UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Lindsey Swank

Assignment Date: 07/07/15
.
1 PATIENT INFORMATION Agency: FHT
Patient Initials: J.C.M. Age: 74 Admission Date: 07/04/15
Gender: Male Marital Status: Married Primary Medical Diagnosis: UTI
Primary Language: English
Level of Education: College Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Government job
Number/ages children/siblings: Stepson-30s

Served/Veteran: NO Code Status: Full resuscitation

If yes: Ever deployed? Yes or No
Living Arrangements: With wife, Susan Advanced Directives: Will
If no, do they want to fill them out?
Surgery Date: Procedure:
Culture/ Ethnicity /Nationality: French, Irish
Religion: Protestant Type of Insurance: Medicaid

1 CHIEF COMPLAINT: Patient states I havent been able to pee for a couple days

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient admitted 07/04/15 after urine C&S revealed urinary tract infection. Patient was straight admit. Urinary tract
infection caused by foley catheter used after kidney surgery 2 weeks prior. Admitted with
urinary retention and altered mental status. Patient is now alert and oriented x3. Patient experiencing
infrequent urination with no pain. Bladder scan revealed >999 ml of urine in bladder, and straight catheter revealed ~1500
ml. Blood present in urine. Patient experiencing urinary retention since 07/03/15.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
6/23/15 Bladder surgery
Past 10 years Simple aspiration for intracerebral hemorrhage
Past 10 years Coronary Artery Bypass Graft
Past 10 years Pacemaker
Past 40 years Stroke (5 strokes within past 40 years)
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma
of

Cancer

Problems

Tumor
Stroke
Allergies

MI, DVT
Gout
MEDICAL Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Heart
Father 54 X
attack
Mother 83 COPD X X X
Brother N/A
Sister N/A
Grandmother 80
Unknown X
s
Grandfather 70
Unknown X
s
Relationship

Comments: Include age of onset

Father: Heart troubles began mid to late 40s
Mother: Asthma began in childhood, mental health issues began in late teens to early 20s
Grandmother (maternal): Mental health issues began in 20s
Grandfather (maternal): Heart trouble began in late 60s

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations X U
Routine adult vaccinations for military or federal service X U
Adult Diphtheria (Date) X U
Adult Tetanus (Date) Is within 10 years? X U
Influenza (flu) (Date) Is within 1 years? X
Pneumococcal (pneumonia) (Date) Is within 5 years? X
Have you had any other vaccines given for international travel or
occupational purposes? Please List X
If yes: give date, can state U for the patient not knowing date received
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 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
N/A

Medications

Dust/pollen Sneezing, labored breathing, watery eyes, congestions

Other (food, tape, Chocolate Wheezing, labored breathing, shortness of breath
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)
A urinary tract infection happens when the urinary epithelium becomes inflamed by bacteria that are a part of the normal
Microflora of the gut, as stated by Huether & McCance (2012). Urinary tract infections, or UTIs for short, are usually
Treated with oral antibiotics, but my patients infection was resistant to oral antibiotics. He was given IV antibiotics as a
Result. The prognosis for urinary tract infections is good, as the patient was able to take IV antibiotics for several days
And was being discharged soon. Some symptoms of UTIs are usually dysuria, polyuria, hematuria, cloudy urine, and
Passing small amounts of urine. My patient did not have a genetic factor that impacted diagnosis seeing as he developed
The UTI as a result of an indwelling catheter. However, genetics can play a role in predispositions for urinary tract
Infections. Genetics can determine how a vagina is shaped, which can contribute to increased chances for recurrence, and
Gender also is a factor that determines whether or not a person is prone to UTIs. Females have a higher chance of
Developing UTIs due to simple anatomical differences from males. The female urethra is shorter, which makes it easier
For bacteria to travel up to the kidneys, and the female urethral opening is close to the rectum, making it simple for E. coli
To be transferred from the gastrointestinal tract to the urinary tract.

