UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Ardy Emile

PATIENT ASSESSMENT TOOL .

Agency: FHT

1 PATIENT INFORMATION
Patient Initials:
Gender:

E.S

Assignment Date: 09/15/15

Age: 39

Admission Date: 09/14/15

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

L5/S1 Spondylosis M47.016

Primary Language: English

Level of Education: 4 Year University

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Military

Not Applicable

Number/ages children/siblings: 3 Children: 5, 7, 10 YO. No

siblings

Served/Veteran: Active Duty

Code Status: Full Resuscitation

Living Arrangements: Lives in a home with wife and kids.

Advanced Directives: Living Will

If no, do they want to fill them out?
Surgery Date:09/15/15
Procedure: L5- S1
Lumbar Surgery

Culture/ Ethnicity /Nationality: Caucasian

Religion: Christian

Type of Insurance: Tricare

1 CHIEF COMPLAINT:
Ive been having really bad pain in my lower back, hips and my left leg.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient came in on 09/14/15 at 5:30 AM for an L5/S1 lumbar surgery. Patient has been having pain in lower back and left
leg. The pain in his back is dull and the pain in his left leg is more tingling and electric. Hes had this pain for about 10
years now. It hurts more when he slightly bends over. It feels better when he lies down. Pain level was an 8 out of 10.

University of South Florida College of Nursing Revision August 2013

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation

Father

64

Mother

66
N/
A
N/
A

Brother
Sister

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable
)
NA

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Patient has a history of inflammatory bowel syndrome
Patient has a history of chicken pox
Patient has a history of a discectomy
Patient has a history of a colonoscopy
Patient has a history of a vasectomy
Patient has a history of sleep apnea

Age (in years)

Date
N/A
11 years old
5 months ago
2 years ago
2 years ago
N/A

NA
N/A
N/A

relationship
relationship
relationship

Comments: Patients father is allergic to bees and he doesnt know the onset. Patients mother has type 2 diabetes and hypertension and
he does not know the onset.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) 5 years ago
Adult Tetanus (Date)
7 years ago
University of South Florida College of Nursing Revision August 2013

NO

Influenza (flu) (Date) Every year

Pneumococcal (pneumonia) (Date) 3 years ago
Have you had any other vaccines given for international travel or
occupational purposes? Please Lit: Patient states, Smallpox, anthrax;
theres too many for me to remember.
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Not applicable
Medications

Not applicable
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)
Mr. Steele suffers from a lumbosacral spondylosis. Spondylosis is when damage occurs to the structures (Bony
bridges) that connect the upper and lower facet joints due to weakness or stress fractures (Syrmou et al., 2010). It is
referred to as degenerative changes in the spine due to other disease processes such as osteoarthritis. Lumbosacral
spondylosis affects the lumbar and the sacral vertebrae; Mr. Steeles L5 & S1 (Driver, 2015). Spondylosis is prevalent in
6% of the population and its occurrence is attributed to hereditary and certain risk factors. Its especially found in men and
people who participate in high risk sports (Syrmou et al., 2010). In Mr. Steeles case, the spondylosis presentation is
probably due to the conditioning and high stress situations of the military. Also, osteoarthritis development in older age
could be a factor as well. Spondylosis can be asymptomatic but is usually manifested as sever lumbar pain and is
aggravated by activity (Syrmou et al., 2010). The majority of issues occur on L5. Radiography has been found to be useful
in the initial diagnoses of spondylosis but CT scans and MRIs are more sensitive in establishing the diagnoses. For
treatment, less invasive methods are used first such as pain relief medications, pulsed ultrasounds, and therapeutic
isometric contractions. NSAIDS should not be used because they deter bone growth and healing. Surgical treatment
should only be used for symptomatic patients where less invasive methods were not effective. The surgical procedures are
typically performed for direct repair and fusion using techniques such as translaminar screw fixation, cerclage wiring
loop, pendiculolaminar hook screws, and etc. (Syrmou et al., 2010)

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]

University of South Florida College of Nursing Revision August 2013

Name cefazolin (Ancef)

Concentration (mg/ml)

