
diarrhea, flatus, heartburn, altered taste, drug-induced hepatitis, dyspepsia, increased liver enzymes, nausea, pancreatitis,
erectile dysfunction, rashes, pruritus, hyperglycemia, rhabdomyolysis, arthralgia, immune-mediated necrotizing myopathy,
myopathy, hypersensitivity reactions, photosensitivity.
Nursing considerations/Patient teaching: Teach patient to avoid grapefruit while taking this medication. Monitor blood lipid
levels periodically while on this medication, monitor liver function tests while on this medication. If patient complains od
muscle tenderness CPK levels should be monitored. Teach the patient to notify the health care provider of any muscle pain.
Teach the patient that this medication is to be used in addition to lifestyle modifications to lower blood lipid levels, and to
wear sunscreen when outdoors to prevent photosensitivity reactions. Teach patient to take the medication exactly as
directed.
Name: pantoprazole (Protonix)

Concentration: N/A

Dosage Amount: 40 mg

Route: PO
Frequency: BID
Pharmaceutical class: proton pump inhibitor
Home
Hospital
or
Both
Indication: treatment of gastroesophageal reflux disease (GERD)
Side effects: headache, pseudomembranous colitis, abdominal pain, diarrhea, eructation, flatulence, hyperglycemia,
hypomagnesemia, bone fracture.
Nursing considerations/Patient teaching: Monitor magnesium levels, assess patient for abdominal pain and monitor bowel
function. Teach patient to avoid alcohol, aspirin, NSAIDs, and foods that may cause GI irritation. Notify the health care
provider if the patient experiences black tarry or bloody stools, diarrhea, rash, fever, or abdominal cramping.

University of South Florida College of Nursing Revision August 2013

Name: amphetamine-dextroaamphetamine Concentration: N/A

Dosage Amount: 20 mg
(Adderall XR)
Route: PO
Frequency: once daily
Pharmaceutical class: central nervous system
Home
Hospital
or
Both
stimulants
Indication: narcolepsy
Side effects :hyperactivity, insomnia, restlessness, tremor, aggression, anger, behavioral disturbances, dizziness,
hallucinations, headache, mania, irritability, skin picking, talkativeness, thought disorder, tics, blurred vision, mydriasis,
sudden death, palpitations, tachycardia, cardiomyopathy, hypertension, hypotension, peripheral vasculopathy, anorexia,
constipation, cramps, diarrhea, dry mouth, metallic taste, nausea, vomiting, erectile dysfunction, increased libido, alopecia,
urticarial, growth inhibition, paresthesia, psychological dependence.
Nursing considerations/Patient teaching: Monitor the patients pulse, blood pressure, and respirations, watch for behavioral
changes and sings of depression in the patient. Instruct the patient to take this medication earlier in the day to avoid sleep
disturbances, take this medication exactly as directed, and do not stop suddenly or it may cause extreme fatigue and
depression. Tell the patient not to take this drug with anything else, limit caffeine intake, use caution while driving because
this medication can impair judgment. Notify the health care provider of any behavioral changes, nervousness, restlessness,
insomnia, dizziness, anorexia, numbness, pain, skin color changes from pale to blue to red, coolness or sensitivity to
temperature in fingers or toes, or severe dry mouth. Caution patient to notify the healthcare provider if they have had any
issues with drug or alcohol abuse, as this drug does have abuse potential.
Name: aspirin

Concentration: N/A

Dosage Amount: 81 mg

Route: PO
Frequency: once daily
Pharmaceutical class: antipyretics/ nonopioid
Home
Hospital
or
Both
analgesics
Indication: decrease platelet aggregation
Side effects: tinnitus, GI bleeding, dyspepsia, epigastric distress, nausea, abdominal pain, anorexia, hepatotoxicity,
vomiting, anemia, hemolysis, rash, urticarial, allergic reactions including anaphylaxis.
Nursing considerations/Patient teaching: monitor hepatic function, monitor salicylate levels periodically, monitor for signs
of bleeding or salicylate toxicity which includes tinnitus, headache, hyperventilation, agitation, mental confusion, lethargy,
diarrhea, and sweating. Instruct patient to take aspirin with a full glass of water and to remain in an upright position for 1530 minutes after administration. Teach patients to report any tinnitus, bleeding of gums, bruising, black tarry stools, or
fever. Advise patients to use caution with alcohol or other NSAIDs while taking aspirin. If tablets get a vinegar like odor
they should be thrown out. Aspirin may need to be withheld for 1 week prior to surgery, so notify health care professional
of aspirin regimen prior to surgery.
Name: ropinirole (Requip)

