UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL

Student: Kayleigh Shelton,

SN
Assignment Date: 6/25/14
Agency: VA

1 PATIENT INFORMATION
Patient Initials: A.S Age: 68

Admission Date: Aug 26, 2013

Gender:

Primary Medical Diagnosis:

Male

Marital Status: Single

Primary Language: English

Level of Education: College
Occupation (if retired, what from?): Retired, Pilot
Number/ages children/siblings

C5-C7 incomplete tetraplegia

secondary to emergency ejection
Other Medical Diagnoses: (new on
this admission)
Cervical spondylosis, neurogenic
bladder, neurogenic bladder,
hypertension,
anxiety.
Chronic back pain.

4 brothers (80, 70, 67, 64) 1 twin sister (68)

Served/Veteran: yes

Code Status: Full resuscitation

Living Arrangements: none

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: 08/27/2013
Procedure: C5-C7 laminectomy

Culture/ Ethnicity /Nationality: White, Non

Hispanic
Religion: Roman Catholic

Type of Insurance: VA hospital

1 CHIEF COMPLAINT:
I came in for a laminectomy and they messed up and paralyzed me.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to
the hospital course of stay)
Patient presents with incomplete quadriplegia. Onset was 1973, with progressive muscle
weakness. The course and
duration of symptoms are gradually worsening. There is decreasing function of muscles
from the arms down.
At onset patient had arm weakness, neck pain, and history of falls. Exacerbating factors
include turning of head, movement, and time.
University of South Florida College of Nursing Revision September 2014

Resting and lying down are relieving factors for neck pain, but muscle weakness is
declining with no relieving factors.. Associated symptoms include loss of control and
feeling in both legs and feet, and progressive loss of control of arms.
. Pain is at 0 /10 on the pain scale.

Father
Mother
Brother
Sister

9
9
9
4
6
4
6
8

Tumor

Stroke

Ulcers
Stomach

Seizures

Problems
Health
Mental

Hypertensio
n
Problems
Kidney

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Arthritis
Asthma

Anemia

alEnvironment
Allergies

Cause
of
Death
(if
applica
ble)
Natura
l
causes
Alzhei
mers

Alcoholism

2
FAMILY
MEDICAL
HISTORY

years)
Age (in

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for

any medical illness or operation; include treatment/management of disease
Date
Operation or Illness
8/27/2013
C5-C7 fusion cervical laminectomy no complications medium hemovac
8/27/2013
Anemia
9/26/2013
Tracheotomy no complications
10/04/2013
Right distal ureteral stone Right ureteral stent
1/08/2014
Cystoscopy with stent removal

X
X

relationsh
ip
relationsh
ip
University of South Florida College of Nursing Revision September 2014

relationsh
ip
Father lived a long healthy life.
Mother gained Alzheimers at about 88 years old, and gradually got worse until her death
at 94 years old.
Brother and sister are both alive and well. They were both diagnosed in their 30s with
diabetes. His brother had a heart attack in his 50s, but survived and is living without
complications.
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and
YES
NO
Routine childhood vaccinations
U
Routine adult vaccinations for military or federal service
U
Adult Diphtheria (Date)
U
Adult Tetanus (Date) Is within 10 years?
11/08/2008
X
Influenza (flu) (Date) Is within 1 year?
9/27/2012
X
Pneumococcal (pneumonia) (Date) Is within 5 years?
X
8/26/2013
Have you had any other vaccines given for international
travel or occupational purposes? Please List
U
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative
Agent
NKA

Type of Reaction (describe explicitly)

Medications

Other (food,
tape, latex, dye,
etc.)

