UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Danielle Finethy

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION

Assignment Date: 6/23/15

Agency: BMT

Patient Initials: RM

Age: 74

Admission Date: 6/19/15

Gender: Male

Marital Status: Married

Primary Medical Diagnosis:

Primary Language: English

Osteoarthritis

Level of Education: Masters Degree in Electrical Engineering

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired: Management of Aerospace

Company
Number/ages children/siblings: 5 children (3 biological) 49, 47,
44, 35, 33.
4 siblings (all female) all deceased

DVT bilateral LE

Served/Veteran: Never
If yes: Ever deployed? Yes or No

Code Status: Full Code

Living Arrangements: One story home, 5 steps to enter. Lives with

wife in St. Pete, FL.

Advanced Directives: yes Living will

Surgery Date: 6/17/15 Procedure: bilateral TKR

Culture/ Ethnicity /Nationality: Caucasian American

Religion: Jewish

Type of Insurance: Medicare, Supplemental drug

coverage.

1 CHIEF COMPLAINT: Bone to bone knees. Ive had knee trouble for a great many years, I finally
decided it was time to do something about it.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
74 year old male with a history of bilateral knee pain since 1987. Patient has pain in both knees. Pain is present constantly,
more so when on a decline. Pain is dull, aching. Not running downhill makes pain better. Walking/running uphill is
tolerable. Patient has tried conservative measures without relief. The patient is an active runner, biker and former rower.
He is now having difficulty walking extended periods without discomfort. Patient had bilateral total knee replacements
(TKR) on 6/17/2015, no complications noted during surgery. Postoperatively, the patient was examined by another
physician who did not perform surgery, was noted to be recovering well. Patient had episode of becoming hypotensive and
orthostatic during physical therapy (PT). Patient has since had slightly elevated creatinine and was given fluids of 125 an
hour; he does have a history of chronic kidney disease. Patient is noted to have a significant rash on his back, cause
unknown possibly medication.
Patient has been admitted to acute rehab to work on mobility, self-care, as well as medical management of orthostatic
hypotension, anemia, electrolyte and renal function. A Doppler scan done on bilateral lower extremities postoperatively
showed evidence of nonocclusive thrombus in popliteal veins bilaterally. Patient had an Inferior Vena Cava filter placed

University of South Florida College of Nursing Revision September 2014

on 6/22/15 to prevent pulmonary embolism.

Father
Mother
Sister
Sister

U
nk
51
d
76
d
41
d

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Cause
of
Death
(if
applicable
)

Arthritis

2
FAMILY
MEDICAL
HISTORY

Anemia

Hypertension
Arthritis TKR done during this admission
Polycystic kidney disease
Chronic kidney disease renal insufficiency
Dyslipidemia Patient takes atorvastatin to manage

Environmental
Allergies

unkown
1987
unknown
unknown
unknown

Alcoholism

Operation or Illness
Right rotator cuff surgery
Ruptured disk - Spinal fusion performed
Kidney stones hospitalization
Cataracts Crystal lens surgery
Sigmoid colon resection
Appendectomy

Age (in years)

Date
unknown
1993
1993
2010
2014
2014

(angina,
MI, DVT
etc.)
Heart
Trouble

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

MVA
Lung
cancer
unk
Brain
tumor

relationship
relationship
relationship

Comments: Patients ability to recall family information is limited. Family history is somewhat unknown due to immigration and early
deaths. Does not know much about paternal side, reside in Russia. Maternal side resides in Romania.

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)
U
Adult Tetanus (Date) Is within 10 years?
Yes, date U
University of South Florida College of Nursing Revision September 2014

NO

Influenza (flu) (Date) Is within 1 years?

Nov 2014
Pneumococcal (pneumonia) (Date) Is within 5 years?
Nov 2014
Have you had any other vaccines given for international travel or
occupational purposes? Please List
Patient states various travel to many countries over the years, no dates
known but many vaccinations received. , confirmed vaccinations for
yellow fever.
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Possible/unknown

Type of Reaction (describe explicitly)

Patient has developed a rash on entire back while admitted, possible
medication allergy.

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)
A condition in which a blood clot forms unexpectedly in one area of the body and has the possibility of
traveling to another area of the body is called a deep vein thrombosis (DVT). Contributions to having a DVT
can be related to many factors. The condition occurs when the walls of a vein or artery becomes partially or
fully occluded by the attachment of a thrombus. A thrombus is composed of fibrin and blood cells and can
develop in either the arterial or venous system. Huether, S. E., & McCance, K. L., (2012). The formation of a
thrombus can develop from a patient with prolonged stasis, a state of hypercoagulability, or a genetic factor can
also contribute. If a thrombus becomes large enough, it can restrict blood flow in the vein or artery, therefore
compromising blood flow to other organs or surrounding tissue; the results of this can be fatal by depriving the
brain, lungs, or heart of essential oxygen and needed nutrients. (Huether & McCance, 2012, p. 530.) The patient
may feel pain accompanied by warmth and color changes in the skin around the area where the DVT is
underlying.
University of South Florida College of Nursing Revision September 2014