Route: IV

Dosage Amount (mg): 2 G

Frequency: Q8H

Pharmaceutical class: First generation cephalosporin

Home

Hospital

or

Both: Hospital

Indication: Treatment of infections due to susceptible organisms, preoperative prophylaxis, not suitable for treatment of meningitis
Side effects/Nursing considerations: Seizures in high doses, pseudomemnranous colitis, stevens-johnsons syndrome, phlebitis at IV site, allergic
reactions/anaphylaxis, nausea, vomiting. Patient should report symptoms of superinfection and allergy.
Name: docusate (Colace)

Concentration: 1 Cap

Route: Oral

Dosage Amount: 100 mg

Frequency: Q12H

Pharmaceutical class: Stool softeners

Home

Hospital

or

Both: Hospital

Indication: Prevention of constipation, used as enema to soften fecal impaction

Side effects/Nursing considerations: Rashes, throat irritation, mild cramps and diarrhea. Advise patients that laxatives should only be used fleetingly. Advise
patients to choose other forms of bowel regulation and to increase fluid intake.
Name ferrous sulfate (Fer-Iron)

Concentration: 1 Tab

Route: Oral

Dosage Amount: 325 mg

Frequency: Daily

Pharmaceutical class: Iron Supplements

Home

Hospital

or

Both: Both

Indication: Treatment & prevention iron deficiency anemia.

Side effects/Nursing considerations: Dizziness, syncope, nausea, constipation, dark stools, GI bleed, and vomiting. Instruct patient in iron rich foods and advise
patient that stools may become dark green or black.
Name: heparin (Hep-Lock)
Concentration:
Dosage Amount: 5,000 units
Route: SubQ

Frequency: Q12H

Pharmaceutical class: Antithrimbotics

Home

Hospital

or

Both: Hospital

Indication: Prophylaxis and treatment of various thromboembolic disorders

Side effects/Nursing considerations: Bleeding, heperain induced thrombocytopenia, pain at injection site, alopecia, fever, drug induced hepatitis. Advise patient
to report symptoms of unusual bleeding or bruising to healthcare professional immediately, to avoid NSAIDS, and to avoid IM injections.
Name: potassium chloride (Klor-Con)

Concentration: 1 Tab

Route: Oral

Dosage Amount: 40 mEq

Frequency: Daily

Pharmaceutical class: Mineral and electrolyte

replacements/supplements
Indication: Treatment/prevention of potassium depletion

Home

Hospital

or

Both: Both

Side effects/Nursing considerations: Confusion, weakness, arrhythmias, abdominal pain, N/V, diarrhea, GI ulceration, paralysis. Education patient about
purpose of medication, advise patient to avoid salt substitutes, educate patient about sources of potassium. Instruct patient to report dark, tarry stools.
Name: oxycodone/acetaminophen (Percocet)

Concentration: 1 Tab

Route: Oral

Dosage Amount: 650 mg

Frequency: PRN Q4H

Pharmaceutical class: Opioid + Analgesic

Home

Hospital

or

Both: Both

Indication: For the relief of moderate to moderately severe pain

Side effects/Nursing considerations: Dizziness, sedation, N/V, Thrombocytopenia, neutropenia, hemolytic anemia, and hypoglycemic coma. Advise patient to use
medication as prescribed it can slow or stop breathing. Do not crush, break or open. This medication can cause addiction, overdose, and death.
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

