Med Surg 1 Pat

UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
Student: Bryan Trinh
PATIENT ASSESSMENT TOOL .
Assignment Date: 10/16/15

Agency: VA
1 PATIENT INFORMATION
Patient Initials: L.S
Age: 69
Admission Date: 9/10/15
Gender:
Marital Status:
Primary Medical Diagnosis with ICD-10 code:
Primary Language: English
Renal Failure
Level of Education: Some college
Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired. Was a telephone Engineer
Obstructive Sleep Apnea, Anemia, Renal Cyst,

Hematoma, End Stage Renal Failure, Chronic
Kidney Disease.
Number/ages children/siblings: 3 children: Son 52, Son 51,

Daughter 44. Had 8 siblings now only 5: 3 sisters, 1 brother.
Served/Veteran: Air Force Combat
Code Status: Full
Living Arrangements: House
Advanced Directives: Living will

If no, do they want to fill them out?
Surgery Date: 9/21/15
Procedure: Right
Knee Debridement. 9/28/15 STSG to right knee
wound.
Culture/ Ethnicity /Nationality: Jewish/Catholic

Religion: None
Type of Insurance: VA 100%
1 CHIEF COMPLAINT:
I have Renal failure.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
No pain
End State Renal Failure
Chronic Kidney Disease
Hypertension
Patient was admitted to the hospital due to kidney failure. Patient receives dialysis three times a week and has recently had
right knee debridement. Hemovac in place over right knee promoting healing.
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
Sister
25
Suicide
Brother
63
Sister
66
Sister
70
Comments: Include date of onset
Cancer
Asthma
Anemia
Tumor
Stroke
Suicide
Stomach Ulcers
25
Gout
Brother
Glaucoma
73
Diabetes
Mother
Arthritis
51
Alcoholism
Father
Cause
of
Death
(if
applicable
)
Disability
from
WWII
N/A
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
(angina,
MI, DVT
etc.)
Heart
Trouble
2
FAMILY
MEDICAL
HISTORY
Age (in years)
10/31/11
9/24/12
10/15/12
9/21/15
9/28/15
Bleeds Easily
Operation or Illness
Gout: Controlled with diet low in protein and allopurinol 300 mg tab Q daily
Hypertension: Controlled with diet and losartan 5mg tab Q daily hold if SBP <110
Hypothyroidism: Controlled by levothyroxine 0.075 mg tab Q daily taken on empty stomach early
morning.
Chronic kidney disease: Controlled by diet and Dialysis
End stage renal disease: Controlled by diet and Dialysis
Anemia in Chronic kidney disease controlled by epoetin given during hemodialysis
Right knee debridement: Promote healing by hemovac and diet. Pain management
STSG to right knee wound: Promote healing and pain management
Environmental
Allergies
Date
8/1/08
8/1/08
8/1/08
x
x
I dont know when my family was diagnosed with their diseases.
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
x
Routine childhood vaccinations
x
Routine adult vaccinations for military or federal service
x
Adult Diphtheria (Date)
06/03/05
Adult Tetanus (Date)
x
Influenza (flu) (Date)
09/02/14
x
Pneumococcal (pneumonia) (Date)
5/12/14
NO
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS
NAME of
Causative Agent
Lisinopril
Type of Reaction (describe explicitly)

Cough (Adverse reaction)
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)
Chronic renal failure, also referred to as chronic kidney disease is usually an irreversible and progressive loss of kidney
function. Signs and symptoms do not usually appear until renal capacity decreases 10 to 15% from normal and by that
time patient will have reached end-stage renal disease. If the patient goes without treatment, the uremic toxins will cause
fatal physiological changes in all major organ systems. (Stetina, P,. Wraa, C. (2014).) Risk factors for renal failure include
diabetes, hypertension, urinary tract obstruction, chronic glomerular disease and chronic infections. Current patient has
hypertension and an enlarged prostate that causes urinary tract obstruction that can cause back pressure and
hydronephrosis. Patient also has a history of kidney stones that can also infection when passed. Medical management and
slowing progression include controlling hypertension with ACE inhibitors and ARBs. (Stetina, P,. Wraa, C. (2014).)
Plasma creatinine and potassium should be checked regularly while using these drugs. Patients will also need to maintain
a low protein diet of about 0.6 to 0.75 g/kg per day. (Stetina, P,. Wraa, C. (2014).) For patients with severe kidney failure,
hemodialysis will be performed three times a week for about 3 to 4 hrs. While on dialysis patients should maintain a low
protein diet and restrict liquid intake. Medications should be given after dialysis. (Stetina, P,. Wraa, C. (2014).)
5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name
Concentration (mg/ml)
Dosage Amount (mg)
vancomycin (Vancocin)
500mg in DSW 100ml
500mg
Route
Frequency Over 60 minutes
IV over 60 minutes
Pharmaceutical class
Home
Hospital
or
Both
Anti-infective
Indication
Treatment of potentially life-threatening infections when less toxic anti-infective are contraindicated.
Side effects/Nursing considerations
Ototoxicity, hypotension, nausea, vomiting, nephrotoxicity, red man syndrome, anaphylaxis. Instruct patient to notify provider and report signs of
hypersensitivity, tinnitus, vertigo or hearing loss. Do not double dose and take as directed. (Nursing Central 2015.)
Name
Concentration
Dosage Amount
Morphine (Duramorph PF)
2mg/1mL
2mg
Route
Frequency
Injection
Q4h, PRN pain > 7/10 hold if RR <10 and SBP<100
Home
Hospital
or
Both
Opioid analgesics
Indication
Management of moderate to severe pain. Pulmonary edema and pain associated with MI.