5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name Cefepime/Maxipime Concentration 100ml/hr Dosage Amount

Route IVPB Frequency Q8H

th
Pharmaceutical class 4 gen cephalospore Home Hospital or Both
Indication Treatment of uncomplicated and complicated urinary tract infections
Adverse/ Side effects Seizures, pseudomembranous colitis, anaphylaxis, superinfection
Nursing considerations/ Patient Teaching Advise patient to report signs of superinfection and allergy, notify healthcare if fever or diarrhea develop

Name Ezetimibe/Ezetrol Concentration Dosage Amount 10 mg

Route PO Frequency Daily

Pharmaceutical class Cholesterol absorption inhibitor Home Hospital or Both
Indication Management of hypercholesterolemia
Adverse/ Side effects Angioedema
Nursing considerations/ Patient Teaching Instruct patient to take meds as directed at same time each day, meds should be used in conjunction with diet

Name Herparin flush/Hep-Lock Concentration Dosage Amount 50 units

Route INJ Frequency Q8H

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Pharmaceutical classAnticoagulants Home Hospital or Both
Indication Maintains patency of IV catheters
Adverse/ Side effects Bleeding, heparin-induced thrombocytopenia, alopecia, urticaria
Nursing considerations/ Patient Teaching Advise patient to report any symptoms of unsual bleeding or bruising to healthcare professionals immediately

Name Lisinopril/Prinivil Concentration Dosage Amount 10 mg

Route PO Frequency Daily

Pharmaceutical class Antihypertensive Home Hospital or Both
Indication Management of heart failure and hypertension
Adverse/ Side effects Angioedema, dizziness, hypotension, impaired renal function
Nursing considerations/ Patient Teaching Advise patient to take medication as directed at same time each day, avoid salt substitutes

Name Pantoprazole/ Protonix Concentration Dosage Amount 40 mg

Route PO Frequency Daily

Pharmaceutical class Antiulcer Home Hospital or Both
Indication Erosive esophagitis associated with GERD
Adverse/ Side effects Pseudomembranous colitis
Nursing considerations/ Patient Teaching notify healthcare providers immediately if rash, diarrhea, cramping, fever, or bloody stools occur

Name Rosuvastatin/ Crestor Concentration Dosage Amount 40 mg

Route PO Frequency Daily

Pharmaceutical class Lipid lowering agent Home Hospital or Both
Indication Adjunctive management of primary hypercholesterolemia
Adverse/ Side effects rhabdomyolysis, confusion, memory loss, amnesia
Nursing considerations/ Patient Teaching Notify healthcare provider if unexplained muscle pain, tenderness, or weakness occurs

Name Saccharomyces boulardii/ probiotics Concentration Dosage Amount 250 mg

Route PO Frequency BID

Pharmaceutical class Antidiarrheal Home Hospital or Both
Indication Treatment and prevention of diarrhea
Adverse/ Side effects Constipation, thirst
Nursing considerations/ Patient Teaching Instruct patient to take as directed

Name Sodium Chloride//Slo-Salt Concentration 10mL Dosage Amount

Route IV Push Frequency Q8H

Pharmaceutical class Mineral & Electrolyte Replacement Home Hospital or Both
Indication Hydration and provision of NaCl in deficiency states
Adverse/ Side effects Heart failure, pulmonary edema, hypernatremia
Nursing considerations/ Patient Teaching Explain to patient the purpose of infusion

Name Torsemide/Demadex Concentration Dosage Amount 20mg

Route PO Frequency Daily

Pharmaceutical class Antihypertensive Home Hospital or Both
Indication Edema due to heart failure and hypertension
Adverse/ Side effects Stevens-Johnson Syndrome, toxic epidermal necrolysis, dehydration, hypokalemia, hyponatremia, increased BUN
Nursing considerations/ Patient Teaching Contact healthcare professionals if rash muscle weakness, cramps, nausea, dizziness, or numbness occur

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Cardiac diet Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Eats healthy Consider co-morbidities and cultural considerations):
24 HR average home diet: According to MyPlate, my patient has consumed over the
Breakfast: Coffee, bacon egg cheese croissant Recommended amount for both vegetables and proteins.
He ate less than recommended for both his grains and dairy,
Lunch: Circle K Cuban sandwich 6-inch, OR hamburger, But ate 0 fruits to be added to that group. He ate over his
diet soda, fries occasionally Recommended amount of saturated fats, empty calories,
Dinner: Starch, vegetable, & protein (usually chicken, Oils, and sodium, even though he should be on a cardiac
ham, or beef), sometimes pasta Diet. His 24-average home diet is roughly ~1750 calories
Snacks: Little to no snacks, sometimes ice cream Which is right around the recommended amount for him.

Liquids (include alcohol): Wine with dinner, water, diet

soda
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Patient states Susan, she always takes care of me, and she is the one who remembers all
this crap!