According to Huether and McCance (2012) there are specific factors contributing to risk of development
of a spontaneous thrombi, referred to as the Vichow triad: (1) injury to the blood vessel endothelium, (2)
abnormalities of blood flow, and (3) hypercoagulability of the blood. (p. 530). When a blood vessel is injured,
the body has a natural response to the injury; it forms a platelet plug to surround the site of injury and the
leaking is stopped, this is known as primary haemostasis. After this is achieved, the plug is stabilized by
secondary haemostatis when a web of fibrin is created by the platelets. (Malone, P. C., & Agutter, P. S. 2008, p.
36) In normal healing this is a wanted occurrence. In patient that are limited in mobility and stasis is occurring,
they are at risk for a venous thrombus due to fresh blood not circulating as it normally does. This is rather
common in patients who have undergone invasive surgery such as an orthopedic procedure. Other factors that
increase a patients risk for a DVT are age, occur more frequently in elderly population, prolonged inactivity
sometimes with travel, a family history of blood clots, and smoking. Women who smoke and take birth control
pills are at an increased risk as well.
There are different options for treatment which are typically decided depending on the location of the
thrombus, the patients physical condition, and risk for further complication. The goal of therapy is to dissolve
the clot or to remove it completely. Certain patients may benefit from anticoagulation therapy as treatment or
prevention, this is seen primarily in venous thrombosis. For patients with an arterial thrombosis anticoagulation
therapy is not recommended. (Huether & McCance, 2012. p. 530) Use of oral drugs to prevent early
coagulation or excess coagulation of the blood may be used as treatment or prophylaxis, an example of one
commonly used is warfarin. If the patient is not a good candidate for this type of therapy providers may choose
a procedure to prevent the clot from moving, particularly to the lungs. A common procedure for patients in this
situation is the insertion of an inferior vena cava filter. This is a small device that is inserted by interventional
radiology. It is a small filter placed in the right or left femoral or jugular vein to prevent access of an emboli
from reaching the lungs. These filters may be left in permanently or in some cases they can be taken out or
retrieved as it is called. (Funaki, 2006)
Not every patient who has a DVT will have a pulmonary embolism. If the DVT is found, it will be
University of South Florida College of Nursing Revision September 2014

treated in the best manner to fit the patients health and specific needs. Many people may suffer from a DVT
and exhibit no symptoms and it resides on its own. It is important to be cautious of the risks population it will
affect most when considering implications in nursing. Providers will often prescribe compression stockings to
help keep pressure on the lower legs, keeping blood flowing appropriately; these stockings can also help with
pain after having a blood clot. Patients should adhere to the medication regimen recommended by their doctor
as well. Adequate knowledge of the formation and symptoms of DVT can help patients to prevent themselves
from harm.

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: atorvastatin (Lipitor)

Concentration

Dosage Amount: 10 mg

Route: oral

Frequency: PO, Daily/HS (bedtime)

Pharmaceutical class: hmg coa reductase inhibitor

Home

Hospital

or

Both

Indication: management of dyslipidemia.

Adverse/ Side effects: abdominal cramps, constipation, diarrhea, heartburn, confusion, dizziness, weakness, rash, pruritus. Adverse: Rhabdomyolysis,
hypersensitivity reaction; angioneurotic edema.
Nursing considerations/ Patient Teaching: Avoid grapefruit juice and fruit during therapy may increase toxicity; to be used in conjunction with diet
restrictions and exercise. May be taken with or without food. Take as instructed, do not miss doses and do not double missed doses. Instruct patient to notify
health care professional if any unexplained muscle pain, tenderness, or weakness especially if accompanied by fever or malaise. Emphasize need for follow up
exams and lab work to determine effectiveness and monitor side effects.
Name: cholecalciferol (Vitamin D3)

Concentration

Dosage Amount: 5000 IU (5 tabs)

Route: oral

Frequency: PO, Daily

Pharmaceutical class: fat soluble vitamins

Home

Hospital

or

Both

Indication: treatment of or prevention of Vitamin D deficiency

Adverse/ Side effects: headache, anorexia, constipation, dry mouth, bone pain, weakness; Hypercalcemia, Pancreatitis.
Nursing considerations/ Patient Teaching:
Use with thiazide diuretics may result in hypercalcemia; Calcium containing drugs and/or foods high in calcium may result in hypercalcemia.
May be taken without regard to meals. Advise patient to take as directed, take missed doses as soon as remembered unless close to next dose do not double.
Encourage patient to comply with recommended diet from healthcare professional; a well-balanced diet along with sunlight exposure.
Name: docusate-senna (PeriColace)

Concentration

Dosage Amount: 2 tabs

Route: oral

Frequency: PO, Daily/HS (bedtime)

Pharmaceutical class: stimulant laxative/stool softener

Home

Hospital

or

Both

Indication: Treatment of constipation associated with dry, hard stools and decreased intestinal motility. Also for prevention of opioid-induced constipation.
Adverse/ Side effects: fluid and electrolyte imbalances, abdominal cramps, nausea, vomiting, diarrhea, rashes, urine discoloration.
Nursing considerations/ Patient Teaching:
Assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel. Asses color, consistency, and amount of stool produced.
Administer with full glass of water or juice, not within 2 hours of other laxative. Advise patient that laxatives should only be used in short term; long term may
cause electrolyte imbalance and dependence.
Encourage healthy bowel regulation with the patient, advise to increase bulk of diet, increase fluid intake and increase mobility. Advise patient to avoid
straining, especially cardiac disease.