NKA

University of South Florida College of Nursing Revision September 2014

 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)
Mechanics: Cervical spondylosis is a very common degenerative disease. It works by the
hardening of the intervertebral disks causing pressure or impinging on the cervical spine.
(Nursing , 2014)
Risk Factors: Some risk factors can be: aging, smoking, trauma, and congenital cervical
stenosis. You can also be genetically prone to this process, even though they dont know
exactly what genetic factors cause it. (Nursing , 2014)
Diagnoses: certain signs and symptoms (such as scapular pain, loss of neck extension
ability, and congenital cervical stenosis usually diagnose this process. Cervical spondylosis
can easily be taken for another disease process, so there are several tests to differentiate
it from other possible occurrences. Some of these tests are CBC differential, Xray, ESR,
and a rheumatoid factor test. (Nursing , 2014)
Treatment: This condition is treated with surgery; usually a C5-C7 laminectomy. (Nursing ,
2014)
Prognosis: The prognosis for this condition is 75% are either completely relived or have
significant relief without surgery. (Nursing , 2014)
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: BACLOFEN
Concentration : 10 mg
Dosage Amount: 5 mg
Route: NG tube
Frequency: Q8H
Pharmaceutical class : gammaHospital
amino butyric acid
Indication: muscle relaxer
Adverse/ Side effects: seizure, hallucinations, drowsiness, insomnia, polyuria, and
headache.
Nursing considerations/ Patient Teaching: Do not take if you are prone to kidney
disease,
Epilepsy, or other seizure disorder; or if you have a history of stroke or blood clots.
Name: LISINOPRIL
Concentration : 2.5 mg
Dosage Amount: 5 mg
Route : ORAL
Frequency: Q12H
Pharmaceutical class: angiotensinHospital
converting enzyme inhibitor
Indication: treats hypertension and CHF
Adverse/ Side effects: blurred vision, cloudy urine, confusion, decrease urine output,
sweating, fatigue
Nursing considerations/ Patient Teaching: avoid alcohol and notify your healthcare
provider before stopping the drug. Hold dose if SBP is <115. Do not take potassium
supplements.
Name: OXYBUTYNIN CHLORIDE Concentration: 5 mg
Dosage Amount: 5 mg
Route :ORAL
Frequency: Q8H
Pharmaceutical class:
Hospital

anticholinergic

University of South Florida College of Nursing Revision September 2014

Indication: relaxes bladder muscle (antispasmodic)

Adverse/ Side effects: dry mouth, dizziness, blurred vision, nausea, vomiting,
headache, dry eyes
Nursing considerations/ Patient Teaching: should not be taken if patient has
glaucoma or internal bleeding
Name : TERAZOSIN
Concentration : 5mg
Dosage Amount: 5 mg
Route : ORAL
Frequency: Q12H
Pharmaceutical class: Alpha blocker Hospital
Indication : treats high BP and enlarged prostate
Adverse/ Side effects: chest pain, tachycardia, fever, numbness, edema, joint pain
Nursing considerations/ Patient Teaching : no alcohol and if you miss a dose take it
as soon as possible. Hold for SBP <110.
Name: Amlodipine
Concentration: 5mg
Dosage Amount: 10 mg
Route: oral
Frequency : Qdaily
Pharmaceutical class: Calcium
Hospital
channel blocker
Indication: treats high BP or angina
Adverse/ Side effects: dizziness, chest pain, tiredness, edema , fainting
Nursing considerations/ Patient Teaching: dont take if have liver disease, heart
disease, or COPD.
Name: Dantrolene
Concentration : 25 mg
Dosage Amount: 25 mg
Route : G tube
Frequency: TID
Pharmaceutical class : muscle
Hospital
relaxant
Indication: malignant hyperthermia, spasticity
Adverse/ Side effects : loss of appetite, diarrhea, chest pain, jaundice, dark urine, pale
stools
Nursing considerations/ Patient Teaching: dont take if have history of liver or heart
disease
Name Lansoprazole
Concentration: 30 mg
Dosage Amount: 30 mg
Route G tube
Frequency BID
Pharmaceutical class: Proton-pump
Hospital
inhibitor
Indication treats stomach ulcers and GERD
Adverse/ Side effects: itching, hives, trouble breathing, swelling or tingling in mouth,
seizures
Nursing considerations/ Patient Teaching: dont take with liver disease, osteoporosis,
or low magnesium.
Name Albuterol
Concentration: .83%
Dosage Amount one vial
Route inhalation
Frequency PRN
Pharmaceutical class: Beta2Hospital
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5

adrenergic agonist
Indication asthma
Adverse/ Side effects dry mouth, cough, chest tightness, nausea, vomiting
Nursing considerations/ Patient Teaching dont take with hyperthyroidism, low
potassium, kidney or heart disease.
Name Ipratropium
Concentration: 2.5 ml
Dosage 2.5ml
Route inhalation
Frequency PRN
Pharmaceutical class Anticholinergic Hospital
Indication: Helps control symptoms of lung diseases.
Adverse/ Side effects: dry mouth, eye pain, blurred vision, dizziness, tachycardia,
trouble urinating or passing stools, worsening asthma symptoms.
Nursing considerations/ Patient Teaching: This medication will not stop an asthma
attack that has already started. Dont take stop corticosteroids treatments if you use
corticosteroids to treat your asthma.
Name Docusate
Concentration 100 mg
Dosage 200 mg
Route oral
Frequency PRN
Pharmaceutical class: sulfonic acids Hospital
Indication: stool softener
Adverse/ Side effects: bitter taste, bloating, cramping, diarrhea, and irritation in throat.
Nursing considerations/ Patient Teaching
Dont use if you have abdominal pain, nausea, or vomiting.