University of South Florida College of Nursing Revision August 2013

Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

University of South Florida College of Nursing Revision August 2013

 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 pt follows at home? Regular diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Scrambled eggs, sausage, biscuit and
With a 2,000 calorie a day diet, Mr. Steele should try to
strawberries.
follow these guidelines. He should intake at least 6 ounces
of grains each day with at least 3 ounces of those being
whole grains. Hes doing pretty well since he already eats
whole grain bread. Some other foods with grains and whole
grains are cereals, rice, pasta, grits, oats and etc. He should
intake 2 cups of vegetables consisting of dark greens,
red/orange veggies, beans, peas and etc. He should intake 2
cups of fruit and 3 cups of dairy per day. Only 6 tsp. of oil
is advised per day and less than 258 calories are advised to
be empty calories (Calories from foods with no nutrients).
Last but not least, 5 ounces of proteins are needed per
day with 8 ounces of seafood per week. Some other good
sources of protein are white meat/poultry, eggs, beans, milk
and etc. Overall, considering Mr. Steeles last 24 hour
dietary intake, he has a pretty healthy diet.
Lunch: Turkey sandwich with whole wheat, tomatoes,
Swiss cheese, and lettuce.
Dinner: Chicken, carrots, asparagus and brown rice.
Snacks:
Liquids (include alcohol): One glass of milk and orange
juice. One bottle of cranberry juice. Three 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 reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My wife and kids.
How do you generally cope with stress? or What do you do when you are upset?
Patient states, I like to take naps. Patient states he likes playing golf and likes being with his family.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient states, Nothing that I can think of.

University of South Florida College of Nursing Revision August 2013

+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?_ Im in the military. ______________ Have you ever been hit punched or
slapped? ____Yeah but not in a relationship. __________
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? ______________________
Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

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

I believe Mr. Steele is in the generativity vs. stagnation stage. He falls on the generatitivity side. People in the
generativity side of this stage commit to giving back to others and the community through public service. In this stage,
people are productive members of society and are able to pay it forward for future generations (Vogel-Scibilia et al.,
2009). People in this stage stay productive by forming meaningful relationships like having children and attaining
accomplished careers. If generativity is not met, the person may be left in self-absorption (Treas & Wilkinson, 2014). Mr.
Steele is in the military and works/fights for all the Americans in our country as well as his wife and kids.

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

Since my patient has this lumbosacral spondylosis, it causes him a great deal of severe pain. Therefore, he is unable to
bend over, walk effectively, or partake in strenuous work. He has to do a lot of resting to make sure he doesnt cause any
more damage. He may feel useless and feel like hes losing time when he could be doing his job in the military.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I dont know, being in the military.stress and a lot of strenuous work.
What does your illness mean to you
I dont knowa lot of pain.

+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 August 2013

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? _________________Yes__________________________
Are you currently sexually active? ____________Yes_______________When sexually active, what measures do you
take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? __Patient is in a monogamous
relationship and has had a vasectomy. ______________________________
How long have you been with your current partner?______15
years__________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ______Yes, because of the pain.
_____________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision August 2013

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

What importance does religion or spirituality have in your life?
_____I guess its important.
_________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
________Patients says that through prayer he wishes that procedure went well and the pain wont bother him as much.
_____________________________________________________________________________________________
______________________________________________________________________________________________________

+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: NO
For how many years? X years
(age N/A

thru 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? No

Has the patient ever tried to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)
Yes; patient drinks beer, liquor and wine once A pack of a beer a month. Wine once
and a while.
a week.

For how many years?

(age: 18

thru : 39

If applicable, when did the patient quit?

N/A
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
Yes; Marijuana
How much?
For how many years?
Patient has tried it a couple
(age N/A
thru
N/A
times
Is the patient currently using these drugs?
Yes No: 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
Patient says, Yes, Im in the military.

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF: 30
Bathing routine: Twice a day
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
x/day
Routine dentist visits
x/year
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
2

Diabetes

Type:

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox

University of South Florida College of Nursing Revision August 2013

10

Other:

Other:

Other:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Nothing that I havent already mentioned.

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

University of South Florida College of Nursing Revision August 2013

11

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

General Survey: 39 year old Height: 510
Weight: 162 lbs BMI: 23.2 Pain: (include rating & location)
8/10 (Lower back, left leg, and hips)
Caucasian male whos neat
Pulse: 85
Blood
and alert & oriented with a
Pressure: 121/72 (Left arm)
(include location)
pleasant affect.
Temperature: (route taken?)
Respirations: 20
97.8 (Oral)
SpO2 : 99
Is the patient on Room Air or O2: Room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin

talkative
withdrawn

quiet
boisterous
aggressive
hostile

flat
loud

Peripheral IV site Type: 20 gauge

Location: Left AC
Date inserted: 9/14/15
no redness, edema, or discharge
Fluids infusing?
no
yes - what? Patient being discharged by the end of day.
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Date inserted:
Fluids infusing?
no
yes - what?
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