How do you generally cope with stress? or What do you do when you are upset? Patient states I usually do yard work, or
if my muscle
cars are working, I will take one for a drive. Sometimes when Susan isnt home, I will sit in peace and quiet with Jack the
cat and take a nap.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) Patient states I
dont get
stressed out easily, but I guess sometimes I felt stress about the surgery

+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? Hell yeah_______ Have you ever been hit punched or slapped? Yes___________

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?

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_No_________________________________________ If yes, have you sought help for this? ______________________

Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego XIntegrity 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: This stage occurs during late adulthood from age 65 through the end of life. During this period of time, people
reflect back on the life they have lived and come away with either a sense of fulfillment from a life well lived or a sense of regret and
despair over a life misspent.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The stage my patient is in is Integrity vs Despair. This stage describes people above the age of 65, who either look back
on their lives with fond memories of fulfillment and knowledge learned, or look back with a sense depression over a life
wasted. I believe my patient is displaying Integrity over despair, because he displayed pride when recollecting memories
About hobbies and friends to me, as well as describing to me how he uses his fond memories to shape who he is today and
The actions he takes.

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

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? Patient states No idea, calcium build up maybe?

What does your illness mean to you? Patient states Means Im stuck in here

+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? _Me, no. Susan, I have no idea_______________

Are you currently sexually active? _Not since getting the UTI__________________________ If yes, are you in a
monogamous relationship? Yes____________________ When sexually active, what measures do you take to prevent
acquiring a sexually transmitted disease or an unintended pregnancy? _Condoms_______________________________

How long have you been with your current partner?_11 years _______________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? _UTI_______________________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
_Medium______________________________________________________________________________________________
______________________________________________________________________________________________________
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? Yes No
If so, what? How much?(specify daily amount) For how many years? X years
Smoking 1 pack a day (age 25 thru 40s )
Quit for 10 years, picked back up
in 50s, quit again 4 years ago
If applicable, when did the
Pack Years:
patient quit? 4 years ago

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? If yes, what did they use to try to quit? Cold turkey
No

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Wine How much? Small wine glass For how many years? 15
Very rarely scotch Volume: (age 60 thru 74 )
Frequency: With dinner
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 thru )

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
When I was young, I used to work in construction. Oftentimes back then, we would use asbestos. I was probably around
it for 4 to 5 years before I changed jobs.

5. For Veterans: Have you had any kind of service related exposure? N/A

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? I would consider myself in good health before all these kidney and heart problems

Integumentary: No skin problems

HEENT: Ive worn glasses for 50 years, but my eyesight is stable. And I had nasal surgery 3-4 years ago
Pulmonary: Sometimes I have asthma attacks, but rarely and only with pollen. I use my inhaler when this
happens
Cardiovascular: I had a quadruple bypass a couple years ago, and Ive had a couple heart attacks
GI: I can only sleep in my chair upright because I have GERD
GU: Well obviously I have issues with UTIs, and I recently had a kidney surgery
Women/Men Only: No problems
Musculoskeletal: Every so often I feel tightness in my hands, and I get cramps very easily in my legs
Immunologic: No problems
Hematologic/Oncologic: No problems
Metabolic/Endocrine: No problems
Central Nervous System: Ive had 5 strokes, and Ive had bleeding on the brain
Mental Illness: No problems
Childhood Diseases: I had chickenpox, tonsillitis where I had to get my tonsils removed, and whooping cough

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Ive had a lot of recurring back problems because I have a slipped disk. Nothing ever seems to help and the problems
always come back