Name Enoxaparin
Concentration 0.4ml
Dosage 0.4 ml
Route subcutaneous
Frequency QPM
Pharmaceutical class low molecular
Hospital
weight heparin
Indication unstable angina
Adverse/ Side effects: hematuria, black stools, chest pain , fever, coughing up blood
Nursing considerations/ Patient Teaching: High risk if you have hypertension,
hemophilia, diabetes, and if you have a catheter.
Name Oxazepam
Route g tube
Pharmaceutical class
Benzodiazepine
Indication anxiety

Concentration 10 mg
Dosage 10 mg
Frequency PRN
Hospital

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects depression, confusion, hallucination, slurred speech, irregular

heart beat.
Nursing considerations/ Patient Teaching: talk with your doctor if you have
glaucoma, liver or kidney disease.

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR

analysis with recommendations.
Diet ordered in hospital? 2200 calorie carb
controlled
Diet patient follows at home? Lives at
hospital(same diet)
24 HR average home diet:
Breakfast: Eggs, white toast with butter,
sausage, ketchup

average home diet, and your nutritional

Analysis of home diet (Compare to My
Plate and
Consider co-morbidities and cultural
considerations):

Lunch: hamburger and French fries

Dinner: meatloaf with mashed potatoes
and green beans
Snacks: chocolate cake
Liquids (include alcohol): water, chocolate
milk, cranberry juice
According to choosemyplate.gov, my
patient should be eating 6 oz of grains, 2.5
cups of vegetables, 2 cups of fruit, 3 cups
of dairy, and 5.5 oz of protein. My patient
eats about 6 oz of grains, 2.25 cups of
vegetables, a half of a cup of fruit, 1 cup of
dairy, and 7.5 oz of protein. Over all, my
patient is right on track with his grains, and
vegetables. My patient is under what he
needs to be taking in on fruits and dairy.
My patient is also over on proteins. I think it
is okay that my patient if over on proteins
because choosemyplate.gov hasnt taken
into consideration he is recovering from a
stage 3 pressure ulcer. The increase in
protein is good for healing. I would suggest
for my patient that he eats more fruit and
less fried food such as fries. It is very
important for him to have a healthy diet
right now in his state of healing. Instead of
chocolate milk he should drink skim milk,
and more of it. This could help with his
bone rigidity and low calcium. Finally, due
to my patients condition he cannot go out
and exercise; so I would encourage
physical therapy to come and work with
him.
University of South Florida College of Nursing Revision September 2014

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help

guide your discussion)
Who helps you when you are ill?
My dog Fallon.
How do you generally cope with stress? or What do you do when you are upset?
I used to go read when I couldnt sleep. I like to sleep with Fallon in my bed. I tuck him
in the covers and pushes me out of the bed sometimes.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships,

friends, social life)
I look around me and everyone is getting worse. But me, Im getting better. I wish I
could just go home and be with my dog.

+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 never
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? Im not in a relationship.

University of South Florida College of Nursing Revision September 2014

 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 Integrity vs. X 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: In integrity versus despair, an older adult would reflect on their life
and decide if it was fulfilling or if it was wasted. The term integrity comes from the
sense of accomplishment one might feel with their life as it gets closer to the end. The
word despair describes the state of depression or incompleteness that may occur if
someone doesnt feel happy with their life choices as a whole. (Eriksons, 2011)
Describe the stage your patient is in and give the characteristics that the patient exhibits
that led you to your determination:
My patient, at first, seemed to be exhibiting integrity. He would tell me elaborate
stories of how he went to school to be an engineer and flew planes for the air force. Then
he would say things like I look around and everyone around me are getting worse;
which changed the energy to a more depressed feeling. After looking into his chart I
found that he really didnt do half of the things he said he did, and that most of what he
told me was made up. This lead me to conclude that he is actually in a despaired state,
in which he feels he has to lie to keep up his morale. Overall I think he is displeased with
the way he lived his life and wishes he could have done a lot of the things he pretends
he has done.
Describe what impact of disease/condition or hospitalization has had on your patients
developmental stage of life:
My patients extreme decrease in mobility prevents him from going out and
accomplishing and even making right the things he hasnt done or maybe even feels
guilty for. My patient I snow extremely dependent on other people and expresses the
sense that maybe he would have lived his life differently had he the chance.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I guess the doctors say its from being a pilot and sitting for 4000 hours in a small
plane. I dont know.