University of South Florida College of Nursing Revision September 2014

Name: docusate-senna (Senokot-S)

Concentration

Dosage Amount: 1 tab

Route: oral

Frequency: PO, BID

Pharmaceutical class: stimulant laxative/stool softener

Home

Hospital

or

Both

Indication: Treatment of constipation associated with dry, hard stools and decreased intestinal motility. Also for prevention of opioid-induced constipation.
Adverse/ Side effects: fluid and electrolyte imbalances, abdominal cramps, nausea, vomiting, diarrhea, rashes, urine discoloration.
Nursing considerations/ Patient Teaching:
Assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel. Asses color, consistency, and amount of stool produced.
Administer with full glass of water or juice, not within 2 hours of other laxative. Advise patient that laxatives should only be used in short term; long term may
cause electrolyte imbalance and dependence.
Encourage healthy bowel regulation with the patient, advise to increase bulk of diet, increase fluid intake and increase mobility. Advise patient to avoid
straining, especially cardiac disease.
Name: famotidine (Pepcid)

Concentration

Dosage Amount: 20 mg

Route: oral

Frequency: PO, Daily

Pharmaceutical class: histamine h2 antagonist

Home

Hospital

or

Both

Indication: Prevention of GI bleeding, management of GI symptoms.

Adverse/ Side effects: confusion, dizziness, constipation, hypersensitive reactions; Arrhythmias, agranulocytosis, aplastic anemia, blood dyscrasias
Nursing considerations/ Patient Teaching:
Monitor CBC periodically during therapy. Teach patient to take with meals or immediately following. Advise patient not to take the maximum does continuously
for more than 2 weeks without contacting physician. Advise patient to avoid alcohol, products containing aspirin or NSAIDS to decrease GI upset.
Name: ferrous sulfate (Iron supplement)

Concentration

Dosage Amount: 325 mg (1 tab)

Route: oral

Frequency: PO, BID

Pharmaceutical class: iron supplements

Home

Hospital

or

Both

Indication: Treatment and prevention of iron deficiency anemia.

Adverse/ Side effects: nausea, constipation, dark stools, epigastric pain, GI bleeding, vomiting, dizziness, headache, syncope.
Nursing considerations/ Patient Teaching:
Monitor hemoglobin, hematocrit, and reticulocyte values prior to administration and every 3 weeks during start of therapy. Administer 1 h prior or 2 h after
meals to avoid decreased absorption.
Advise patient that stools may become dark. Advise patient to follow a diet that is high in iron. Warn of risk of overdose in children, safe storage of medication.
Name: fluticasone nasal (Flonase)

Concentration

Dosage Amount: 50mcg/metered spray

Route: intranasal

Frequency: 1 spray each nostril, Daily

Pharmaceutical class: corticosteroid

Home

Hospital

or

Both

Indication: seasonal or perennial allergic or nonallergic rhinitis

Adverse/ Side effects: headache, epistaxis, nasal burning/irritation, nausea, vomiting, rash, cough; Anaphylaxis, angioedema
Nursing considerations/ Patient Teaching:
Advise patient to take as prescribed, consistently. Teach correct technique for nasal spray administration (shake well before use, prime before use). Instruct
patient to contact healthcare professional immediately if any signs of anaphylaxis occur.
Name: folic acid

Concentration

Dosage Amount: 0.4 mg (1 tab)

Route: oral

Frequency: PO, Daily

Pharmaceutical class: water soluble vitamin

Home

Hospital

or

Both

Indication: Prevention and treatment of megaloblastic and macrocytic anemias.

Adverse/ Side effects: rash, fever, irritability, difficulty sleeping, malaise, confusion
Nursing considerations/ Patient Teaching: Advise patient the best source of vitamins is well-balanced diet. Foods high in folic acid include vegetables, fruits, and
organ meats. Caution patient taking at home not to exceed the recommended daily allowance (RDA). Folic acid may make urine intensely yellow.
Name: hydrochlorothiazide (Microzide)

Concentration

Dosage Amount: 25 mg (1 tab)

Route: oral

Frequency: PO, Daily

Pharmaceutical class: Thiazide diuretics

Home

Hospital

or

Both

Indication: management of mild to moderate hypertension; treatment of edema associated with heart failure, renal dysfunction, cirrhosis.
Adverse/ Side effects: hypokalemia, hyperglycemia, hyperuricemia, hypercholesterolemia, dehydration, hypotension, dizziness, drowsiness, muscle cramps,
blood dyscrasias, Stevens-Johnsons syndrome.