Concentration: N/A

Dosage Amount: 2mg

Route: PO
Frequency: once daily
Pharmaceutical class: dopamine agonists
Home
Hospital
or
Both
Indication: restless leg syndrome
Side effects: sleep attacks, dizziness, syncope, confusion, drowsiness, fatigue, hallucinations, headache, dyskinesia, impulse
control disorders, weakness, abnormal vision, orthostatic hypotension, peripheral edema, constipation, dry mouth,
dyspepsia, nausea, vomiting, sweating, melanoma.
Nursing considerations/Patient teaching: Assess patients blood pressure, and monitor for signs of drowsiness or sleep
attacks. Tell patients to take the medication exactly as directed, change positions slowly, and to use caution while driving
due to risk of drowsiness or sleep attacks. Advise patients to avoid alcohol or other central nervous system depressants,
notify the provider if any impulse control behaviors occur, and to have routine skin assessments to look for melanoma.
Name: Potassium citrate (Effer-K)

Concentration: N/A

Route: PO
Pharmaceutical class: mineral and electrolyte
replacement

Dosage Amount: 20 mEq

Frequency three times a day (TID) with meals

Home

Hospital

or

Both

University of South Florida College of Nursing Revision August 2013

Indication: treatment or prevention of potassium depletion

Side effects:confusion, restlessness, weakness, arrhythmias, ECG changes, abdominal pain, diarrhea, flatulence, nausea,
vomiting, GI ulceration, stenotic lesions, paralysis, paresthesia.
Nursing considerations/Patient teaching: Monitor serum potassium, magnesium, and sodium levels, and renal function.
Assess for signs of hyperkalemia such as slow, irregular heart rate, muscle weakness, paresthesia, fatigue, confusion,
dyspnea, ECG changes. Encourage patient to take this medication exactly as directed, instruct patients to avoid salt
substitutes and prevent excess potassium intake, instruct patient to report dark tarry stools, weakness, unusual fatigue,
tingling in extremities, nausea, vomiting, diarrhea, or abdominal discomfort. Emphasize the importance of follow up visits,
and regular monitoring of serum levels.
Name: vancomycin (Vancocin)

Concentration: 3.5mg/mL

Dosage Amount:1,750 mg

Route: IV
Frequency: q12hrs
Pharmaceutical class: antibiotic
Home
Hospital
or
Both
Indication: treatment of urinary tract infection
Side effects: ototoxicity, hypotension, nausea, vomiting, nephrotoxicity, rashes, eosinophilia, leukopenia, phlebitis, back
and neck pain, hypersensitivity reactions, chills, fever, red man syndrome, and superinfection. Nephrotoxicity.
Nursing indication/Patient teaching: Monitor IV site closely, vancomycin is irritating to tissues, monitor blood pressure,
monitor for signs of ototoxicity, monitor for signs of superinfection, monitor renal function and CBC. Administer over at
least an hour. Infusion may need to be slowed to avoid red man syndrome. Instruct patient to report sings of
hypersensitivity, tinnitus, vertigo, or hearing loss. Teach the patient the importance of taking the full prescribed dose, even
if the patient is feeling better.

