UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Christina Weyant

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION
Patient Initials:
Gender:

Female

Assignment Date: 10/15/14

Agency: Morton Plant Hospital

Age:

Admission Date:

Marital Status:

Primary Medical Diagnosis:

Osteoarthritis requiring bilateral hip replacement

Primary Language: English

Level of Education:

Other Medical Diagnoses: (new on this admission)

None

Occupation (if retired, what from?):

Number/ages children/siblings:.

Served/Veteran:
If yes: Ever deployed? Yes or No

Code Status: Full code

Living Arrangements: Patient lives alone in a house with three

dogs, and two cats.

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: Procedure: Total
left hip replacement

Culture/ Ethnicity /Nationality:

Religion: t

Type of Insurance:

1 CHIEF COMPLAINT:
The patient states Dr.. I was in intense pain, and having difficulty walking because of my hips. He sent me in.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient has osteoarthritis requiring bilateral total hip replacements. Right hip replacement was done on. Left hip
replacement was done on.
Onset: Pain began 4 years ago
Location: Pain is in both hips, and the lower back
Duration: constant
Characteristics: Severe aching
Aggravating factors: walking, sleeping on side.
Relieving factors: stretching, sleeping on back.
Treatment: stretching, Meloxacam PO (by mouth) daily, Tramadol PO BID (twice daily)
Tests; multiple hip X-rays
Diagnosis: Osteoarthritis. No cartilage present in either hip.
Plan: bilateral hip replacement.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Operation or Illness

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

N/A

Paternal
grandmother
cousin

Bleeds Easily

Sister

Asthma

N/A

Arthritis

Brother

Father

Anemia

Mother

Cause
of
Death
(if
applicable
)
Lung
cancer
cirrhosis

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Alcoholism

Osteoarthritis
Total right hip replacement
Breast augmentation
hysteroectomy
leiomyomata uteri
Tonsillectomy

relationship

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations U
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) 2004
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

NO

X
X
X
X

University of South Florida College of Nursing Revision September 2014

X
X
X

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

None
Medications

None

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)
Osteoarthritis is a degenerative disorder of synovial joints. It is characterized by an enzymatic destruction of articular
cartilage, exposing the underlying bone which then becomes sclerotic. Osteophytes begin to grow on the bone, changing
its shape. These osteophytes can also break off into the synovial cavity and cause inflammation. The joint capsule then
becomes thickened, and begins to adhere to the deformed bones which can reduce movement (Huether & McCance,
2008).
Risk factors for osteoarthritis include being over the age of 40, putting excessive strain on joints such as with athletes,
previous trauma to the joints, inflammation in the joints, joint instability, obesity, neurologic disorders such as diabetic
neuropathy, skeletal deformities, hematologic or endocrine disorders, and the use of drugs that stimulate the collagendigesting enzymes in the synovial membrane (Huether & McCance, 2008).
Diagnosis is done through assessment of the musculoskeletal system, CT scans, arthroscopy, and MRI (Huether &
McCance, 2008).
Treatment includes rest of joint until inflammation is reduced, range of motion to prevent joint capsule contraction, use of
assistive equipment such as a cane or crutches to limit weight bearing in the lower extremities, weight loss if the person is
obese, pharmacological intervention with the use of analgesics, anti-inflammatory drugs, glucosamine, and chondroitin.
Intra-articular injections, and surgical interventions may also be done (Huether & McCance, 2008).

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
Route

Meloxicam

N/A

PO

Pharmaceutical class
Indication

Concentration

Dosage Amount
Frequency

Non-steroidal anti-inflammatory drug

Home

Hospital

15mg

Once daily
or

Both

Arthritis

Adverse/ Side effects Diarrhea, constipation, gas, sore throat, cough, runny nose, fever, blisters, rash, hives, itching, swelling of the eyes, face, tongue, lips,
throat, arms, hands, feet, ankles, or lower legs, difficulty breathing or swallowing, hoarseness, pale skin, rapid heartbeat, weight gain, nausea, excessive
tiredness, yellowing of the skin or eyes, pain in the right upper part of the stomach, flu-like symptoms, cloudy, discolored, or bloody urine, back pain, and
difficult or painful urination.
Nursing considerations/ Patient Teaching Call your doctor if you experience any adverse effects. Store the medication at room temperature and away from