What does your illness mean to you?

Its not fair. I used to be able to walk and feed myself.

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10

+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 of course._
Are you aware of ever having a sexually transmitted infection?
__REFUSED_
Have you or a partner ever had an abnormal pap smear?_____
I dont know.
Have you or your partner received the Gardasil (HPV) vaccination? _________
I dont know.
Are you currently sexually active? _______no__
If yes, are you in a monogamous relationship? n/a_
_ When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? No answer
How long have you been with your current partner? I dont have a current partner.
Have any medical or surgical conditions changed your ability to have sexual activity?
________yes___________________
Do you have any concerns about sexual health or how to prevent sexually transmitted
disease or unintended pregnancy?
no

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11

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

What importance does religion or spirituality have in your life?
___I dont know anymore.__________________________________________________
__________________________________________________________________________________________
____________
Do your religious beliefs influence your current condition?
___I dont think so._____________________________________________________
__________________________________________________________________________________________
____________
+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
No
How much?(specify daily
For how many years?
If so, what?
amount)
X years
(age
thru
N/A
N/A
)N/A
If applicable, when did
the patient quit?N/A

Pack Years:N/A
Does anyone in the patients household
smoke tobacco? If so, what, and how much?
N/A

Has the patient ever tried to quit?

If yes, what did they use to try to quit?N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
No
What?N/A
How much? N/A
For how many years?
(age
thru
Volume:N/A
)N/A
Frequency:N/A
If applicable, when did the
patient quit?
N/A
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?
No
If so, what?N/A
How much?N/A
For how many years? N/A
(age
thru
)
Is the patient currently using
these drugs?
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
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12

Well I was shot at in planes all the time if that counts.

5. For Veterans: Have you had any kind of service related exposure?
I was the pilot so I was always being shot at.

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13

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health?
As good as it gets for me I guess.
Integumentary: Patient denies problems with dandruff, psoriasis, hives or rashes, and
skin infections. Patient presents with a stage 3-pressure ulcer on sacrum, clubbing, and
sunburn. Mild bruising and edema present on right foot. Patient was not using sunscreen.
Patient is bathed Qdaily.
HEENT Patient denies difficulty seeing, cataracts, glaucoma, ear infections, sinus pain or
infection, nose bleeds, post- nasal drip, oral or pharyngeal infection, and dental
problems. Patients presents with difficulty hearing. Patients teeth are brushed Qdaily.
Patient is over due for both dentist visits and visin screening.
Pulmonary: Patient presents difficulty breathing and is on the ventilator QPM. Patient
denies cough, asthma, bronchitis, emphysema, pneumonia, TB, and environmental
allergies. Last CXR was 09/12/14.
Cardiovascular: Patient presents with hypertension and a history of a thrombus. Patient
denies hyperlipidemia, chest pain/angina, MI, CAD/PVD, CHF, murmur, rheumatic fever,
myocarditis, and arrhythmias. Patients last EKG screening was 3/26/14.
GI: Patient denies diarrhea, GERD, indigestion, hemorrhoids, yellow jaundice, pancreatitis,
colitis, diverticulitis, appendicitis, abdominal abscess, irritable bowel syndrome,
cholecystitis, gastritis/ulcers, blood in the stool, hepatitis, and constipation. Patient does
not remember when last colonoscopy exam.
GU: Patient denies noturia, dysuria, hematuria, polyuria, kidney stone, and bladder and
kidney infections. Patient is on catheter.
Men Only: Patient denies infection of male genitalia/prostate, BPH, and urinary retention.
Patient doesnt remember frequency or his last prostate exam.
Musculoskeletal: Patient presents with an injured foot from losing control of wheelchair
and crushing his foot into the wall. No strength or feeling in legs and feet bilaterally or
below diaphragm. Diminishing muscle strength in arms and hands bilaterally. Patient
denies pain and gout. Patient presents with osteomyelitis and arthritis.