University of South Florida College of Nursing Revision August 2013

12

Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th intercostal space, midclavicular line
Heart sounds: S1 S2 Regular: Yes Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
Carotid:
Brachial:
Radial: 3
Femoral:
Popliteal:
DP: 3 & 2
PT:
No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color:
Previous 24 hour output:
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM:\(date: 09 / 13
/ 15 ) Formed : Yes
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown Medium Brown: Yes Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ____5___ RUE ___5____ LUE ___4____ RLE

& __2_____ in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias
Couldnt get patient out of bed to perform musculoskeletal tests. Patient not allowed to bend at waist.
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

Biceps:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

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

Dates
09/14/15

Trend
Patient came in with
severe lower back pain
and was scheduled for
surgery for L5/S1
Spondylosis.

Hgb

13.4

09/14/15

Hct

39.9

09/14/15

Patients lab values for

hemoglobin, hematocrit,
and platelets seem to be
within normal limits.

Plts

218

09/14/15

Wbc

14.8

09/14/15

K+

3.4

09/14/15

Patients lab values for

white blood cell count is
a little higher than the
normal range of 4-10.

Analysis
An X-Ray is beneficial
before the procedure to
see the spine and
vertebrae and help
diagnose the spondylosis.
With and X-Ray we are
able to see the stress
fractures and movement
of position. An X-Ray is
also beneficial postsurgery as well see if the
surgery was successful.
These are good findings
because it shows that the
patient isnt anemic due
to the surgery. It shows
that the patient is still
having good blood flow
and isnt at danger of
bleeding out and at
danger of anoxia. Patient
is connected to a
hemovac.
Wbc is important because
an elevated count
indicates that the patient
could be having an

Glucose

103

09/14/15

The potassium level is

only slightly lower than
the 3.5-5.0 range.

infection. Potassium is
important because it can
affect the function of the
heart so it would be
paramount to monitor the
levels.

Normal blood glucose

levels are 70-100.

The blood glucose is

slightly above range.
Although this is not
much, this glucose
reading is in the range of
prediabetes 100-125.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
At this point, the patient has no further diagnostic tests other than the spine X-Ray post-surgery. The patient
doesnt have any accuchecks because he is not a diabetic. The patient is on a regular diet and doesnt participate
in too much activity because too much activity will aggravate the pain and he is not advised to bend at the waist
or to twist his back. He does have consults to meet with physical therapy to learn proper ways to get in and out of
bed and proper ways to use ambulatory aids. His consults with physical therapy also help him regain muscle and
bone strength because being on bedrest and being sedentary can cause weakness. This also prevents occurrences
of skin breakdown.

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

1. Risk for infection R/T L5/S1 surgery.
2. Impaired mobility R/T L5/S1 Surgery as evidenced by lower back, hip, and leg pain.
3. Risk for imbalanced nutrition R/T blood glucose of 103.
4.Risk for impaired skin integrity R/T impaired mobility
5.

 15 CARE PLAN
Patient Goals/Outcomes
No new symptoms of infection by
the end of shift

Nursing Diagnosis: Risk for infection R/T L5/S1 surgery.

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Wash hands before and after
When the nurse has good aseptic
working with patient. Use
habits, infections are less likely to
appropriate wound care technique
occur. Its important to monitor
and using aseptic technique with
WBC and temperature because
IVs. Monitor WBC and
they can indicate infection. Most of
Temperature and vitals.
the times fever is the first sign of
infection (Ackley, 2010).

Evaluation of Goal on Day care is

Provided
Although patients WBC was the
14.8 by end of shift, there were no
new symptoms of infection.

Restate back symptoms of

infection that they need to watch
for by end of shift.

Teach patient the symptoms of

infection and have them restate
back later on the shift.

Teaching the patient the symptoms

of infection will help them be
cognizant. They will know when
something is wrong and be able to
alert the nurse or healthcare
provider.

Patient was taught about the

symptoms of infection and had an
understanding of the symptoms.

Bring down and maintain WBC at

normal range by the end of shift.