Confusion, dizziness, hypotension, respiratory depression, blurred vision, bradycardia, constipation, nausea, vomiting and physical dependence. May cause
drowsiness and dizziness so avoid smoking, ambulating and driving. Change positions slowly to avoid hypotension.
Name
Concentration
Dosage Amount
Epoetin (Epogen)
6500 units in 0.65 ml
6500 units
Route
Frequency
IV in hemodialysis
Tuesday, Thursday and Saturday
Home
Hospital
or
Both
antianemics
Indication
Anemia associated with chronic kidney disease.
Seizures, headache, HF, MI, Stroke, Thromboembolic events, transient rash. Discuss ways of preventing self injury in patients with risk of seizures. Avoid
driving. Notify provider if signs of blood clots (chest pain, trouble breathing, or shortness of breath and pain in legs without swelling.) (Nursing Central 2015.)
Name
Concentration
Dosage Amount
Calcium acetate (Eliphos)
200mg/1 cup
200 mg
Route
Frequency
PO
TID
Home
Hospital
or
Both
Mineral and electrolyte replacements/supplements
Indication
Control of hyperphosphatemia in end stage renal disease.
Headache, arrhythmias, bradycardia, constipation, nausea and vomiting. Advise patient to take on a regular schedule and to take missed disease as soon as
possible and then return to regular schedule. Advise patient of the signs and symptoms of hypercalcemia. (Nursing Central 2015.)
Name
Concentration
Dosage Amount
Allopurinol (Zyloprim)
300mg/1 tab
300mg
Route
Frequency
PO
Q daily
Home
Hospital
or
Both
Antigout agent
Indication
Prevention of gouty arthritis and nephropathy.
Hypotension, bradycardia, heart failure, drowsiness, nausea, vomiting, renal failure and rash. Take as directed and maintain an alkaline diet. May cause
drowsiness so avoid driving. Report any skin rashes or blood in urine or signs of fever and muscle aches to the provider. (Nursing Central 2015.)
Name
Concentration
Dosage Amount
Finasteride (Propecia)
5mg/ 1 tab
5mg
Route
Frequency
PO
Q daily
Home
Hospital
or
Both
Hair growth stimulants
Indication
Benign prostatic hyperplasia.
Gynecomastia, prostate cancer, decreased libido, breast cancer, ED, infertility. Take as directed and advise males that ejaculate may be decreased and erectile
dysfunction and decreased libido may occur. High risk of prostate cancer while taking this drug. (Nursing Central 2015.)
Name
Concentration
Dosage Amount
Losartan (Cozaar)
50mg/ 1 tab
50mg
Route
Frequency
PO
Q daily hold if SBP <110
Home
Hospital
or
Both
Antihypertensive
Indication
Management of hypertension.
Hypotension, dizziness, nausea, headache, angioedema, hyperkalemia and hypoglycemia. Advise patient to take medication at the same time each day. Avoid salt
substitutes and high levels of potassium. May cause dizziness so advise patient to avoid driving. (Nursing Central 2015.)
Name
Concentration
Dosage Amount
Niacin (Nicotinamide)
1000mg / 1 tab
1000mg
Route
Frequency
PO
Q daily
Home
Hospital
or
Both
Lipid lowering agent
Indication
Treatment and prevention of niacin deficiency.
Dizziness, nausea, hepatotoxicity, hypotension, blurred vision, flushing, hyperglycemia. Report signs and symptoms of hepatotoxicity. Inform patient that
flushing may occur. Encourage patient to comply with dietary recommendations of health care professionals. Foods high in niacin include meats, eggs, milk, and
use this medication with fat restrictions. (Nursing Central 2015.)
Name
Concentration
Dosage Amount
Rifampin (Rifadin)
300mg/ 1 cap
300mg
Route
Frequency
PO
Q 12h
Home
Hospital
or
Both
Antituberculars
Indication
Active tuberculosis, elimination of meningococcal carriers. Prevention of disease caused by Haemophilus influenza type B
Confusion, drowsiness, rash, headache, red tears, nausea, red urine and flu-like symptoms. Take medication as directed and notify provider if any signs of
hepatitis occur. Avoid alcohol and report signs and symptoms of the flu. (Nursing Central 2015.)
Name
Concentration
Dosage Amount
Tamsulosin (Flomax)
0.4mg/ 1 cap
0.4mg
Route
Frequency
PO
QHS
Home
Hospital
or
Both
Peripherally acting antiadrenergics
Indication
Management of outflow obstruction in male patients with prostatic hyperplasia.
Dizziness, headache, rhinitis, orthostatic hypotension, diminished ejaculation. May cause dizziness, advise patient to avoid driving. Change positions slowly to
avoid orthostatic hypotension. Take medication as directed. (Nursing Central 2015.)
Name
Concentration
Dosage Amount
Levothyroxine (Synthroid)
0.075 mg/ 1 tab
0.075 mg
Route
Frequency
PO
Q daily on an empty stomach in the morning.
Home
Hospital
or
Both
Thyroid preparations
Indication
Thyroid supplementation in hypothyroidism
Head ache, insomnia, angina pectoris, hyperthyroidism, arrhythmias, tachycardia and vomiting. Take medication as directed at the same time each day. Explain
the signs and symptoms of hypothyroidism. Notify provider if signs of headache, chest pains and pulse increases with palpitations. (Nursing Central 2015.)
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Dialysis Diet
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? Dialysis Diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Chronic Kidney disease
Breakfast: 2 scrabbled eggs, grape juice, milk, toast
End stage renal disease
Lunch: Hamburger and veggies
Dinner: Pork roast and veggies
Snacks: small piece of cake
Liquids (include alcohol): 1 cup of coffee, 1 cup of water
restricted 32 oz a day
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.
Total Calories: 1666