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14

Immunologic: Patient denies chills with severe shaking, night sweats, fever, HIV or AIDS,
lupus, rheumatoid arthritis, sarcoidosis, tumor, life threatening allergic reactions,
enlarged lymph nodes.
Hematologic/Oncologic: Patient denies cancer and blood transfusions. Patient presents
with anemia, bleeding easily, and bruising easily. Blood type unknown.
Metabolic/Endocrine: Patient denies diabetes, hypothyroid/hyperthyroid, intolerance to
hot/cold, and osteoporosis.
Central Nervous System: Patient presents with spinal cord injury, loss of feeling and
movement in legs and partially in arms. Presents with tremors, headaches, and is at risk
for seizures. Patient denies dizziness, migraines, ticks, encephalitis, and meningitis.
Mental Illness: Patient denies schizophrenia and bipolar disorder. Patient presents with
anxiety and mild depression.
Childhood Diseases: Patient denies measles, mumps, polio, chicken pox, and scarlet
fever.

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

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

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10 PHYSICAL EXAMINATION:
General survey ________________Patient is very talkative and seems to be very awake and
oriented. _____________________________________________________________________
Height ________76 inches____Weight_224 IBS_________ BMI __27.3_________ Pain
(include rating and location)___0 out of 10 _______________ Pulse___94____ Blood
Pressure (include location)____135/80 right brachial___Temperature (route
taken)___98 F_________
Respirations____21________ SpO2 ______99___________ Room Air
________________________
Overall Appearance Patient is clean, hair combed, dressed appropriate for setting and
temperature, maintains eye contact, no obvious handicaps other than paralysis from
condition.________________________________________________________________________________.
______________________________________________________________________________
Overall Behavior____ Patient. is awake, calm, relaxed, interacts well with others,
judgment
intact.____________________________________________________________________________________
_______
Speech Patient's speech is clear, crisp diction
_____________________________________________________________________________________
Mood and Affect______ Patient is talkative, cooperative, and boisterous.
Integumentary_ Skin is warm, dry and intact, skin turgor is elastic, no rashes, lesions or
deformities (other than stage 3 pressure ulcer on sacrum, nails with clubbing, capillary
refill 3 seconds, hair is evenly distributed, clean, without vermin.
___________________________________________________________________________________
IV Access No IV inserted at this time.
HEENT_ Patient's facial features are symmetric, no pain in sinus region, no pain or
clicking of TMJ, trachea midline, thyroid not enlarged, no palpable lymph nodes, sclera is
white and conjunctiva is clear and without discharge, eyebrows, eyelids, orbital area,
eyelashes, and lacrimal glands symmetric without edema or tenderness, PERRLA pupil
size 5 mm, peripheral vision intact, EOM intact through 6 cardinal fields without
nystagmus, ears symmetrical without lesions or discharge, whisper test heart 10 inches
away in both ears, nose without lesions or discharge, lips, buccal mucosa, floor of mouth
& tongue pink & moist without lesions.____________
__________________________________________________________________________________________
Pulmonary/Thorax__ Respirations are regular and unlabored, transverse to AP ratio 2:1,
chest expansion is symmetric, lung sounds are all clear, no sputum production
______________________________________________________________________________
Cardiovascular_ No lifts, heaves, or thrills, PMI felt, Heard S1 and S2 sounds, no
murmurs, clicks, or adventitious heart sounds, no JVD. Calf pain bilaterally negative,
pulses bilaterally equal (3 normal), apical pulse:3, carotid:3, brachail:3, radial:3,
femoral:3, popliteal:3, DP: (could not take due to injury), PT: (could not take due to injury),
no temporal or carotid bruits, edema is mild 1+, edema in right lower extremity (nonpitting), extremities warm with capillary refill of 3 seconds.
___________________________________________________________________________________________
____________________________
GI__ Bowel sounds active x 4 quadrants, no bruits auscultated, no organomegaly,
percussion dull over liver and spleen and tympanic over stomach and intestine, abdomen
University of South Florida College of Nursing Revision September 2014
16

is nontender to palpation.
Cant recall last BM.
GU_Urine output is clear, 24 hour output 1000 mL, folly catheter, CVA punch without
rebound tenderness.
Musculoskeletal__ Strength at 1 RUE, 1 LUE, 0 RLE and 0 LLE. Vertebral column without
kyphosis or scoliosis, neurovascular status intact: peripheral pulses palpable, no pallor,
but presents with paralysis. Patient has no pain and parathesias in his extremities.
___________________________________________________________________________________
Neurological Patient is awake, alert, oriented to person, place, time, and date, CN 2-12
grossly intact, sensation intact to touch, pain, and vibration everywhere besides
extremities, Unable to test Romberg, sterognosis, graphesthesia, and propioception intact,
regular with symmetric length of the stride, DTR: , triceps: +1, biceps: +1, brachioradial:
0, patellar: 0, achilles: 0 ankle clonus: negative, Babinski: negative. Unable to perform
gait because of surgery.