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 patients diet consists of 1992 total calories which is
just slightly below the daily allowance of 2000, so this is an
acceptable amount. The patients diet does, however, have a
surplus of grains, and protein, and a deficit of fruits,
vegetables, and dairy. The patients diet consists of 8
ounces of grains instead of the recommended 6 ounces, and
most of that comes from refined grains instead of whole
grains. It also consists of 7 ounces of protein compared to
the recommended 5.5 ounces. The patient is only slightly
below the recommended 2.5 cups of vegetables per day,
with 2 cups in his diet. Fruit, and dairy is substantially
lacking with 0.5 cups of fruit, and 0.75 cups of dairy
compared to the recommended 2 cups, and 3 cups
respectively. The patients fat intakes for oils, and saturated
fats is within the recommended daily limits, however his
sodium intake is 4162mg which is much higher than the
2300mg recommended limit. My recommendations would
be to add a little more vegetables to the salad that the
patient typically has for dinner. Adding carrots or other
vegetables to the salad could help add a variety of
vegetables to his diet. The patient may also want to
consider replacing a snack of combos with a snack of fresh
fruit, and a cup of yogurt. This will help reduce the amount
of salt, and refined grains in the patients diet, and help add
fruit, and dairy. To further reduce sodium intake the patient
may want to remove the ham from his usual sandwich, and
replace it with only turkey. The patient could additionally

University of South Florida College of Nursing Revision August 2013

try adding vegetables to the sandwich to help boost his

vegetable intake. He may also want to think of replacing
the white bread with whole grain bread so a higher
percentage of grains come from whole grains compared to
refined grains. Finally he could try adding more milk, or an
additional cup of yogurt with fresh fruit to his breakfast in
the morning. This will help him to reach the daily
recommendations of fruit, and dairy.
Breakfast: one bowl of raisin bran with whole milk
Lunch: Ham and turkey sandwich with mayonnaise on
white bread
Dinner: Lettuce salad with grilled chicken with ranch
dressing
Snacks: One chocolate chip muffin. One small bag of
combos
Liquids (include alcohol): One cup of coffee with
sweetened creamer. 5-6 glasses of water. 3 glasses of pink
lemonade.
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:

Who helps you when you are ill?
My wife.
How do you generally cope with stress? or What do you do when you are upset?
I usually turn on a funny movie or a Disney movie.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I have been having some anxiety over my hospital stay.

+2 DOMESTIC VIOLENCE ASSESSMENT

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____________

University of South Florida College of Nursing Revision August 2013

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? __N/A_________________
Are you currently in a safe relationship? Yes

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:

During the stage of generativity a person is productive, and gains fulfillment through their career, and family, or other
productive activities. During stagnation a person may not be receiving fulfillment, and instead they may be experiencing
difficulties with work or family. (Karkouti, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is in a stage of generativity. Although he is unemployed, and on disabilities, he takes on the major
responsibility of raising the children while his wife works. His family appears to be a great source of pride, and fulfillment
to the patient. He expressed that he occasionally misses work, but he does not regret being a stay at home father. Overall,
he seems content with the life he has.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

This hospitalization in particular has very little effect on his developmental stage; however, his diagnosis of narcolepsy
makes it difficult to work, and at times may get in the way of taking care of his children. This could put him at a greater
risk of entering the stagnation stage, however, the narcolepsy is controlled fairly well, and he claims it does not have too
much of an impact on his life.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I think maybe because I take so much medication, it may have caused the kidney stones.
What does your illness mean to you?
I think it means that I need to better take care of myself, and watch what I am eating.

+3 SEXUALITY ASSESSMENT:
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? _Vasectomy and monogamy___________
How long have you been with your current partner? __We have been married 15 years, but been together for 23 years.
_____________

University of South Florida College of Nursing Revision August 2013

Have any medical or surgical conditions changed your ability to have sexual activity? _Kidney stones have decreased my
ability to have sexual relations.____
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 do believe there is a life after death. I think it does go on.______________________________________________________
______________________________________________________________________________________________________
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)
N/A
N/A

Yes
No
For how many years? 0 years
(age

thru

If applicable, when did the

patient quit?
N/A

Pack Years: 0
Does anyone in the patients household smoke tobacco? If
so, what, and how much?
No

Has the patient ever tried to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Beer
How much? (give specific volume)
1-2 beers 1-2 times a week

For how many years?