Breakfast 496 Calories
Scrambled eggs (no milk added), cooked with nonstick
spray
2 large egg(s)
149 Calories
(39 Empty Calories)
My Favorite Remove Edit
Bread, white whole wheat
1 regular slice
71 Calories
(11 Empty Calories)
Milk, reduced fat (2%)
1 cup
122 Calories
(37 Empty Calories)
Grape juice
1 cup
152 Calories
(0 Empty Calories)
Coffee, brewed, regular
1 mug (8 fl oz)
2 Calories
(0 Empty Calories)
Lunch 190 Calories
Hamburger bun, white
1 medium (2-1/2" across)
100 Calories
(8 Empty Calories)
Mixed vegetables (corn, lima beans, peas, green beans,
carrots), canned, cooked without fat

1 cup
89 Calories
(0 Empty Calories)
Dinner 594 Calories
Pork, raw, roast, loin, boneless, fat not trimmed
1 pound
505 Calories
(126 Empty Calories)
Mixed vegetables (corn, lima beans, peas, green beans,
carrots), canned, cooked without fat
1 cup
89 Calories
(0 Empty Calories)
Snacks 387 Calories
Cake, chocolate, devil's food or fudge, with icing, from mix
1 piece (1/12 of 2-layer cake)
387 Calories
(295 Empty Calories)
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Wife
How do you generally cope with stress? or What do you do when you are upset? No Stress, but if Im upset I play golf.
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?
____If yes, have you sought help for this? ______________________
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 x 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:
Stage 8: Ego Integrity Versus Despair (Over 65 years)