University of South Florida College of Nursing Revision September 2014

moisture. Do not let anyone take your medication. People who take meloxicam are at a higher risk for heart attack. Tell your doctor if you or anyone in your
family has heart disease, stroke, if you smoke, have high cholesterol, high blood pressure, or diabetes. Seek medical attention if you experience chest pain,
shortness of breath, weakness in one side of the body, or slurred speech. If you are undergoing a coronary artery bypass graft do not take meloxicam right
before or right after the surgery. Meloxicam may cause ulcers, bleeding, or holes in the stomach or intestine. Do not take meloxicam with anticoagulants, other
NSAIDs, or oral steroids.
Name

Tramadol

Route

PO

Concentration

Pharmaceutical class Opioid Analgesic

Indication

Dosage Amount

Home

Frequency

Bid

Hospital

or

Patient unsure

Both

Arthritis pain

Adverse/ Side effects Dizziness, weakness, sleepiness, difficulty falling asleep or staying asleep, headache, nervousness, uncontrollable shaking of a part of the
body, muscle tightness, changes in mood, heartburn or indigestion, nausea, vomiting, diarrhea, constipation, loss of appetite, sweating, dry mouth, seizures,
fever, hives, rash, blisters, difficulty swallowing ot breathing, swelling of the eyes, face, throat, tongue, lips, hands, feet, ankles, or lower legs, hoarseness,
hallucinations, agitation, loss of consciousness, lack of coordination, fast heartbeat
Nursing considerations/ Patient Teaching Call doctor if you experience any serious side effects. Tell doctor if you have an opioid allergy. Tell doctor all of the
medications you are taking including prescription, over the counter, and herbal supplements. Tell your doctor if you have slowed breathing, lung disease,
asthma, seizures, any history of increased intracranial pressure. Do not drive or operate heavy machinery, do not drink alcohol or take street drugs while taking
this medication. Do not take this medication if you have phenylketonuria (PKU). Tell your doctor if you are pregnant, or breast feeding. Tell doctor if you have a
history of depression or suicidal ideation.

Name

docusate (Colase)

Route

PO

Concentration

Dosage Amount 100mg

Frequency Bid

Pharmaceutical class Stool softener

Home

Hospital

or

Both

Indication constipation prevention

Adverse/ Side effects rectal bleeding or irritation, numbness or a rash around your rectum, severe diarrhea or stomach cramps, continued constipation,
diarrhea, nausea.
Nursing considerations/ Patient Teaching Do not use if you are allergic to docusate, or if you have an intestinal obstruction. Do not use mineral oil while using
docusate. Tell your doctor if you are on a low salt diet, are pregnant or breastfeeding, or had a sudden change in bowel movements lasting longer than two
weeks.
Name hydormorphone (Dilaudid)

Concentration

Dosage Amount 0.2 mg/mL 10 mg

Route PCA (patient controlled analgesia)

Frequency PRN

Pharmaceutical class Opioid analgesic

Home

Hospital

or

Both

Indication Pain management

Adverse/ Side effects nausea, vomiting, headache, difficulty falling asleep or staying asleep, loss of appetite, dry mouth, lightheadedness, dizziness, drowsiness,
heavy sweating, muscle, back or joint pain, stomach pain, anxiety, flushing, itching, depression, rash, hives, swelling of the eyes, lips, tongue, mouth, throat,
ankles, and lower legs, difficulty breathing or swallowing, hoarseness, seizures, chest pain, extreme drowsiness, fainting, lightheadedness when changing
positions.
Nursing considerations/ Patient Teaching Hydromorphone may cause serious or life-threatening breathing problems. Do not take with antidepressants, other
narcotic pain medications, medications for anxiety, nausea, or mental illness, muscle relaxants, sedatives, sleeping pills, or tranquilizers. Do not drink alcohol.
Do not drive or operate heavy machinery. Hydromorphone may be habit-forming. Tell your doctor if you are pregnant or plan to become pregnant.

