UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Ashley Kavumkal

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

TC

Assignment Date: 09/10/2014

Agency: SMH

Age: 41

Admission Date:

Marital Status: Divorced

Primary Medical Diagnosis with ICD-10 code:

S12.490A
Fx of cervical vertebra

Primary Language: English

Level of Education: Associates degree

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): in Post Office

Number/ages children/siblings: 4 siblings

Served/Veteran: no

Code Status: full code

Living Arrangements: home in Bradenton

Advanced Directives:
If no, do they want to fill them out? No
Surgery Date: 9/6/2014 Procedure: C5-C11
anterior cervical fusion, C6-7 corpectomies

Culture/ Ethnicity /Nationality: Caucasian

Religion: Christian

Type of Insurance: Medicare, Medicaid

1 CHIEF COMPLAINT: neck pain. Patient reports a constant posterior neck pain of 5 which increases with
movement and decreases with resting and medication.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient admitted on 9/5/2014 with neck pain. She had a fall and developed an acute onset of worsening pain in her neck
and worsening numbness in upper extremities bilaterally. Noticed weakness bilaterally and difficulty with grasping
objects in her right hand. Movement increases pain and nothing decreases it.

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
Date

Operation or Illness

Father

67

Mother

65

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

Heart
attack

Brother
Sister

Cause
of
Death
(if
applicable
)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Appendectomy
cholecystectomy
colonoscopy
Lysis of ovarian cyst

42

sister
brother
relationship

Comments: Include date of onset

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

YES

University of South Florida College of Nursing Revision August 2013

NO

occupational purposes? Please List

1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Medications

pollen
Tape
latex

Other (food, tape,

latex, dye, etc.)

Sneezing, itchy eyes

rash
rash

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)
Fracture of cervical vertebra is an injury involving the neck that results from a rapid forceful, backward motion that could
be due to a vehicle accident, sports injury, falls and assaults. Risk factors include osteoporosis, conditions predisposing to
spinal rigidity such as ankylosing spondylitis. Acute presentation is usually with mechanism of cervical hyperextension
and complaints of neck pain, stiffness or headaches with neurologic symptoms. Treatment includes stability determined by
imaging, pain control as needed with opiate analgesics, muscle relaxants, acetaminophen, surgical fixation, wearing neck
collar for 8-14 weeks.
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software]. Retrieved from
http://www.unboundmedicine.com/products/nursing_central

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

Bisacodyl

Concentration (mg/ml) 5mg/tablet

PO

Frequency once a day

Pharmaceutical class stimulant laxatives

Indication

Dosage Amount (mg) 5mg

Home

Hospital

or

Both

treatment of constipation, part of bowel regimen in spinal cord injury patients

Side effects/Nursing considerations: abdominal cramps, nausea, diarrhea

Name: Cefazolin

Concentration: 2g/50ml

Route: IVPB

Dosage: Amount 2g

Frequency: Q8H

Pharmaceutical class: first generation cephalosporins

Home

Hospital

or

Both

Indication: treatment of infections due to susceptible organisms UTI, pneumonia, genital infections, bone & joint infections, septicemia etc
Side effects/Nursing considerations: seizures, pseudomembranous colitis, stevens-jhonsons syndrome, pain at IM site, phlebitis at IV site

University of South Florida College of Nursing Revision August 2013

Name: creon

Concentration:

Route: PO

Dosage Amount: 2cap

Frequency 2cap PO AC

Pharmaceutical class: pancreatic enzymes

Home

Hospital

or

Both

Indication: pancreatic insufficiency associated with chronic pancreatitis, cystic fibrosis, GI bypass surgery, ductal obstruction secondary to tumor
Side effects/Nursing considerations:fibrosing colonopathy, abdominal pain, diarrhea, nausea, stomach cramps
Name: Duloxetine

Concentration:

Route: PO

Dosage Amount: 60mg capsule

Frequency: 60 mg PO BID

Pharmaceutical class: SSNRIs

Home

Hospital

or

Both

Indication: Major depressive disorder

Side effects/Nursing considerations:Neuroleptic malignant syndrome,seizures, suicidal thoughts, fatigue, drowsiness, insomnia, decreased appetite, constipation,
drymouth, nausea
Name: Heparin Inj

Concentration

Dosage Amount: 5000 units (1 ml)

Route Subcute

Frequency: Q12H

Pharmaceutical class: antithrombotics

Home

Hospital

or

Both

Indication:prophylaxis and treatment for various thromboembolic disorders

Side effects/Nursing considerations: bleeding, heparin induced thrombocytopenia, anemia
Name: topiramate

Concentration 25mg tab

Route PO

Dosage Amount 75mg (3 tab)

Frequency QHS

Pharmaceutical class: anticonvulsants

Home

Hospital

or

Both

Indication:seizures, prevention of migrane head ache in adults

Side effects/Nursing considerations: seizures, suicidal thoughts, dizziness, drowsiness, fatigue, impaired memory, speech problem, sedation
Name: Acetaminophen

Concentration: 325mg/tab

Route: PO

Dosage Amount: 650mg (2tab)

Frequency:Q4H PRN

Pharmaceutical class: antipyretics, nonopioid analgesics

Home

Hospital

or

Both

Indication:treatment of pain, fever

Side effects/Nursing considerations: hepatotoxicity, acute generalized exanthematous pustulosis, stevens Johnson syndrome, toxic epidermal necrolysis
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
Name