(age 18

thru 45

If applicable, when did the patient quit?

N/A
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
N/A
How much?
For how many years?
(age
thru
)
N/A
Is the patient currently using these drugs?
Yes No

If not, when did he/she quit?

N/A

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No.
5. For veterans: Have you had any kind of service related exposure?
N/A

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: 8-15
Bathing routine: shower once 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
2
x/day
Routine dentist visits last visit 2
years ago
Vision screening last visit was 1.5
years ago
Other:

Gastrointestinal
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? Never had one
Other:

Genitourinary
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 10 x/day
Bladder or kidney infections

Immunologic
Chills with severe shaking
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: unknown
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? 2014 it was clear
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur

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? never
Date of last prostate exam? Never
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

Childhood Diseases

University of South Florida College of Nursing Revision August 2013

Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? A few
weeks ago. Normal Sinus rhythm.
Other:

Weakness
Pain
Gout
Osteomyelitis

Measles
Mumps
Polio
Scarlet Fever

Arthritis

Chicken Pox

Other:

Other:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Narcolepsy, restless leg syndrome, and sleep apnea.

Any other questions or comments that your patient would like you to know?
none.

University of South Florida College of Nursing Revision August 2013

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

General Survey: The patient is Height: 177.8 cm
Weight: 109.1 kg BMI: 34.5 Pain: (include rating & location)
an overweight male, who is
5 out of 10 in groin area
Pulse: 69
Blood
calm, and appears to be resting
Pressure: 134/86 on right
comfortably.
upper arm
(include location)
Temperature: (route taken?)
Respirations: 14
98.3 oral
SpO2: 94%
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: 20 gauge

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

Location: left hand

Location:

talkative
withdrawn

quiet
boisterous
aggressive
hostile

flat
loud

Date inserted: 3/18/15

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 / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear6 inches & left ear6 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments: Patients pupils are unequal due to a congenital deformity. The left pupil is 2mm while the right pupil is
4mm.The pupils are round, reactive to light and accommodation.
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

RUL clear LUL clear

RML clear LLL fine crackles
RLL fine crackles

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th ICS MCL
Heart sounds: S1 S2 X Regular X 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: regular Carotid: 2+ Brachial: 2+ Radial: 2+ Femoral: 2+ Popliteal: 2+ DP: 2+ PT: 2+
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: N/A
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: 5025 mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 3 / 18 / 15 )
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
Not assessed, patient alert, oriented, denies problems
Other Describe:
Patients abdomen is tender to palpation in the left and right lower quadrants. The patient also requested that the CVA punch
not be performed, he did state, however, the last time it was performed it caused him pain.
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

Lab
WBC

Dates
3/16/15
3/18/15
3/20/15

Trend
13.3 (high)
11.3 (high)
7.3 (normal)

HGB

3/16/15
3/18/15
3/20/15

13.1 (low)
12.4 (low)
12.4 (low

Analysis
The patients white blood
cell count was high upon
admission. This is a sign
that there is an infection.
In this patient an elevated
WBC was expected
because he presented with
a urinary tract infection.
The white blood cell
count has been trending
down since admission
which is a sign that the
therapy is working and
the patient is fighting off
the infection.
The HGB measures the
amount of hemoglobin
present in the blood
(Nabili, 2014). A low
HGB can mean that the
person is anemic, or it
could mean that the
patient is fluid volume
overloaded, and the
hemoglobin is just diluted
in the total blood volume.
This patient does not have
signs of fluid volume
overload so it is more
likely that he is anemic.
The patients HGB was
low when he came in, and
dropped slightly over the
course of his stay. This

University of South Florida College of Nursing Revision August 2013

HCT

3/16/15
3/18/15
3/20/15

39.0 (low)
37.1 (low)
37.0 (low)

RDW

3/16/15
3/18/15
3/20/15

14.9 (high)
15.0 (high)
14.6( high)

PLT

3/16/15
3/18/15
3/20/15

177 (normal)
200 (normal)
244 (normal)