Name omeprazole (Prilosec)

Route

Concentration

Dosage Amount 20 mg

PO

Frequency

Pharmaceutical class Proton pump inhibitor

Home

Hospital

Once daily
or

Both

Indication treat the symptoms of GERD

Adverse/ Side effects constipation, gas, nausea, vomiting, headache, rash, hives, itching, swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, and
lower legs, difficulty breathing or swallowing, hoarseness, irregular, fast, or pounding heartbeat, excessive tiredness, dizziness, lightheadedness, muscle spasms,
uncontrollable shaking of a part of the body, seizures, diarrhea with watery stools, stomach pain, fever.
Nursing considerations/ Patient Teaching Tell you doctor if you are allergic to omeprazole, tell your doctor about any other medications you are taking including
over the counter, and herbal supplements. Tell your doctor if your heartburn has lasted 3 months or longer. Tell your doctor if you are pregnant or may become
pregnant. Tell your doctor if you are of Asian descent, have low magnesium, or have liver disease.

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Regular diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home?
Regular diet
Consider co-morbidities and cultural considerations):

University of South Florida College of Nursing Revision September 2014

24 HR average home diet:

Breakfast: Corn flakes, one bowl with whole milk. One
cup of yogurt.

Client is undernourished in all major food groups. The

patient only consumes 824 of the recommended 2000
calories. This diet only has 3 ounces of grains compared
to the recommended 6 ounces, cup of vegetables to the
recommended 2 cups , 1 cup of fruits compared to the
recommended 2 cups of fruit, 1 cups of dairy to the
recommended 3 cups, and 2 ounces of protein compared to
the recommended 5 ounces.

Lunch: Patient usually skips lunch

Dinner: Tuna sandwich with 1 tbs mayonnaise, 1 can of
tuna, and two slices of wheat bread.
Snacks: none
Liquids (include alcohol): one large cup of coffee. One cup
of orange juice. Eight glasses of water.
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as 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 My little brother lives on the next street over. His wife, my sister-in-law also helps me. I have a really good
friend, Josie, who lives a street over that helps me too.
How do you generally cope with stress? or What do you do when you are upset?
Patient states I walk around the house, or play with my dogs. Before my hips got bad, I would take a walk around my
neighborhood.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient states Only one day I was a little down, but generally no. I was just feeling old, and not being able to walk was
frustrating.

+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.

University of South Florida College of Nursing Revision September 2014

Have you ever felt unsafe in a close relationship? _No_

Have you ever been talked down to? Patient states Sometimes at work
Have you ever been hit punched or slapped? Patient states One time, an old boyfriend in the 80s
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_Patient states Just the one boyfriend in the 80s__ If yes, have you sought help for this? __Patient states yes, I went
to counseling___
Are you currently in a safe relationship? Patient states No I am not in a relationship, but thats the safest kind right?

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is in the psychosocial stage of generativity vs. stagnation. This stage occurs in middle adulthood, and involves
either generativity which is gaining fulfillment in ones life, and contributing to the next generation, or stagnation which is
a lack of fulfillment or productivity (Slater, 2003). Generativity can be accomplished through raising children, fulfillment
at work, or community service. I feel that this patient is in the stagnation stage. She never had children or a family, and
therefore does not receive fulfillment from raising children. She also never finished her college degree, and expresses
regret for never going back to school. She has a job that she described as dull, and unfulfilling, and she has limited
community involvement. She does receive a limited amount of fulfillment from taking in animals that have been
abandoned; however I do not feel that the client views taking care of her animals as sufficient to have a fulfilling life.

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

I believe this clients disease process has a minimal impact on her developmental stage. The only way I could foresee it
affecting her developmental stage is a lack of community involvement due to her decreased ability to walk.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The patient states Arthritis caused my illness. The cartilage is gone in both my hips. Probably sitting at a computer for so
many years for work. Heredity also probably plays a part. My grandmother and cousin have the same problem.
What does your illness mean to you?
The patient states It made me reevaluate planning for the future, and getting older. I didnt think it would happen to me.
It has just been a lot of lifestyle adjustments.