University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching: Monitor intake and outputs, daily weight, assess for peripheral edema daily; monitor blood pressure (BP) before and
periodically throughout therapy, monitor electrolytes closely.
Teach patient to take this at the same time each day, take missed doses as soon as remembered unless close to next dose; do not double. Instruct patient to
monitor weight, and to change positions slowly to avoid orthostatic hypotension. Advise patient of potassium requirements while taking this drug. Encourage
patient to monitor their BP at home and teach correct technique; advise to continue taking the drug even if they are feeling better. Regular health follow ups are
needed.
Name: lidocaine topical (Lidoderm 5% topical patch)

Concentration:

Route: transdermal

Dosage Amount: 2 patches (1 patch each knee)

Frequency: Topical, Daily, 1 patch each knee

Pharmaceutical class: anesthetic

Home

Hospital

or

Both

Indication: topical anesthetic for knee pain, post operatively

Adverse/ Side effects: stinging, burning, contact dermatitis, allergic reactions; Anaphylaxis (more common in systemic use)
Nursing considerations/ Patient Teaching: Advise patient to apply the patch to the most painful area of intact skin only, may cut the patch down to smaller size
before removing liner. Advise to always remove the previous patch before applying another one. If experiencing burning or irritation, patient may remove the
patch until irritation subside. Always wash hands after application and avoid contact with eyes. Dispose of used patches to avoid access by children or pets.
Name: triamclinolone topical (Kenalog 0.5% cream)

Concentration

Dosage Amount: 1 application of cream to back

Route: transdermal

Frequency: Topical 1 application, BID/ 7 days

Pharmaceutical class: corticosteroid

Home

Hospital

or

Both

Indication: management of inflammation and pruritis associated with various allergic or immunologic skin problems.
Adverse/ Side effects: allergic contact dermatitis, atrophy, burning, dryness, edema, hypersensitivity, secondary infection; adrenal suppression (occlusive
dressings and/or long term use)
Nursing considerations/ Patient Teaching: Instruct patient on correct technique of medication administration; emphasize to avoid eyes. Advise if a dose is
missed, to apply as soon as remembered unless near next dose time, do not double. Instruct patient to avoid using cosmetics, bandages or dressings over treated
area unless instructed by health care professional. Instruct patient to seek care if symptoms return or worsen or signs of infection develop.
Name: warfarin (Coumadin)

Concentration

Dosage Amount: 5 mg (1 tab)

Route: oral

Frequency: PO, Daily

Pharmaceutical class: anticoagulant (coumarin)

Home

Hospital

or

Both

Indication: prophylaxis and treatment of venous thrombosis, pulmonary embolism, atrial fibrillation with embolization.
Adverse/ Side effects: cramps, nausea, dermal necrosis, fever; Bleeding
Nursing considerations/ Patient Teaching: Assess for signs of bleeding or hemorrhage (bleeding gums, tarry black stools, easy bruising, fall in hematocrit or BP);
Always obtain baseline PT/INR before administration. Regular monitoring of PT/INR as well as renal and liver function. High alert medication, double check
dosage and review other mediations for possible interactions. Administer at the same time every day.
Instruct the patient to take medication exactly as prescribed, take missed doses as soon as remembered, do not double; patient should inform healthcare
professional at time of checkup or lab test of missed doses. Inform patient that anticoagulation effect may persist for 2-5 days following discontinuation; make
all healthcare providers aware of use. Patient needs to be aware of interaction with vitamin K, advise to keep a consistent intake of vitamin K if part of their
regular diet. Do not increase level of Vitamin K as it makes warfarin less effective. Instruct patient to report any signs of unusual bleeding or bruising, and or
pain, color, or temperature change to any part of their body to a health care professional immediately. Patient should not drink alcohol, take other OTC,
prescription, or herbal products (especially aspirin or NSAIDS) or to start or stop any mediations without advice of their doctor. Emphasize the importance of
follow up care and tests while on this medication regimen to monitor coagulation factors.
Name: acetaminophen (Tylenol)

Concentration

Dosage Amount: 500 mg (1 tab)

Route: oral

Frequency: PO, Q4H, PRN

Pharmaceutical class: antipyretics, nonopioid analgesic

Home

Hospital

or

Both

Indication: mild to moderate pain, scale 1-3

Adverse/ Side effects: renal failure, increased liver enzymes, rash, urticaria; Hepatotoxicity ( doses), Stevens-Johnsons syndrome, Toxic epidermal necrolysis
Nursing considerations/ Patient Teaching: Chronic high doses may increase risk of bleeding with warfarin therapy. Potential for hepatotoxicity increases with
concurrent alcohol use. Interactions with other drugs may increase risk for liver damage. NSAID use concurrently increase risk for renal effects. Do not confuse
Tylenol with Tylenol PM. Before administration check for other medications (opioids) containing acetaminophen as well to avoid risk for toxicity.
Advise patient to take drug as prescribed. Advise patient the importance of avoiding alcohol if taking chronically. Advise patient to avoid taking more than one
acetaminophen containing product at once. Risk for toxicity and symptoms should be explained to patient. Instruct to contact healthcare professional if
symptoms are not relieved by routine doses or if fever greater than 103 F persists longer than 3 days.
Name: alprazolam (Xanax)