Potassium

3/16/15
3/18/15

4.2 (normal)
3.8 (normal)

means that he was

probably anemic when he
came in and has become
more anemic.
Hematocrit is a measure
of the percentage of red
blood cells that make up
the total blood volume
(Nabili, 2014). If it is low
it means the patient could
be anemic or he could be
fluid volume overloaded.
In this patient it is more
likely that he is anemic.
The patients HCT was
low when he came in, so
he was probably anemic
when he came in. It has
decreased slightly over
the course of his stay so
he has become more
anemic.
The RDW is a measure of
the red blood cell
distribution width. This
tells you how much
variation in size amongst
red blood cells there is. A
high RDW means there is
a high variation of sizes
of red blood cells (Nabili,
2014). This could be
indicative of a
megaloblastic anemia
such as B12 deficiency
anemia or folate
deficiency anemia.
The patients platelet
levels are in a normal
range, but are trending
up. The higher the
platelet count, the higher
the risk of the patient
developing a clot.
Because the platelets are
within normal range it is
safe to continue giving
the patient aspirin.
The patients potassium
levels are within normal

University of South Florida College of Nursing Revision August 2013

3/20/15

3.9 (normal)

BUN/Creatinine

3/16/15
3/18/15

13 (normal)
10 (normal)

ALT

3/16/15

109 (high)

AST

3/16/15

63 (high)

Magnesium

3/16/15

2.0 (normal)

Vanco Trough

3/18/15
3/20/15

15.3
12.5

Urinalysis

3/16/15

Enterococcus faecalis

range so it is safe to give

the patient his potassium
citrate.
BUN/Creatinine is a ratio
used to measure kidney
function. The patients
levels are within normal,
but dropped over the
course of the patients
stay. This indicates that
the kidneys are
functioning properly.
ALT is a liver enzyme. It
is elevated in this patient,
and that is usually
indicative of some kind of
liver damage. This could
indicate that the patient is
experiencing an adverse
effect from one of, or a
combination of
medications he is taking.
AST is another liver
enzyme. It is elevated in
this patient, and that is
usually indicative of
some kind of liver
damage. This could
indicate that the patient is
experiencing an adverse
effect from one of, or a
combination of
medications he is taking.
The patients magnesium
levels are normal. This
indicates that the patient
is not experiencing an
adverse effect from
Protonix.
The vanco trough is a
measure of the amount of
vancomycin in a patients
blood. These levels are
within normal range,
which means the drug is
at a therapeutic dose.
The patient has an
infection with
Enterococcus faecalis in his
urinary tract.

University of South Florida College of Nursing Revision August 2013

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

Patient is on a regular diet, vitals every 8 hours, and activity is up with assist. The patient is due to be discharged
so there are no diagnostic tests ordered at this time. There is a consult to social services to find out if the patients
insurance covers linezolid, otherwise the patient will be sent home with a less expensive antibiotic.

8 NURSING DIAGNOSES
1. Pain related to inflammatory process in the urinary tract and recent surgery as evidenced by reported pain of 5 out
of 10 in the groin area, guarding, and complaints of pain during urination.
2. Impaired urinary elimination related to inflammation of urinary tract as evidenced by frequent urination, urinary
urgency, and urinating small volumes at a time.
3. Risk for infection related to recent surgery and stent placement
4. At risk for falls related to urinary urgency and frequency and use of narcotic pain medication.
5. Disturbed sleep pattern related to nocturia as evidenced by the patient getting up several times in the night to use
the urinal, and the patient reporting being tired from lack of sleep.
6. Anxiety related to being in the hospital and cost of stay as evidenced by patient frequently asking what will be
covered by insurance, and patient wringing hands, and grimacing when financial concerns are discussed.

University of South Florida College of Nursing Revision August 2013

 15 CARE PLAN
Nursing Diagnosis: Impaired urinary elimination related to inflammation of urinary tract as evidenced by frequent urination, urinary urgency, painful urination,
and urinating small volumes at a time.

Patient Goals/Outcomes
Patient will completely empty
bladder each time he urinates.

Nursing Interventions to Achieve

Goal
Encourage patient to drink at least
1500mL of water a day.