+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

University of South Florida College of Nursing Revision September 2014

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? ____men, heterosexual__
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? __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? __Patient uses a condom__
How long have you been with your current partner? __N/A_
Have any medical or surgical conditions changed your ability to have sexual activity? ___Patient states My hip pain
makes it difficult.__
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision September 2014

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

What importance does religion or spirituality have in your life?
_____Patient states It is important__________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
___Patient states It helps me, it keeps me calm and positive___________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)
N/A
N/A

Yes
No
For how many years? 0 years
(age

thru

N/A
If applicable, when did the
patient quit? N/A

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

Has the patient ever tried to quit?

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?
Yes
What?
How much?
Jose Cuervo, and a shot of Amaretto
Volume: one or two margaritas
Frequency: every Sunday
If applicable, when did the patient quit?
N/A

No
For how many years? 38 years
(age

20

thru

current

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
N/A
How much?
For how many years? 0
(age
thru
)
N/A
N/A
Is the patient currently using these drugs?
If not, when did he/she quit?
Yes No
N/A
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
None
5. For Veterans: Have you had any kind of service related exposure?
N/A

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health? its good

Integumentary: Patient indicates thickening of the big toe nails, and dandruff. Patient denies changes in
appearance of skin, psoriasis, hives or rashes, and skin infections. Patient uses SPF 20 sunscreen when she goes
out in the sun. Her bathing routine includes showering every morning, and sometimes at night.
HEENT: Patient indicates difficulty seeing, and uses corrective lenses. She denies cataracts, glaucoma, difficulty
hearing, ear infections, sinus pain or infections, nose bleeds, post-nasal drip, oral/pharyngeal infection, and
dental problems. Patients dental routine involves brushing her teeth two to three times daily. Patient visits
dentist every three months for cleanings. Patients last vision screening was 10 years ago.
Pulmonary: Patient denies difficulty breathing, cough, asthma, bronchitis, emphysema, pneumonia, tuberculosis,
and environmental allergies. Patients last CXR (chest x-ray) was in July 2014.
Cardiovascular: Patient denies hypertension, hyperlipidemia, chest pain or angina, myocardial infarction,
coronary artery disease, peripheral vascular disease, congestive heart failure, murmur, thrombus, rheumatic
fever, myocarditis, and arrhythmias. Last EKG (electrocardiogram) was July 2014
GI: Patient has gastroesophageal reflux disease. Denies nausea, vomiting, diarrhea, constipation, irritable
bowel, indigestion, cholecystitis, hemorrhoids, gastric ulcers, blood in stool, yellow jaundice, hepatitis,
pancreatitis, colitis, diverticulitis, appendicitis, abdominal abscess. Patient is unsure of last colonoscopy.
GU: Patient has nocturia, usually gets up twice a night. Denies dysuria, hematuria, polyuria, kidney stones, and
bladder or kidney infections. Normal frequency of urination is 5-7 times a day.
Women/Men Only: Patient does monthly self-breast exam. Patient denies infection of the female genitalia.
Patients last gynecological exam was 2 years ago. Frequency of pap/pelvic exams is every 2-3 years. Patients
last menstrual cycle was 8 years ago before her hysterectomy. Patients menarche was 12 years old, menopause
was 50 years old after her hysterectomy. Last mammogram was in 2010, and it was clear. Last DEXA bone
density was in July 2014, and the results showed onset of osteoporosis.
Musculoskeletal: Patient indicates arthritis in both hips, low back, and hands, and pain in lower back and both
hips. Patient denies injuries or fractures, weakness, gout, osteomyelitis.

University of South Florida College of Nursing Revision September 2014

Immunologic: Patient denies chills, night sweats, fever, HIV or AIDS, lupus, rheumatoid arthritis, sarcoidosis,
tumor, life threatening allergic reaction, and enlarged lymph nodes.
Hematologic/Oncologic: Patient used to be anemic, but the problem has resolved. Patient denies easy bleeding,
easy bruising, cancer, and blood transfusions. Patient is unsure of her blood type but reports it is the most
common one.
Metabolic/Endocrine: Patient has signs of onset of osteoporosis. Patient denies diabetes, hypothyroid and
hyperthyroid, and intolerance to heat or cold.
Central Nervous System: Patient has severe headaches a few times a year. Patient denies cerebrovascular
accident, dizziness, migraines, seizures, ticks or tremors, encephalitis, and meningitis
Mental Illness: Patient denies depression, schizophrenia, anxiety, and bipolar.
Childhood Diseases: Patient had measles, mumps, and chicken pox. Patient denies polio, and scarlet fever.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
None

Any other questions or comments that your patient would like you to know?
Acid reflux was a concern, but it is going away.