Concentration

Dosage Amount: 0.5 mg (1 tab)

Route: oral

Frequency: PO, BID, PRN

Pharmaceutical class: benzodiazepine

Home

Hospital

or

Both

Indication: for anxiety associated with hospitalization

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects: dizziness, drowsiness, lethargy, confusion, depression, blurred vision, constipation, diarrhea, nausea, vomiting, rash; Physical dependence,
psychological dependence, tolerance (with prolonged use)
Nursing considerations/ Patient Teaching: Assess degree and manifestations of anxiety and mental status prior to administration and during therapy. Assess
patient for drowsiness, lightheadedness and dizziness. Administer greatest dose at bedtime to avoid daytime sedation.
Instruct patient to take as prescribed; if a dose is missed take within one hour otherwise skip and resume normal schedule. Advise patient to contact provider if
medication becomes less effective, do not stop taking medication abruptly. Advise patient to avoid driving or activity requiring alertness until known response to
mediation is known. Advise patient to avoid drinking grapefruit juice during therapy. Alcohol should be avoided while taking medication. Teach patient to
utilize other methods to decrease anxiety such as exercise, relaxation techniques, deep breathing, or support groups). Patient should be advised not to share
mediation with anyone and to keep from reach of children.
Name: oxycodone (Oxycontin immediate release)

Concentration

Dosage: 5mg (1 tab)

Route: oral

Frequency: PO, Q4H, PRN pain scale 7-10

Pharmaceutical class: opioid agonist

Home

Hospital

or

Both

Indication: For moderate to severe pain in knees.

Adverse/ Side effects: confusion, sedations, dizziness, euphoria, constipation, dry mouth, orthostatic hypotension, blurred vision, nausea, vomiting; Respiratory
depression
Nursing considerations/ Patient Teaching: Assess pain for type, location, intensity prior to administration and 1 hour after medication is taken. Assess BP, pulse,
and respirations before and after administration; if respiratory rate is <10/min, assess for sedation level, patient may need physical stimulation to prevent
hypoventilation. Administer a stool softener or laxative concurrently with this medication to prevent constipation.
Instruct patient this may cause drowsiness or dizziness, advise patient to call for help when ambulating; instruct to avoid driving or other activities requiring
alertness until response is known. Encourage patient to make position changes slowly to prevent orthostatic hypotension; encourage to turn, cough, and breathe
deeply every 2 hours to prevent atelectasis.

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Regular
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: 1 6 oz. strawberry lowfat yogurt and 1 cup
Cheerios cereal with cup reduced fat milk.
Lunch: 4 slices packaged lean ham & 2 slices cheddar
cheese, no bread.
Dinner: 1 5 oz. baked boneless skinless chicken breast and
1 cup green beans sauted with olive oil.
Snacks: 2 chocolate chip cookies, 1 dark chocolate Hershey
bar.
Liquids (include alcohol): diet sodas, diet iced tea drinks,
glass of wine with dinner, occasionally 1 vodka drink

Total percentage of target

.

Analysis: The should try to limit sweets intake, he is prone

to snacking frequently on chocolate and other sweets.
From analysis on MyPlate the patient is consuming more
than the needed amount of protein daily, this will help him
with wound recovery. The patient needs to increase his
intake of fruits and vegetables, as shown in the graph above
he is not taking in the recommended daily amount. His
sodium and saturated fat intake are above
recommendations; patient has history of hypertension and
hyperlipidemia so he should be cautious of the amounts
sodium and fat he eats. Increased sodium may put him at
higher risk for developing edema, and taking in too much
fat especially saturated fat increase risk for atherosclerosis
to develop. Based on his physical history he is in good
health overall, he would benefit from swapping out
chocolates and cookies with more fruits to substitute the
sugar. Reducing sodium and fats will further benefit the
patient in the long term.

University of South Florida College of Nursing Revision September 2014

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.

Daily Limits
Total Calories Eaten: 1859
Empty Calories Eaten: 912
Empty Calories Limit: 258 Total Limit: 2000
Oils
Eaten: 4 tsp.
Limit: 6 tsp.

Saturated Fat
Eaten: 45g
Limit: 22g

Sodium
Eaten: 2832mg
Limit: 2300mg

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? wife helps him when ill (she is present during exam, helps him to answer questions)
How do you generally cope with stress? or What do you do when you are upset?
Various forms of exercise help patient to cope with stress. Patient likes to bike states he will go on a bike ride if
something is stressing him; or he will visit the gym and use a rowing machine patient is a former Rower.
Uses food as a coping mechanism occasionally, typically goes for chocolate.
Patient is also a carpenter, patient and wife both agree he copes with stress by making things in his workshop. He builds
furniture.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Pt states feelings of anxiety while hospitalized, has history of anxiety. Feels claustrophobic while in the hospital, like he is
confined to a small space, feeling trapped. Wife states that being here is very hard for him and is some of the reason he
delayed this surgery for so long; the complications that have arisen are also making him more anxious.