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
11/03/2014
WBC 5.61
BASO .03
EOS .17
RBC 3.89
SODIUM 139
GLUCOSE 100
CO2 26
MAGNESIUM 2.1

CALCIUM 8.8 (LOW)

Dates
(11/01/2014)

Trend

Analysis

All remained stable.

This shows no
present risk of
infection.
Magnesium may be
at risk for
decreasing due to
low calcium and
potassium. RBC
count is also at risk
due to anemia.

Calcium is trending
downward.

The calcium could

be decreasing due
to the Amlodipine
that the patient is
taking. Amlodipine is
a calcium channel
blocker used for BP.

(11/03/2014)

(11/01/2014)
(11/03/2014)

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POTASSIUM 3.4
(LOW)

(11/01/2014)

Potassium is
trending downward.

(11/03/2014)
HCT 34.1 (low)

(11/01/2014)

HCT is trending
downwards.

(11/03/2014)

Potassium could be
affected by patients
use of stool softener
and dehydration.
HCT could be
directly affected by
patients anemia.

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

scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and
frequency if applicable.)
Patient has a Foley which is changed Q4 weeks to prevent infection.
Patient is on ventilator at night
Patient gets bowel care three times a week.
Patient receives respiratory treatment.
Patient gets sacral wound care, which consists of cleaning, xeroform and sacral mepilex
three times a week.
Patient is ordered to keep HOB as low as possible for healing of sacral wound.
Patients diet consists of 2200-calorie carbohydrate controlled diet.
Patient mobilizes with chair and is free to leave hospital with CAN.

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

1. Impaired skin integrity R/T immobility as evidence by open lesion involving dermis.
((Ackley, 2014)
2. Impaired mobility R/T muscle weakness as evidence by paralysis.
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3.
4.
5.

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 15 CARE PLAN
Nursing Diagnosis: Nursing Diagnosis goes here
Patient
Nursing
Rationale for
Evaluation of
Goals/Outcomes
Interventions to
Interventions
Goal on Day Care
Achieve Goal
Provide
is Provided
References
Improve healing of
Increase calorie and Carbohydrates are
Patient will be able
patients stage 3
fluid intake.
one of the main
to lower his risk of
sacral pressure ulcer
energy sources for
infection when
over the next few
cells, so increasing
healed and feel
months.
carbohydrates will
less restricted in
help speed up the
positioning and
process of healing.
constant rotations.
Fluid keeps the cells
hydrated because
most of our body is
made of water; we
need to stay
hydrated for all
processes in our
body to function
properly. (Greiger,
2011)
Keep HOB low as
Keeping the HOB low The wound should
much as possible.
will decrease the
heal faster and
pressure on the
decrease risk of
patients sacrum.
infection when
healed.

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)
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Consider the following needs:

X SS Consult *
X Dietary Consult *
X PT/ OT*
Pastoral Care
X Durable Medical Needs *
X F/U appointments *
X Med Instruction/Prescription *
are any of the patients medications available at a discount pharmacy? *Yes
No
X Rehab/ HH *
X Palliative Care *

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References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed., pp. 548-555). United
States: Mosby, an imprint of Elsevier Inc.
Choose My Plate. Retrieved November 1, 2014, from
www.choosemyplate.gov
Davis's Drug Guide for Nurses (Thirteenth edition), (2014). F.A. Davis Company
Eriksons Stages of Psychosocial Development. (2011, November 29). Retrieved November 1, 2014, from
http://allpsych.com/psychology101/social_development.html
Greiger, Lynn. Nutrition and Wound Care. (2011, August). Retrieved November 1, 2014, from
http://www.todaysdietitian.com/newarchives/072709p12.shtml

Nursing Central by Unbound Medicine: Cervical spondylosis. (2014). (ver. 1.610.627) [Mobile Application Software] Retrieved from
http://nursing.unboundmedicine.com/nursingcentral/

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