This stage of life is where acceptance of ones life, worth and eventual death is realized. Ego integrity is a reflection of
satisfaction or dissatisfaction with ones life and understanding of their life in the life cycle. Despair can be felt from the
sense of loss and discomfort with life and aging and fear of the death. (Treas, L., & Wilkinson, J. (2014).
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
According to Eriksons stages, my patient falls into the Ego integrity versus Despair stage due to his age (69). My patient
exhibits Ego integrity but not despair. He is still happily married and reports no pain even with his right kneed
debridement surgery. Patient states I am not stressed or upset. The only complaint he has is that he feels limited with his
diet as mentioned below. When he is upset the patient states that he enjoys golf.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? I dont know. I just developed kidney stones one day.
What does your illness mean to you? Means Im limited. I love potatoes and I cant eat them.
+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? ________Vasectomy __
How long have you been with your current partner?_______________50 years ____________________
Have any medical or surgical conditions changed your ability to have sexual activity? ________No
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
_______________________________________________________Nothing
______________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_________________________________________________________No _____________________________________________
______________________________________________________________________________________________________
+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? Cigarettes
How much?(specify daily amount)
5 cigarettes a day
Yes
No
For how many years? 5 years
(age 19
thru
24
If applicable, when did the

patient quit? 45 years ago
Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No
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)
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
No
10 REVIEW OF SYSTEMS
General Constitution
Gastrointestinal
Immunologic
Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:
HEENT
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
x Last colonoscopy? 2 years ago
Other:
Genitourinary
x
x
x
Recent weight loss or gain
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
x Use of sunscreen
SPF: 50
Bathing routine: Shower every day
Other:
Difficulty seeing (wears glasses)

Cataracts or Glaucoma
x Difficulty hearing (hearing aid)
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
x Routine brushing of teeth
2x/day
x Routine dentist visits
other year /year
x Vision screening (this year)
Other:
nocturia
x dysuria
hematuria
polyuria
x kidney stones
Normal frequency of urination:
x/day
Bladder or kidney infections
Hematologic/Oncologic
Anemia
Bleeds easily
Bruises easily
Cancer
x Blood Transfusions
Blood type if known: AB+
Other:
Metabolic/Endocrine
Diabetes
every
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold

Osteoporosis
Other:
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
x last CXR? 6 months ago
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
x 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
x Infection of male genitalia/prostate?
x Frequency of prostate exam?
Annually
Date of last prostate exam? 9/24/13
x BPH
x 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
x Gout
Osteomyelitis
Childhood Diseases
x
x
Measles
Mumps
Polio
x Scarlet Fever
10
Last EKG screening, when? now

Other:
x Arthritis
Other:
x Chicken Pox
Other:
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
11
10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey:
Temperature: (route taken?)
Oral 98.2
Height: 68 in
Pulse: 77
Respirations: 18
Weight: 235.4 lbs BMI: 35.87 Pain: (include rating & location) 0/10
Blood
Pressure: 139/79 Right Arm
(include location)
SpO2 92
Is the patient on Room Air or O2: Room Air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
x 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]
x awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
x clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
x
flat
apathetic
bizarre
agitated
anxious
tearful
Other:
Integumentary
x Skin is warm, dry, and intact
x Skin turgor elastic
x No rashes, lesions, or deformities
x Nails without clubbing
x Capillary refill < 3 seconds
x Hair evenly distributed, clean, without vermin
talkative
quiet
withdrawn
aggressive
boisterous
hostile
loud
STSG Right knee wound

Peripheral IV site Type:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Fluids infusing? x no
yes - what?
Location:
Date inserted:
Location:
Date inserted:
Location:
Date inserted:
HEENT: x Facial features symmetric x No pain in sinus region x No pain, clicking of TMJ x Trachea midline
x Thyroid not enlarged
x No palpable lymph nodes x sclera white and conjunctiva clear; without discharge
x Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
x PERRLA pupil size / mm x Peripheral vision intact x EOM intact through 6 cardinal fields without
nystagmus
x Ears symmetric without lesions or discharge x Whisper test heard: right ear- 10 inches & left ear- 10
inches
x Nose without lesions or discharge x Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:
12
Pulmonary/Thorax: x
symmetric
Respirations regular and unlabored

CL Clear
WH Wheezes
CR - Crackles
RH Rhonchi
D Diminished
S Stridor
Ab - Absent
x
x
Transverse to AP ratio 2:1 x
Chest expansion
Lungs clear to auscultation in all fields without adventitious sounds

Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
No sputum, lung sounds normal.
Cardiovascular: x No lifts, heaves, or thrills PMI felt at:

Heart sounds: S1 S2 Regular
Irregular Murmur
No murmurs, clicks, or adventitious heart sounds
JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
No
x Calf pain bilaterally negative x 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
x No temporal or carotid bruits
Edema:
none
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
none
pitting
non-pitting
x Extremities warm with capillary refill less than 3 seconds
GI/GU: x Bowel sounds active x 4 quadrants; no bruits auscultated

x No organomegaly
x Percussion dull over liver and spleen and tympanic over stomach and intestine
x Abdomen non-tender to
palpation
Urine output: x Clear
Cloudy
Color: yellow
Previous 24 hour output: very little
mLs N/A
Foley Catheter x Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 09 / 26 / 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
Other Describe:
Not assessed, patient alert, oriented, denies problems
Musculoskeletal: Full ROM intact in all extremities without crepitus

x 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]
x
x
vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias
Neurological: x Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
x 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:
Biceps:
Brachioradial:
Patellar:
x Achilles:
Ankle clonus: positive negative Babinski: positive
negative
10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
RBC 2.37 L (4.1 -5.7 N)
2.83 L (4.1 -5.7 N)
Dates
9/22/15
9/28/15
9/22/15
Potassium 5.3 H (3.5 -5.2
N)
9/28/15
4.8 N (3.5 -5.2 N)
Trend
Red blood count is
consistently low before
and after dialysis on
Tuesday. Dialysis also
occurs Thursdays and
Saturdays for this patient
High potassium levels are

indicated before dialysis
treatment but are brought
within normal ranges
after dialysis, showing
that dialysis is working to
normally sustain bodily
function for the patient.
Analysis
The consistent low RBC
is indicative of renal
failure because the
kidneys are not able to
produce enough
erythropoietin due to
chronic kidney disease.
This also causes the
patient to become anemic.
(Stetina, P,. Wraa, C.
(2014).)
Patients with Chronic
Kidney Disease (CKD)
need to monitor their
potassium levels because
normally excess
potassium is filtered out
by the kidneys and
excreted in urine. The lab
9/22/15
Glucose 85 N (65-110 N)
92 N (65-110N)
Sodium 137 N (136-143

N)
139 N (136143N)
9/28/15
9/22/15
9/28/15
Glucose levels are in

normal range for the past
week. Patient is not at
risk for diabetes.
Diabetes can be a risk

factor for CKD. Patient
does not have elevated
glucose levels indicating
that diabetes is not a
factor. An HA1C can be
taken if needed for a
wider range of glucose
Sodium levels are slightly control. (Stetina, P,. Wraa,
low but fall within
C. (2014).)
normal range.
9/22/15
9/28/15
Urea Nitrogen 51 H (8-23

N)
48 H (8-
9/22/15
9/28/15
results show an increase

in potassium before
dialysis which is normal
because during dialysis
the potassium will be
excreted. Symptoms of
hyperkalemia include
muscle weakness,
dizziness, and nausea,
diaphoresis and heart
irregularities. (Stetina, P,.
Wraa, C. (2014).)
Urea Nitrogen levels are

high both before and after
dialysis but there is a
decrease.
Patients with CKD need

to monitor their sodium
levels because normally
excess sodium is filtered
out by the kidneys and
excreted in urine. The lab
results show an increase
in sodium before dialysis
but still fall within normal
range. The lab results
indicate that the patient is
following a strict low
sodium diet.
Hypernatremia can cause
symptoms of change in
mental status, seizure,
lethargic, agitated,
dehydration and fever.
(2014).)
23 N)
Elevated Urea Nitrogen
levels is normal in
Creatinine 7.5 H (0.8-1.3