Concentration

Dosage Amount

University of South Florida College of Nursing Revision August 2013

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? Mechanical soft diet
Analysis of home diet (Compare to My Plate and
Diet pt follows at home?regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: frosted flakes-1 bowl, 1 regular donut,1/2 cup
The patients diet is rich in proteins and grains, should
2% milk
incorporate more fruits and vegetables and low sodium
foods in the diet as well as reduce consumption of empty
calories.
Lunch: turkey sandwich & soup ,or spaghetti
Dinner:1 turkey sandwich, or 1 cheese burger
Snacks: salt and vinegar chips, apple, grapes
Liquids (include alcohol): sprite, Gatorade 1can 12oz
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? mother
How do you generally cope with stress? or What do you do when you are upset?
Yell and cry

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)

+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? _______________yes________________________________________
Have you ever been talked down to?___yes____________ Have you ever been hit punched or slapped?
______yes________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? yes

University of South Florida College of Nursing Revision August 2013

__________________________________________ If yes, have you sought help for this? yes______________________

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: stagnation refers to the feeling of a lack of purpose in life. In middle age , people discover a sense of contributing
to the world usually through family and work (generativity) or they may feel a lack of purpose (stagnation). (Myers, 2008, p. 87)
Reference:
Myers, D. G., (2008). Development through the life span: Psychology in everyday life (pp. 78) New York, Worth Publishers.
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 a stagnation stage. She stated that she is very depressed by her life and thinks that she is unfortunate, especially at
this point because of her multiple falls and being in the hospital with too much pain. The only person she can count on while in need
is her mother.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: Hospitalization has
played a huge role in the stagnation stage of her life. She seems more depressed in this situation.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? I am having a bad time now!

What does your illness mean to you?

It is very upsetting!

+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? __men__________________________________________
Are you aware of ever having a sexually transmitted infection? ___yes, when younger_____________________________
Have you or a partner ever had an abnormal pap smear?___yes, younger_______________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ________no_______________________
Are you currently sexually active? _____no______________________When sexually active, what measures do you
take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? _____________________________
How long have you been with your current partner?_did not
answer________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _______yes_________________

University of South Florida College of Nursing Revision August 2013

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? goes to church on Sundays, RC
Do your religious beliefs influence your current condition? praying helps sometimes_______________________________

+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? Menthol cigarettes
How much?(specify daily amount)
pack a day

Yes
No
For how many years? 20 years
(age

thru

If applicable, when did the

patient quit?

Pack Years: 182 approx

Does anyone in the patients household smoke tobacco? If
so, what, and how much?

Has the patient ever tried to quit? Yes, several times

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)

For how many years?

(age

thru

If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
none

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:
Bathing routine:
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
Routine dentist visits
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
x/day
x/year

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 :pollen
last CXR?
Other:

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

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? 8 months ago
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result: 2 yrs
ago
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
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision August 2013

10

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?
none

University of South Florida College of Nursing Revision August 2013

11

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

General Survey:
Temperature: (route
taken?)oral 98 F

Height:167.60 cm
Pulse: 85
Respirations: 16

Weight: 57.88Kg BMI:20.59 Pain: 5 on 10 posterior of

Blood
Pressure: 102/74

neck

(include location)

SpO2
98
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
Sleepy, easy to wake but goes back to sleep immediately
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

Peripheral IV site Type: PICC RFA

no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Fluids infusing?
no
yes - what?

talkative
withdrawn

Location: left arm

Location:
Location:

quiet
boisterous
aggressive
hostile

Date inserted:

flat
loud

9/9/14

Date inserted:
Date inserted:

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:
Heart sounds: S1 S2 Regular
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:
Femoral:
Popliteal:
DP:
PT:
No temporal or carotid bruits
Edema:
[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: yellow
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
/
/
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

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

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ___4____ RUE ___4____ LUE ___4____ RLE

& ____3___ 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

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
WBC

Dates
9.4

Normal (4.5-11)
RBC 3.62
Hemoglobin 10.3
Potassium 2.5
INR 1.07

Trend
normal

Analysis
. NORMAL

normal
normal
Within normal range
normal

normal
normal
Low, diarrhea
normal

(09/06/2014)
9/6/14
9/6/14
9/6/14
9/6/14

+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 mechanical soft diet, activity: bedrest, turn /reposition, vitals Q4H,

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

1.Pain
2. risk for fall
3.physical mobility impaired
4.risk for infection
5. Diarrhea/constipation

 15 CARE PLAN
Nursing Diagnosis: (Which nursing diagnosis you are doing your care plan on goes here.)
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Patient will report pain less than 4
Assess pain level, administer meds, To minimize pain during hospital
Reported pain of 5, meds
provide comfort measures
stay
administered, reminded to take
deep breaths while in too much
pain

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

 15 CARE PLAN
Patient Goals/Outcomes
Patient will remain free from falls

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Located near nurses station, call
To make sure patient does not
light in place and educated to use,
move out of bed without assistance
bed alarm, non-skid socks, fall risk to avoid risk of fall
arm band, top side rails up, bed
positioned in the lowest possible
height , hourly rounds

Evaluation of Interventions on
Day care is Provided
All interventions are done

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

15 CARE PLAN
Patient Goals/Outcomes
Patient will be able to ambulate

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Administer meds, assess ROM,
To assess the strength of
Neuro assessment, turn and
extremities, bones, muscles and
reposition, educate to slightly move gait
extremities to facilitate movement

Evaluation of Interventions on
Day care is Provided
Assessed ROM and Neuro

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
Myers, D. G., (2008). Development through the life span: Psychology in everyday life (pp. 78) New York, Worth
Publishers.
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software]. Retrieved from
http://www.unboundmedicine.com/products/nursing_central