+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, never____________________________________________
Have you ever been talked down to?__No_________ Have you ever been hit punched or slapped? ___No___________
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, in a very safe relationship

University of South Florida College of Nursing Revision September 2014

10

 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:
Of the eight stages of Eriksons Psychosocial Development Theory this patient falls into the last,
Stage 8: Ego Integrity Versus Despair (Over 65 Years). The task of this stage is the acceptance of ones life, worth, and
eventual death. Ego integrity reflects a satisfaction with life and an understanding of ones place in the life cycle. A sense of
loss, discomfort with life and aging, and a fear of death are seen in despair. (Treas & Wilkinson, 2014, p. 164)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

This patient is in the last stage of the developmental theory as explained by Erikson, Ego Integrity versus Despair. I firmly
believe he falls into the Ego Integrity category based on our interactions during this interview and exam. He has 5 children
of which he states he is extremely fond and proud of. He is a quite accomplished man, receiving degrees from Ivy league
schools MIT and George Washington University. He worked for many years in the aerospace field he excelled in
management and was very good at what he did. The patient explains to me that he has been retired for less than five years
and is quite happy with his life. Based on the definition of this stage of Eriksons Theory and judging by what the patient
has expressed, he has reached satisfaction with his life and has an understanding on his place in the life cycle. He is
content with the work that he has done and is accepting of his new life without work. I do not believe he is facing despair
or discomfort with life and aging, largely in part to him deciding to have this surgery which may improve his quality of
life significantly and allow him to enjoy his time freely and without restraint.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

As briefly described above, the impact of this hospitalization will have a beneficial effect on his developmental stage in
life. The patient has had knee pain for close to 30 years and he has finally decided to undergo the surgery to replace both
joints. He does seem to be facing some anxiety regarding the complication of the DVT; as expressed by the patients wife
this will be very good for him in the long run. The patient has been experiencing pain with normal ambulation and he has
been active all of his life; this hospitalization is meant to return him to the active lifestyle he is accustomed to and improve
his quality of living. The Ego Integrity he has will only improve with recovery.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Weak knees Years of running on them did it, going up and down hills didnt help
What does your illness mean to you?
It did not impact my life much, I was still able to excel in my work which was most of my life I worked until I was
wore out, not my knees

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?___Yes_____________________________________________________________
Do you prefer women, men or both genders? _Women only ______________________________________________
Are you aware of ever having a sexually transmitted infection? Yes, I have had herpes_________________

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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? yes___ If yes, are you in a monogamous relationship? ____yes________________
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? _none_________________________________
How long have you been with your current partner?_____28 years________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ___Yes, temporarily (knee
surgeries on this admission__________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

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

What importance does religion or spirituality have in your life? - The patients religion has impacted raising his children. His first
wife was Jewish as well, second wife is not. Follows his religion but it does not rule his daily life, some of his children have had
mitzvahs , but the children from second wife have not. Patient mentions having his own bat mitzvah as relevant to his spirituality he
became a man in the eyes of the religion.
____________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_No, the patients religious beliefs do not influence current condition.
_____________________________________________________________________________________________________
______________________________________________________________________________________________________

+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)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
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?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
How much? 1 glass with dinner
What? red wine, vodka & tonic
occasionally
Volume: 6 oz wine, 2 oz vodka
Frequency: 1x/month
If applicable, when did the patient quit?

For how many years?

(age 15 thru 74 )

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what? cocaine
How much? small amounts
For how many years? 2-3 years
(age 39

Is the patient currently using these drugs?

Yes No

If not, when did he/she quit?

thru 41

Age 41

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient states he was responsible for making sure his staff were protected from any occupational/environmental hazards,
but that he himself was never exposed to any.
5. For Veterans: Have you had any kind of service related exposure?
N/A

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health? Patient (pt) views his overall health as good, he states he is healthy other than his knees.