10 PHYSICAL EXAMINATION:
General survey: Patient is thin year old who is pleasant, alert, and orientated x3
Height: 56
Weight: 125 lbs
BMI: 20.2
Pain (include rating and location): The patient reports pain of a 3 out of 10 in the left hip, and lower back
Pulse: 64
Blood Pressure (include location): 90/55 right upper arm

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10

Temperature (route taken): 98.4 oral

Respirations: 14
SpO2: 99%
Room Air or O2: room air
Overall Appearance: Patient is clean, with hair brushed and pulled back, make-up done, and dressed appropriately. Patient
maintains eye contact, and shows no obvious handicaps.
Overall Behavior: Patient is awake, calm, relaxed, interacts well with others, and her judgment is intact.
Speech: Patient has clear, crisp diction.
Mood and Affect: Patient is pleasant, cooperative, cheerful, and talkative.
Integumentary: Skin is warm, and dry. There is a surgical incision on the left hip, dressing is dry and intact. Hemovac in
the left hip incision. Drainage sanguineous. Skin turgor is elastic, no rashes, lesions, or deformities present. There is no
clubbing, capillary refill was greater than 3 seconds in hands, nail beds and fingertips were pallor, and hands were cool to
the touch. Capillary refill was less than 3 seconds in the feet. Hair evenly distributed, clean, and without vermin.
IV Access: 20 gauge IV in left hand placed on 10/14/14. There is no redness, edema, or discharge present. Fluid infusing is
Lactated Ringhers and 5% dextrose. Dilaudid PCA
HEENT: Facial features are symmetric, patient reports no pain in sinus region, there is some slight clicking of the
temporomandibular joint, trachea is midline, thyroid not enlarged, no palpable lymph nodes, sclera is white and conjunctiva
clear; there is no discharge present in the eyes. Eyebrows, eyelids, orbital area, eyelashes, and lacriminal glands symmetric
without edema or tenderness, PERRLA (pupils equal, round, reactive to light, and accommodation) , peripheral vision
intact, extraocular muscles intact through all 6 cardinal fields without nystagmus, ears are symmetric without lesions or
drainage, whisper test heard at 6 inches in the left and right ear, nose is without lesions or discharge. Lips, buccal mucosa,
floor of mouth, and tongue are pink and moist without lesions. Teeth are intact with slight yellowing of the enamel.
Pulmonary/Thorax: Respirations are regular and unlabored, the transverse to anterior/posterior ratio is 2:1, and chest
expansion is symmetric. Percussion is resonant throughout all lung fields, and dull towards the posterior bases. Lung sounds
are clear in right upper lobe, right middle lobe, right lower lobe, left upper lobe, and left lower lobe. No sputum production
is present.
Cardiovascular No lifts, heaves, or thrills are present. S1 and S2 heart sounds are audible, rate and rhythm is regular, no
murmurs, clicks, or adventitious heart sounds were present. No jugular venous distention present. Patient is not on Tele, and
has no ECG. Calf pain is negative bilaterally. Pulses are equal bilaterally, and 2+ for carotid, brachial, radial, femoral,
popliteal, posterior tibialis, and dorsalis pedis. There are no temporal or carotid bruits present. Edema is present in the
ankles bilaterally and graded 1+ with no pitting. Upper extremities are cool to the touch. Capillary refill in the upper
extremities is 3 seconds. Lower extremities are warm to the touch with capillary refill less than 3 seconds.
GI: Patient has bowel sounds present in all 4 quadrants. Patient has no bruit present in the abdominal area. There is no sign
of organomegaly. Percussion is dull over the liver and the spleen, and tympanic over the stomach and intestines. Patient
reports no abdominal tenderness upon palpation. Patients last bowel movement was 10/14/14 at 9:30 a.m. The stool was
semi-formed and light brown. Patient denies nausea, and emesis. Genitalia are clean, moist, without discharge, lesions, or
odor.
GU: Urine is clear and dark amber in color. Patient has a Foley catheter, and the previous 24 hour output is 900 mLs.
Musculoskeletal: Patient has full range of motion in both upper extremities, and right lower extremity. The left lower
extremity was not assessed due to full left hip replacement. Strength is equal bilaterally in the upper extremities, and rated
at a 5 for the right and left upper extremities. Strength is not equal bilaterally in the lower extremities. The right lower
extremity is rated at a 5, and the left lower extremity is rated at a 4. There was no evidence of kyphosis or scoliosis in the
spinal column. The patients neurovascular status is intact with peripheral pulses palpable at 2+, and no pain, paralysis, or
paresthesia present. Slight pallor is present in the hands.
Neurological: Patient is awake, alert, and oriented to person, place, time, and date. Patient is not confused. Cranial nerves
2-12 are grossly intact. Sensation is intact to touch, pain, and vibration. Rombergs is negative. Stereognosis, graphesthsia,
and proprioception are intact. Gait is smooth, regular with symmetric length of stride.