N)
5.2 H (0.8 -1.3
N)
9/22/15
9/28/15
Creatinine levels are high

in both before and after
dialysis but there is a
decrease.
patients with CKD

because the kidneys are
not able to filter it all out.
It can be controlled with
dialysis and a low protein
diet and prevention of
muscle breakdown.
(2014).)
Elevated Creatinine levels
are indicated by CKD
because as Glomerular
Renal Filtration (GRF)
decreases creatinine
increases. (Stetina, P,.
Wraa, C. (2014).)
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient experiences hypertension but takes losartan to control it. Other than that vitals are in normal
range. Patients diet is low in protein due to end stage renal failure and fluids are limited to 32 oz daily.
Patient is admitted to dialysis every Tuesday Thursday and Saturday for 3 to 4 hours. Patient recently has
had a right knee debridement and STSG on the right knee. Hemovac placed on right knee to promote
healing and drainage is measured Q shift. Patient receives medication after dialysis and pain management
and infection prevention are paramount. Lab are checked at the start of the shift to make sure BUN,
creatinine and potassium are within range that is normal for the patient.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Risk for Electrolyte Imbalance: Risk factor: Renal dysfunction (Ackley, B., & Ladwig, G. (2011.))
2. Impaired urinary elimination r/t effects of disease, need for dialysis (Ackley, B., & Ladwig, G. (2011.))
3. Risk of infection r/t right knee debridement and STSG on right knee wound. (Ackley, B., & Ladwig, G. (2011.))
4. Delayed Surgical recovery r/t decreased oxygen supply to body, increased cardiac workload. (Ackley, B., & Ladwig, G.
(2011.))
15 CARE PLAN
Nursing Diagnosis: Risk for Electrolyte Imbalance: Risk Factor: Renal dysfunction.
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
(Short term goal)
Patient must maintain a low protein Low protein diets will keep BUN
Patient ate half the egg portion of
Maintain electrolytes within
diet. *
levels within in normal ranges for
his breakfast this morning before
normal range levels every day.
the patient. (Stetina, P,. Wraa, C.
dialysis.
Patient must maintain a low
(2014.))
potassium diet.*
Patient did not intake any
Low potassium diets with decrease potassium before dialysis.
Patient should not use salt
the risk of hyperkalemia due to
substitutes that contain potassium.* renal disease. The kidney is unable Patient did not add any salt
to eliminate excess potassium
substitutes to his breakfast before
Patient must eat breakfast before
through urination (Stetina, P,.
dialysis.
dialysis treatment.*
Wraa, C. (2014.))
Patient consumed 50% of his
Fluid restriction to 32 oz daily.
Salt substitutes contain potassium
breakfast before dialysis.
which can increase the risk of
Patient must take Calcium acetate
hyperkalemia (Stetina, P,. Wraa, C.
(Eliphos) Q daily for Mineral and
(2014.))
electrolyte
replacements/supplements.
Patient must eat breakfast because
dialysis treatments usually last
between 3 to 4 hrs (Stetina, P,.
Wraa, C. (2014.))
Patient Goals/Outcomes
Patient must restrict fluid intake to

32 oz daily as prescribed by the
provider due to CKD. Prevention
of urine back up is crucial (Stetina,
P,. Wraa, C. (2014.))
Calcium acetate (Eliphos) is used
to control hyperphosphatemia in
end stage renal disease and is an
(Short term goal)

Patient will proceed to dialysis
three times a week at exactly the
same time each day.
.
(Long term goal)

Prevent major organ damage from
prolonged electrolyte imbalance.
electrolyte replacement (Nursing

Central 2015.)
Patient must attend dialysis
Dialysis treatment performs the
treatment on Tuesday Thursday and jobs the kidneys to flush out and
Saturdays at the same time each
eliminate toxins and waste from the
week.
body. Patients with CKD are
unable to do this on their own and
Patient will take medications after
require dialysis (Stetina, P,. Wraa,
dialysis treatment on days when
C. (2014.))
dialysis is scheduled.
Patient must take medications after
dialysis because treatment
eliminates most medications.
Vitals will be checked before and
after dialysis treatment.
Lab values will be checked
regularly to confirm effectiveness
of dialysis treatment.
Patient must maintain proper
dialysis diet.*
Patient must attend dialysis on
scheduled days.
It is crucial to check vitals before

and after treatment to discover
changes in patients condition. It is
important that blood pressure is
taken before blood pressure
medication is given. (McCulloch,
B., & Osborn, K. (2014.))
Patient attended dialysis on

Tuesday 9/29/15 at approximately
1000 hours.
Patient took scheduled medications
at 1400 hours when he returned
from dialysis
Vital signs were checked in the

morning before dialysis at 1000
hours. Vital signs were checked at
immediately 1400 hours when the
patient returned.
Lab values are viewed every

morning by the nurse. Lab values
Lab values must be checked
that are out of normal range are
regularly to confirm effectiveness
recorded and compared to previous
of dialysis to maintain normal
values to indicate a trend and to
bodily function. Lab values also
indicate if the values are normal for
are indicative of which medications the patient.
should be given or held.
(McCulloch, B., & Osborn, K.
Patient states that he maintains a
(2014.))
proper diet in the hospital and at
home. States I feel limited
Patients must maintain a proper
because I am not able to eat
dialysis diet low in protein, sodium potatoes that I love.
and potassium because excess
amounts are unable to eliminated
There is documentation that the
due to CKD. (Stetina, P,. Wraa, C.
patient has attended dialysis on
(2014.))
each scheduled day.
Patient must attend dialysis on