Integumentary: Pt has changes in appearance of skin. Rash is present on pts back and mildly on front trunk
area. Pt has bilateral knee incisions. Pt denies problems with nails, dandruff, psoriasis, hives or skin infection. Pt
uses SPF 30 sunscreen regularly with outdoor activity.
HEENT: Pt has difficulty seeing. Pt has a history of cataracts but denies glaucoma. Pt has difficulty hearing
(usually wears hearing aids). Pt denies ear infections, sinus pain or infection, or nose bleeds. Pt has occasional
post-nasal drip. Pt has some dental problems, cavities, but denies oral infection. Pt brushes his teeth twice daily
and has routine dental visits four times per year. Pts last vision screening was approximately 4 years ago after a
crystal lens surgery.
Pulmonary: Pt has occasional difficulty breathing. Pt denies cough, asthma, bronchitis, emphysema, pneumonia,
tuberculosis, or environmental allergies. Pts last chest x-ray (CXR) was prior to his knee surgery.
Cardiovascular: Pt has hypertension and hyperlipidemia. Pt denies chest pain, history of myocardial infarction,
CAD/PVD, CHF, murmur, rheumatic fever, myocarditis, or arrhythmias. Pt has had bilateral thrombus detected
in lower extremities during this admission. Pts last EKG was a couple weeks ago.
GI: Pt has had colitis and appendicitis in the past. Pt denies nausea, vomiting, diarrhea, constipation, GERD,
indigestion, hemorrhoids, yellow jaundice, pancreatitis, diverticulitis, abdominal abscess, irritable bowel,
cholecystitis, gastritis, ulcers, blood in stool, or hepatitis. Pts last colonoscopy was in 2014.
GU: Pt has had kidney stones in the past. Pt denies nocturia, dysuria, hematuria, polyuria. Pt states he usually
urinates between 4 and 5 times daily. Pt does not recall if he has history of bladder or kidney infection.
Women/Men Only: Pt denies infection of male genitalia or prostate. Pt denies benign prostate hypertrophy. Pt
denies urinary retention. Pt states he has prostate exam every 5 years, last exam was 4 years ago.
Musculoskeletal: Pt has a history of right rotator cuff injury, ruptured disk in spine, and osteoarthritis in knees.
Pt has pain in bilateral knees. Pt denies weakness, gout, osteomyelitis.
Immunologic: Pt denies chills, night sweats, fever, HIV/AIDS, lupus, rheumatoid arthritis, sarcoidosis, tumor,
life threatening allergic reaction, or enlarged lymph nodes.
Hematologic/Oncologic: Pt has anemia. Pt bruises easily. Pt denies easy bleeding or blood transfusions. Pt has
history of skin cancers on neck, stomach, and face (all removed). Pts blood type is O positive.
Metabolic/Endocrine: Pt denies diabetes, thyroid problems, intolerance to hot or cold, or osteoporosis.
Central Nervous System: Pt denies CVA, dizziness, severe headache or migraine, seizure, ticks or tremor,
encephalitis, or meningitis.
Mental Illness: Pt has anxiety. Pt denies depression, schizophrenia, or bipolar disorder.
Childhood Diseases: Pt has a childhood history of having measles and chickenpox. Pt denies mumps, polio, and
scarlet fever.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
There are no problems that patient has sought other medical attention for.

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Any other questions or comments that your patient would like you to know?
There are no other questions/comments from the patient.

10 PHYSICAL EXAMINATION:
General survey: Patient is a pleasant 74 y.o. Caucasian male who is alert and oriented X 3, in no apparent signs of distress.
Height _61_Weight_174 lbs._ BMI _22.8_
Pain (include rating and location) _4/10 bilateral knee pain _ Pulse_98_
Blood Pressure (include location)_125/81 Right Brachial_ Temperature (route taken)_Oral 100.2 deg F. _
Respirations_19_ SpO2 _97%_ Room Air or O2_Room Air_
Overall Appearance Patient is clean, well groomed, appropriately dressed, maintains good eye contact, both legs wrapped
in ACE bandage from above knee down to ankles. No other handicaps or deficits noted.
Overall Behavior Patient is awake, calm, and relaxed, interactive with others, mildly lethargic secondary to medication,
easily drifts off to sleep.
Speech Patients speech is clear and concise.
Mood and Affect Patient is pleasant and cooperative during exam, he is talkative. Patient is tired and mildly lethargic.
Patients wife states this is due to pain narcotics.
Integumentary Upper extremities warm, dry, and intact skin; elastic skin turgor, no clubbing of nails, capillary refill < 3
seconds. Lower extremities capillary refill 4 seconds. Bilateral vertical knee incisions with sutures in place. Left knee is
non-erythematous, warm, non-draining, mildly tender, no sign of infection. Right knee is mildly erythematous, warm, nondraining, mildly tender, no sign of infection. Rash present on entire back and slightly on front trunk area.
IV Access No IV site on patient.
HEENT Facial features are symmetric, no pain in sinus region, no pain or clicking of TMJ, trachea is midline, thyroid not
enlarged, no palpable lymph nodes, sclera are white and conjunctiva clear without discharge. Eyebrows, eyelids, orbital
area, eyelashes and lacrimal glands symmetric and without edema or tenderness. PERRLA pupils approx. 3 mm bilaterally,
peripheral vision intact, EOM intact with 6 cardinal fields, no nystagmus noted. Ears are symmetric with no lesion or
discharge. Whisper test heard; right ear 48 inches, left ear 36 inches. Nose is without lesions or discharge. Lips, tongue and
oral mucosa are pink, moist and without lesions.
Pulmonary/Thorax Respirations regular and unlabored, transverse to AP ratio 2:1, chest expansion symmetric, percussion
resonant throughout lung fields, dull towards bases. No sputum production, Lung sounds are equal and clear bilaterally, no
wheezes, crackles, or rhonchi heard.
Cardiovascular Heart sounds normal, S1 S2 audible, no murmur or adventitious sounds. No temporal or carotid bruit.
Pulses bilaterally equal. Apical pulse +3, carotid pulse +3, brachial pulse +3, radial pulse +3, femoral pulse +3, popliteal
pulse not assessed due to bandages, pedal pulses +1. Bilateral lower extremities are +2 edematous, non-pitting; calves are
soft and warm.
GI Bowel sounds normactive x4 quadrants, no bruits auscultated; abdomen soft, nontender, nondistended. Last BM was
6/20/15; formed and soft. Genitalia exam not performed, pt denies problems.
GU Urine output clear and yellow, urinal at bedside; patient can ambulate to bathroom with assistance.
Musculoskeletal RUE motor strength 5/5, LUE 5/5, RLE 3/5, LLE 3/5. Full ROM in upper extremities. Unable to assess
vertebral column due to impaired mobility. Patient has no pallor, paralysis or paresthesia noted.
Neurological Patient is awake, alert and oriented to person, place, time, and date. Sensation to touch and pain normal.
Romberg test not done due to impaired mobility. Patient declined deep tendon reflex examination on upper extremities.