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):
University of South Florida College of Nursing Revision September 2014

11

Lab
WBC (white blood cell)

Dates
10/8/14
10/15/14

L 3.9
5.6

RBC (red blood cell)

4.03
L3.36

10/8/14
10/15/14

HGB (hemoglobin)
12.7
L10.3

10/8/14
10/15/14

MCV
91.8
91.0

10/8/14
10/15/14

MCH
31.4
30.6

10/8/14
10/15/14

MCHC
34.2
33.7

10/8/14
10/15/14

Trend
The pre-op blood work
shows that the patients
white blood cells were a
little low, but not by
much. The post-op blood
work should that the
white blood cell count
has increased, but not to a
point outside the normal
range.
The patients pre-op
blood work shows that
the red blood cells are
within the normal range.
The post-op blood work
shows that the RBC has
dropped below the
normal range.
The pre-op blood work
should the patients
hemoglobin to be in the
normal range. The postop blood work shows that
the patients hemoglobin
has dropped below the
normal range.
Both the pre-op, and postop values are in the
normal range, and the
values did not change
significantly from pre-op
to post-op.
Both the pre-op, and postop values are in the
normal range, and the
values did not change
significantly from pre-op
to post-op.

Analysis
The WBC may have
increased in response to
the tissue damage from
the patients left hip
replacement. They,
however, are not high
enough to indicate an
infection is present.
The drop in red blood
cells is most likely due to
blood loss related to the
patients left total hip
replacement.

The drop in hemoglobin

is most likely due to
blood loss related to the
patients left hip
replacement.

The MCV is a measure of

the size of the patients
red blood cells. These lab
values indicate that the
patients red blood cells
are normocytic.
The MCH is a measure of
the amount of
hemoglobin in the
patients red blood cells.
These lab values indicate
that the patients red
blood cells are
normochromic.
Both the pre-op, and post- The MCHC is a measure
op values are in the
of the concentration of
normal range, and the
the hemoglobin in the red
values did not change
blood cell. These values
significantly from pre-op indicate that the patients
to post-op.
red blood cells are
normochromic.

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RDW (red blood cell

distribution width)
13.2
13.4

10/8/14
10/15/14

Both the pre-op, and postop values are in the

normal range, and there
was no significant change
between pre-op, and postop values.

PLT (platelet)
175
153

10/8/14
10/15/14

MPV (mean platelet

volume)
9.1
8.6

10/8/14
10/15/14

Both the pre-op and postop values are in the

normal range, but the
post-op value is on the
lower end of the normal
range. There was a drop
in PLT from the pre-op to
the post-op values.
Both the pre-op and postop values are in the
normal range. There was
a slight drop in MPV
from the pre-op to the
post-op values.

These values indicate that

the red blood cell
distribution width is
normal. Based on this lab
value there is no
indication of nutritional
deficient anemia.
The decreased platelet
count is most likely due
to increased clotting near
the site of the surgical
incision, and blood loss
related to the left total hip
replacement.
The decrease in platelet
volume from pre-op to
post-op is most likely due
to increased clotting
activity near the sight of
the surgical incision, and
some blood loss related to
the left total hip
replacement.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient is on a normal diet. Vitals are ordered q8 hr, activity is up to chair, up with assist, and walk in hallway
with physical therapy. Patient is to use incentive spirometer 10 times an hour. A consult to physical therapy is
ordered. CBC/PLT w/o differential (Hemogram w/ platelet) is ordered for 10/16/14 AM collect.