Any other questions or comments that your patient would like you to know? No

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10 PHYSICAL EXAMINATION:
General survey _Patient is a 74 y.o. male who is alert and oriented x3 and very active _____________________________
Height _180 cm________Weight_80.1kg_________ BMI _25.3________ Pain (include rating and
location)_0/10_______________ Pulse_95______ Blood Pressure (include location)_98/51mmHG_(left arm brachial
artery) Temperature (route taken)_98.3F (sublingual)____
Respirations_18_________ SpO2 _96%______________ Room Air or O2_Room air______________________
Overall Appearance_Patient is well groomed, skin color normal, no signs of distress__________
Overall Behavior_Patient has pleasant mood, interacts well with others, calm, relaxed, alert & oriented _______
Speech_Clear, easy to understand ____________________________________________________________________
Mood and Affect_pleasant, cooperative, talkative, cheerful, ___________________________________________
Integumentary_Skin warm, dry, and intact, cap refill <3 seconds ________________________________________
IV Access_20 gauge, central line, 07/07/15 inserted, no redness, edema, pain at injection site, NS .9% 150 ml/hr _
HEENT_Face symmetrical, PERRLA, no hearing problems, peripheral vision intact, mucous membranes moist _
Pulmonary/Thorax_Respirations normal, no labored breathing, A:P ratio normal, lung sounds resonant _____
Cardiovascular_Heart sounds diminished, patient has defibrillator, no murmurs, pulses 2+ brachial and pedal
GI_Bowel sounds normoactive, abdomen nontender to palpation, bowel movements regular, no nausea ________
GU_Urine output abnormal, bladder scan >999 ml urine in bladder, straight cath ~1500 ml urine, blood present
Musculoskeletal_Full range of motion, slight tightness in hand joints, slipped disc in lower spine
Neurological Patient awake, alert, and oriented x3, sensation intact, gait normal

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

Lab Dates Trend Analysis

WBC Upon admit, the patients Number of infection
6.9 (03/18/2013) WBC were in the low fighting cells. High WBC
normal range. However, indicates the presence of
19.8 H (03/22/2013) WBC are trending an infection or
Normal (4.5-11) upwards indicating either inflammation. High WBC
an infection or is often indicated in an
inflammatory process is exacerbation of ulcerative
occurring. colitis.

This should represent the

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

University of South Florida College of Nursing Revision September 2014 9

My patient has a UTI, so I would make sure to monitor sodium levels due to his urinary retention. The normal
Sodium levels would be between 135 and 145 ml. I would do a C&S of his urine to check for bacteria such as
E. coli. I would also do a bladder scan to make sure the amount of urine in his bladder is below 999ml. Because
my patient is on antihypertensives, I would make sure to monitor potassium level in the body as well. The normal
Potassium level should be between 3.5-5.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Very active, C&S, no consults, routine checkup scheduled in 2 weeks with primary care physician,
vitals every 4 hours, temp 98.3F, heart rate 95 bpm, pulse ox 96% on room air, blood pressure 98/51, respirations
18, cardiac diet (lowfat proteins, low sodium, lower cholesterol).

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

1. Urinary retention related to UTI as evidenced by >999 ml of urine in bladder during bladder scan

2. Ineffective health maintenance related to UTI as evidenced by contraction of UTI from indwelling catheter

3. Altered mental status related to UTI as evidenced by statements from patient

4. Risk for ineffective renal perfusion related to UTI

5. Risk for urge urinary incontinence related to UTI

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 15 CARE PLAN
Nursing Diagnosis: Urinary retention related to UTI as evidenced by >999 ml of urine in bladder during bladder scan
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Have patient prepared for Teach patient to perform clean, Intermittent catheterization allows Patient goal was unmet, patient
Discharge with proper information Self-intermittent catheterization Regular bladder evacuation without Was scheduled for catheterization
About UTI and causes Complication (Ackley & Ladwig, Teaching after end of my shift
2011)
Reduce urinary retention after one Teach patient about maintaining New medications may cause Patient goal was unmet, this is a
Year to prevent further use of Up-to-date medication list. Urinary retention. long term goal
Catheter Encourage patient to report Pathophysiological factors require
Inability to void. Follow-up. (Ackley & Ladwig,
2011)

Include a minimum of one

Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
*Dietary Consult
PT/ OT
Pastoral Care
*Durable Medical Needs
*F/U appointments
*Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes * No
Rehab/ HH
Palliative Care

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 References

Ackley, B.J. & Ladwig, G.B. (2014). Nursing Diagnosis Handbook: An Evidence Based Guide to Planning Care. Missouri: Mosby Elsevier.

Huether, S.E. & McCance, K.L. (2012). Understanding Pathophysiology. Missouri: Elsevier.

Nursing UCentral (n.d.) Davis Drug Guide. Retrieved from http://nursing.unboundmedicine.com/nursingcentral/index/David-Drug-

Guide/All_Entries/A.

Treas, L., & Wilkinson, J. (2014). Development: Older Adulthood. Basic Nursing: Concepts, Skills, & Reasoning. (pp 207-214). Philadelphia, PA:

F.A. Davis Company.

SuperTracker. (2015). My Plate Food Tracker. Retrieved from https://www.supertracker.usda.gov/foodtracker.aspx.

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