All of the above as well as

administering antibiotics
(Responsibly and sparingly)/antiinfectives.

As mentioned above, an abnormal

WBC is an indication of infection.
So when that elevated WBC starts
to come back to normal range, it is
an indication that there is progress.

The WBC was still elevated

slightly by the end of shift

Demonstrate appropriate care of

infection prone site and appropriate
hygienic measures by end of shift.
Maintain good personal hygiene
habits long-term.

Teach patient and family how to

avoid infection and proper hand
hygiene. Teach patient to have
good oral and perineal care habits.

Meticulous infection prevention

precautions are required to prevent
healthcare-associated infection
(Ackley, 2010).

Patient demonstrated good personal

hygiene habits by end of shift and
hopefully he maintains his habits
out of the hospital.

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 appts
*Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? *Yes No
Rehab/ HH
Palliative Care
Patient will be discharged home with his wife. He lives in a home with her and his three kids, they will helo take care of him. All information given
in the care plan will be reviewed with him.

 15 CARE PLAN
Nursing Diagnosis: Impaired mobility R/T L5/S1 Surgery as evidenced by lower back, hip, and leg pain.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Be able to use adaptive equipment Use gait belts when ambulating
Gait belts increases safety and
Patient was taught by PT the proper
effectively by end of shift.
patient. Teach patient how to
prevents injuries (Ackley, 2010). . way to get in and out of bed and
properly get in and out of bed and
Showing the patient the proper to
successfully used walker.
how to use walker.
get in and out of bed will help
prevent further injuries.
Verbalize less fear of falling and
pain with physical activity by end
of shift.

Monitor and treat pain before

activity and make sure patient isnt
over sedated.

Pain limits mobility and is often

exacerbated by movement (Ackley,
2010).

Patient had a good time ambulating

with PT and stated, The pain
wasnt too bad.

Meet goals of ambulation by end of Have patient meet with PT. Obtain
shift.
proper assistive devices.

It is found that regular physical

activity helps decrease impaired
mobility (Ackley, 2010).

Patient met with PT willingly by

the end of shift and participated in
ambulation/physical activity.

Patient should increase physical

activity to at least 7500-10000
steps per day long-term.

Having a plan tailored to your

strength, gender, ethnicity and
culture is very beneficial. These as
well as keeping a log increases
adherence (Ackley, 2010). If the
mobility plan is followed, strength
is increased. Therefore, activity
should increase.

Hopefully in the long run the

patient sticks to his mobility plan,
increases activity, and continues to
consult with PT.

Have patient consult with PT for

evaluation of strength, gait, and to
develop a mobility plan.

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 appts
*Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? *Yes No
Rehab/ HH
Palliative Care
Patient will be discharged home with his wife. He lives in a home with her and his three kids, they will helo take care of him. All information given
in the care plan will be reviewed with him.

15 CARE PLAN
Patient Goals/Outcomes

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References

Evaluation of Interventions on
Day care is Provided

 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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

References
Ackley, B. (2010). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). Maryland
Heights, Mo., Missouri: Mosby.
Driver, C. (2015, February 27). Spondylosis: Learn About Symptoms and Treatment (W. Shiel Jr., Ed.).
Retrieved October 10, 2015.
SuperTracker: My Foods. My Fitness. My Health. (2015, October 10). Retrieved October 10, 2015.
Syrmou, E., Tsitsopoulos, P., Marinopoulos, D., Tsonidis, C., Anagnostopoulos, I., & Tsitsopoulos, P. (2010).
Spondylolysis: A review and reappraisal. Retrieved October 10, 2015.
Treas, L., & Wilkinson, J. (2014). Physical Development of Middle Adults. In Basic nursing: Concepts, skills,
& reasoning (p. 164). Philadelphia, PA: F.A. Davis Company
Unbound Medicine, Inc. (2014). Nursing Central (Version 1.25) [Mobile application software]. Retrieved from
http://itunes.apple.com
Vogel-Scibilia, S., McNulty, K., Baxter, B., Miller, S., Dine, M., & Frese, F. (2009, June 17). The Recovery
Process Utilizing Eriksons Stages of Human Development. Retrieved October
10, 2015.