scheduled days to prevent
prolonged organ damage due to
excess toxins within the body that
are unable to be eliminated because
of CKD. (Stetina, P,. Wraa, C.
(2014.))
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: If the patient is being discharged he will need to maintain a low protein, sodium and potassium diet and will
need to restrict his liquids to 32 oz a day as prescribed by the provider. He also needs to assess his right knee wound daily and report any
signs of infection. He will need to go to dialysis on his scheduled days and take his medications after each treatment on time. Patient will be
educated on signs and symptoms of hyperkalemia, hypernatremia and elevated BUN and creatinine levels. Patient must report to the
provider if any of the conditions mentioned above are experienced.
SS Consult
xDietary Consult
PT/ OT
Pastoral Care
xDurable Medical Needs
F/U appts
xMed Instruction/Prescription
are any of the patients medications available at a discount pharmacy? xYes No
Rehab/ HH
Palliative Care
15 CARE PLAN
Nursing Diagnosis: Delayed surgical recovery r/t decreased oxygen supply to body, increased cardiac
workload.
Patient Goals/Outcomes
Nursing Interventions
Rationale for
Evaluation of
to Achieve Goal
Interventions
Interventions on Day
Provide References
care is Provided
(Short term goals)
Monitor vitals before and It is crucial to record
Patients O2 saturation
Maintain oxygen levels
after dialysis, especially
vitals before and after any was 92 before and after
within normal ranges for
note respirations and
procedure. Assessing the dialysis, which are within
patient
oxygen levels.
patients level of
normal ranges and patient
consciousness, oxygen
was not suffering from
Assess patients ability
levels and respirations
loss of mental status nor
breathing and measure
post dialysis is important showing signs of
level of consciousness.
because CKD results in
hypoxia. Patients O2
decrease production of
normally runs low and
Make sure patient
erythropoietin, which
are within normal limits
receives Epoetin
leads to decrease red
for the patient.
(Epogen) during dialysis blood cell production and
on scheduled days.
anemia and reduced
Epoetin (Epogen) was
oxygen levels (Stetina,
documented as
P,. Wraa, C. (2014.))
administered during
dialysis.
It important that the
patient receives their
prescribed amount of
Epoetin (Epogen) during
their dialysis because it is
used to treat anemia
(Nursing Central 2015.)
(Short term goals)
Make sure patient
It is important that the
The patient maintained a
Promote healing of right
maintains a proper
patient maintains a proper proper diet before and
knee debridement and
balanced dialysis diet.*
dialysis diet to promote
after dialysis and lab
STSG.
healing. Increases in
results were elevated
Document patients
BUN and creatinine,
before dialysis but fell
hemovac output.
sodium and potassium
within normal limits for
levels can be detrimental the patient after.
to patient healing and
cause numerous other
The nurse assess and
negative conditions
documented the output of
the hemovac and
(2014.))
estimated that if
conditions continued; the
It is important to
hemovac would be
document patients
removed within a couple
hemovac output because
days and regular dressing
it will determine if
changes would be needed
healing is occurring. As
to finish healing the knee.
the amount decreases the
hemovac will be removed
and healing will occur
(Long term goals)

Complete recovery of right
knee debridement and
STSG without infection.
Assess patient for pain.

Assess patient for signs
of infection.
Assess patients wound
for signs of infection or
breach.
Remain sterile while
changing dressing post
hemovac.
normally.
Pain needs to be assessed
along with vitals to
determine if there are any
underlying conditions
causing the pain or if
there are any developing
infections. Ackley, B., &
Ladwig, G. (2011).
Assessing the patient for
signs of infection, such as
fever or rash and redness
around the wound is
important to start the
elimination process of
said infection and
promote healing. Ackley,
B., & Ladwig, G. (2011).
Patient reported no pain

throughout the day.
Patient showed no sign of
infection and lab values
indicate no elevated
WBC.
Provided that the
hemovac goes as planned
the nurse will need to
change the dressing once
the hemovac is removed
and remain sterile.
Once the hemovac is

removed normal dressing
changes will need to be
done maintain sterility to
prevent infection and
delay healing.
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: If the patient is being discharged he will need to maintain a low protein,
sodium and potassium diet and will need to restrict his liquids to 32 oz a day as prescribed by the
provider. He also needs to assess his right knee wound daily and report any signs of infection. He will
need to go to dialysis on his scheduled days and take his medications after each treatment on time. Patient
will be educated on signs and symptoms of hyperkalemia, hypernatremia and elevated BUN and
creatinine levels. Patient must report to the provider if any of the conditions mentioned above are
experienced. If patient is returned home and hemovac is removed; patient must be educated on how to
properly change their dressing. Patient must be educated on the signs and symptoms of infection and
must report to the provider if any signs or symptoms present themselves.