Patient will rate pain of no more

than 2 out of 10 each time he
voids.

Encourage patient to avoid

caffeine, alcohol, and spicy or
acidic foods.

Patient will urinate no more than

once every two hours.

Administer antibiotic every 12

hours as ordered.

Patient will rate pain 0 out of 10

with urination by the time of
discharge.

Assess the patients abdomen for

bladder distention post void.
Monitor intake and output as well
as the character of the urine.

Rationale for Interventions

Provide References
Increasing the amount of water the
patient drinks will help flush out
some of the bacteria in the urinary
tract, and it will dilute the urine so
the patient doesnt have as much
pain with urination.
Caffeine, alcohol, and spicy or
acidic foods are bladder irritants.
Avoiding these substances may
help reduce some of the patients
pain.
Administering antibiotics at the
ordered time will eliminate bacteria
from the urinary tract. Once the
infection is cleared the patients
voiding pattern should return to
normal.
This will help determine if the
patient is emptying his bladder
completely each time he voids.
Monitoring intake and output will
help to assess if the patient is
experiencing urinary retention.
Assessing the character of the urine
will help to determine if the
patients infection is getting better
or worse.

Evaluation of Goal on Day care

is Provided
The patient was able to completely
empty his bladder each time he
voided.

Patient has met the goal of having

pain no more than 2 out of 10 with
each void.
Patient met the goal of urinating no
more than once every two hours.

Patient is still progressing toward

the goal of rating pain 0 out of 10
with urination by the time of
discharge.

 15 CARE PLAN
Nursing Diagnosis: At risk for falls related to urinary urgency and frequency and use of narcotic pain medication.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Patient will not have a fall by
Keep the urinal at the patients
Keeping the urinal at the bedside
The patient is progressing toward
discharge.
bedside.
will help reduce the potential of
the goal of not having a fall by
falls by preventing the patient from discharge.
getting out of bed unassisted if he
experiences urinary urgency.
Patient will not have a fall by the
Place the call light within reach of
Making sure the call light is within The patient met the goal of not
end of the shift.
the patient at all times.
reach will increase the likelihood
having a fall by the end of the shift.
that the patient will call for
assistance before ambulating.
Patient will use the call light to ask Keep the walkway free of clutter.
Keeping the walkway free of
The patient did not meet the goal of
for assistance each time he wants
clutter will reduce the likelihood
asking for assistance each time
to ambulate.
that the patient will trip, and fall on before ambulating.
something.
Patient will use the urinal instead
Keep the patients room well lit.
Keeping the patients room well lit Patient met the goal of using the
of the bathroom for voiding.
will help the patient to see any
urinal instead of the bathroom to
obstacles that could potentially
void.
cause a fall.
Educate the patient on the
Educating the patient on the
importance of asking for assistance importance of asking for assistance
before ambulating.
before ambulating will increase the
likelihood that the patient will ask
for help.
Assess the patient for signs of
Narcotic pain medications may
dizziness or hypotension before
cause dizziness or hypotension. It
ambulating.
is important to assess for these side
effects before ambulating with the
patient.

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:

X SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
X F/U appts with the patients primary care doctor and the urologist
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? X Yes No
Rehab/ HH
Palliative Care

References
Carson-DeWitt, R. M. (2011). Urinary tract infections. Salem Press Encyclopedia Of Health
Deglin, J.H., Mansell, H.G., Sanoski, C.A., Vallerand, A.H. (2015). Daviss Drug Guide for
Nurses (14th ed.). Philadelphia, PA: F.A. Davis Company
Karkouti, I. M. (2014). Examining Psychosocial Identity Developmental Theories: A Guideline
for Professional Practice. Education, 135(2), 257-263.
Nabili, S. (2014). Complete Blood Count (CBC): Get the Facts About This Test. Retrieved April
3, 2015 from http://www.medicinenet.com/complete_blood_count/article.htm
USDA. (n.d.). Food Tracker. Retrieved April 1, 2015, from
https://www.supertracker.usda.gov/foodtracker.aspx