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

1.

Pain related to left total hip replacement as evidenced by pain reported at a 3 out of 10, grimacing upon movement,
and yelling in pain upon ambulation.

2. Fall risk related to left total hip replacement, and use of narcotics.
3. Risk for constipation related to decreased activity, and use of narcotics.

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 15 CARE PLAN
Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Pain management. Keep pain under Change position in bed.
Changing position in bed, and
a 2 while resting.
Use pillows to support left leg.
using pillows to support the left leg
Provide a soothing environment.
may help reduce the pressure on
Allow time for rest after
the left hip. Providing a soothing
ambulation.
environment will help the patient to
relax, and allowing time for rest
after ambulation will allow the
patient to recoup after a very
painful and strenuous activity.
Patient will not fall
Assist patient to ambulate.
Assisting the patient to ambulate
Instruct patient to call for help
will help prevent a fall, or allow
before attempting to get out of bed. the staff member to limit injury in
Use a bed alarm.
the event of a fall. Instructing the
Use non-skid footwear for the
patient to call for help, and using
client.
the bed alarm will reduce the
Keep environment free of clutter.
likelihood that the patient will
Ensure adequate lighting in the
ambulate without assistance. The
room before patient ambulation.
use of non-skid footwear will help
Maintain bed in low position.
prevent the patient from slipping.
Raise side rails near head.
Keeping the environment free of
clutter, and ensuring adequate
lighting will reduce tripping
hazards. Keeping the bed in the
low position, and raising the head
rails will prevent the patient from
falling out of bed, or reduce injury
in the event that the patient does
fall out of bed.
Patient will have soft, formed stool Facilitate patient activity.
High fiber diets, and adequate
every day without straining.
Ensure adequate hydration.
hydration will increase moisture
Patient Goals/Outcomes

University of South Florida College of Nursing Revision September 2014

Evaluation of Goal on Day Care

is Provided
Goal was achieved.

Patient goal was achieved for the

day.

Patient goal was not achieved by

the end of the shift.
15

Instruct patient to eat a high fiber

diet.

content of the stool, and increased

activity will encourage peristalsis.

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

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References
ChooseMyPlate.gov. (n.d.). Retrieved October 28, 2014, from http://www.choosemyplate.gov/index.html
Colace (docusate) medical facts from Drugs.com. (2014, September 26). Retrieved October 22, 2014, from
http://www.drugs.com/mtm/colace.html
Complete blood count (CBC). (2014, February 14). Retrieved October 28, 2014, from http://www.mayoclinic.org/testsprocedures/complete-blood-count/basics/results/prc-20014088
Complete Blood Count (CBC): Healthwise Medical Information on eMedicineHealth. (2014, January 1). Retrieved October 28, 2014,
from http://www.emedicinehealth.com/complete_blood_count_cbc-health/article_em.htm
Huether, S., & McCance, K. (2008). The Musculoskeletal and Integumentary System. In Understanding Pathophysiology (4th ed., pp.
1045-1048). St. Louis, Missouri: Mosby Elsevier
Hydromorphone: MedlinePlus Drug Information. (2014, September 24). Retrieved October 22, 2014, from
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http://www.nlm.nih.gov/medlineplus/druginfo/meds/a693050.html
RBC indices: MedlinePlus Medical Encyclopedia. (2014, October 9). Retrieved October 28, 2014, from
http://www.nlm.nih.gov/medlineplus/ency/article/003648.htm
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RDW Blood Test Results Explained. (2013, December 20). Retrieved October 28, 2014, from http://healthresearchfunding.org/rdwblood-test-results-explained/
Slater, C. L. (2003). Generativity Versus Stagnation: An Elaboration of Erikson's Adult Stage of Human Development. Journal Of
Adult Development, 10(1), 53
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http://www.nlm.nih.gov/medlineplus/druginfo/meds/a695011.html

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