SS Consult
xDietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
xMed Instruction/Prescription
are any of the patients medications available at a discount pharmacy? xYes No
Rehab/ HH
Palliative Care
References
Ackley, B., & Ladwig, G. (2011). In Nursing Diagnosis Handbook (9th ed., pp. 841- 843). St. Louis, Missouri:
Mosby Elsevier.
Allopurinol. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October 15,
2015. Retrieved from.
http://nursing.unboundmedicine.com/nursingcentral/ub/
Calcium Acetate. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October
15, 2015. Retrieved from.
Epoetin. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October 15,
Finasteride. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October 15,
Levothyroxine. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October
15, 2015. Retrieved from.
Losartan. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October 15,
Morphine. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October 15,
Niacin. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October 15, 2015.
Retrieved from.
Rifampin. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October 15,
Tamsulosin. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October 15,
Vancomycin. (2015). Nursing Central. Unbound Medicine. Mobile application software. Retrieved October 15,
McCulloch, B., & Osborn, K. (2014). Caring for the Patient with Coronary Artery Disease. Osborn, K., Wraa,
C., Watson, A., & Holleran, R. Medical-Surgical Nursing Preparation for Practice. (2nd ed., pp. 928-929).
Upper Saddle River: Pearson
Stetina, P,. Wraa, C. (2014). Caring for the Patient with Renal and Urinary Disorder. Osborn, K., Wraa, C.,
Watson, A., & Holleran, R. Medical-Surgical Nursing Preparation for Practice. (2nd ed., pp. 1199-1235). Upper
Saddle River: Pearson
Treas, L., & Wilkinson, J. (2014). Development: Infancy Through Middle Age. In Basic Nursing Concepts,
Skills and Reasoning (164-165). Philadelphia, PA: F.A. Davis Company.
U.S. Department of Agriculture. ChooseMyPlate.gov Website. Washington, DC. Accessed October 16, 2015.
https://www.supertracker.usda.gov/foodtracker.aspx

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UNIVERSITY OF SOUTH FLORIDA

PATIENT ASSESSMENT TOOL .

Assignment Date: 10/16/15

Admission Date: 9/10/15

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Level of Education: Some college

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired. Was a telephone Engineer

Obstructive Sleep Apnea, Anemia, Renal Cyst,

Number/ages children/siblings: 3 children: Son 52, Son 51,

Served/Veteran: Air Force Combat

Code Status: Full

Living Arrangements: House

Advanced Directives: Living will

Culture/ Ethnicity /Nationality: Jewish/Catholic

Type of Insurance: VA 100%

University of South Florida College of Nursing Revision August 2013

Age (in years)

I dont know when my family was diagnosed with their diseases.

Type of Reaction (describe explicitly)

Other (food, tape,

University of South Florida College of Nursing Revision August 2013

Side effects/Nursing considerations

University of South Florida College of Nursing Revision August 2013

University of South Florida College of Nursing Revision August 2013

Total Calories: 1666

University of South Florida College of Nursing Revision August 2013

carrots), canned, cooked without fat

+2 DOMESTIC VIOLENCE ASSESSMENT

Trust vs. Mistrust

University of South Florida College of Nursing Revision August 2013

patients age group:

Stage 8: Ego Integrity Versus Despair (Over 65 years)

University of South Florida College of Nursing Revision August 2013

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

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

If applicable, when did the

Has the patient ever tried to quit? Yes

For how many years?

If applicable, when did the patient quit?

Is the patient currently using these drugs?

If not, when did he/she quit?

University of South Florida College of Nursing Revision August 2013

Chills with severe shaking

Nausea, vomiting, or diarrhea

Recent weight loss or gain

Difficulty seeing (wears glasses)

Intolerance to hot or cold

Central Nervous System

University of South Florida College of Nursing Revision August 2013

Last EKG screening, when? now

University of South Florida College of Nursing Revision August 2013

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

STSG Right knee wound

University of South Florida College of Nursing Revision August 2013

Respirations regular and unlabored

Transverse to AP ratio 2:1 x

Lungs clear to auscultation in all fields without adventitious sounds

No sputum, lung sounds normal.

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

GI/GU: x Bowel sounds active x 4 quadrants; no bruits auscultated

Not assessed, patient alert, oriented, denies problems

& __5_ in LLE