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
University of South Florida College of Nursing Revision September 2014
15

include why you expect it to be done and what results you expect to see.
Lab
BUN:
24 H
22 H
24 H
25 H
Normal (6-20)
Creatinine:
2.0 H
2.2 H
1.9 H
1.9 H
Normal (0.6-1.3)
WBC:
10.2
12.5 H
9.1
9.1
Normal (4.5-11.1)
Hgb:
13.4 L
12.2 L
10.9 L
9.7 L
Normal for male (13-18) per nursing

Dates
(6/18/15)
(6/19/15)
(6/20/15)
(6/23/15)
(6/18/15)
(6/19/15)
(6/20/15)
(6/23/15)

(6/18/15)
(6/19/15)
(6/20/15)
(6/23/15)

(6/18/15)
(6/19/15)
(6/20/15)
(6/23/15)

central

Hct:
39.3 L
36.6 L
32.4 L
28.9 L
Normal for male (36-52) per nursing

(6/18/15)
(6/19/15)
(6/20/15)
(6/23/15)

central

US Non-Invasive Doppler Venous

Bilateral Lower Extremities:
(post operative)
Findings: There is evidence of
nonocclusive thrombus within the
popliteal veins bilaterally. There is
also thrombus extending into the
bilateral gastrocnemius veins as
well as visualized left peroneal and
posterior tibial veins. There is
otherwise compressibility
demonstrated within bilateral

(6/20/15)

Trend
Patient has steadily high
levels of BUN and
creatinine following
surgery on 6/17/15. The
trend on his BUN level
seems to be increasing
slowly. The creatinine
level is going down
slowly. These levels
indicate decreased renal
function.

Analysis
Elevated levels of BUN
and creatinine are
indicative of impaired
renal function which the
patient is known to have
with CKD. He had fluids
infused after the increase
in creatinine was noted
after surgery. This
addition may have helped
his levels to start
declining.
Patient had WBC in the
The number of cells in
high normal range and
blood fighting infection.
then a spike into the
The spike in WBC
abnormal high range.
indicates his body is
This may indicate the
healing and inflammation
inflammatory process is
is present at the wound
occurring status post
site, but does not indicate
surgery.
fighting an infection.
The patients hemoglobin Hct level is the amount of
and hematocrit levels are protein making up the red
both trending down. This blood cells. The Hgb
indicates that the patient
level is the volume of red
is anemic and levels are
blood cells compared to
declining after surgery.
the total blood volume of
the patient. Both of these
numbers trending down
indicate that he is anemic
which can be common
with blood loss after
surgery and patients with
CKD(chronic kidney
disease)
Post surgery Doppler
Patient needs an
scan was ordered to rule
intervention to prevent
out or diagnosis a
the clots from moving.
possible thrombus. The
Per radiologist notes, he
scan shows bilateral DVT is not a good candidate
present. This puts the
for anticoagulation
patient at risk for the
therapy. He needed an
thrombus to travel to the
inferior vena cava filter
lungs, which can be
inserted to prevent a
deadly.
pulmonary embolism.

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common femoral through

superficial femoral veins.
Normal (no evidence of thrombus
in bilateral extremities)
X-Ray Right and Left Knee 1-2
Views: (post-operative)
Findings: The patient has
undergone bilateral
tricompartmental knee
replacement. The components
appear well seated and in near
anatomic alignment. Surgical
drains are in place. There is air
within the soft tissues consistent
with recent surgery. There appears
to be a right-sided knee joint
effusion.

(6/17/15)

X-ray is needed after

orthopedic surgery to
ensure correct placement
and alignment of new
joints. The patient seems
to have correct alignment
based on x-ray result. It
also shows effusion of the
right knee joint and air in
soft tissue.

Based on the findings of

this test it seems the
surgery was successful in
replacing the joint
hardware. The air in soft
tissues will dissipate in
days after surgery. The
right knee joint effusion
is not uncommon after an
invasive surgery such as
knee arthroplasty.

Normal (depends on reason for

exam, ie: r/u fracture, check
position of hardware. Want to have
no abnormality for reason)

+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 regular diet, PO intake is encouraged to help with healing and anemia. Special menu provided to
patient for more desirable options.
Vitals are Q4H.
Fall risk for this patient is high. Factors for this risk include his age, limited mobility s/p surgery, and high risk
medication use. He is able to ambulate with rolling walker for assistance, with supervision.
Patients physical therapy is on hold per physician orders the wound sites are warm and erythematous,
hematoma noted.
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Patient is scheduled on 6/24/15 in the OR for a washout of both knee incisions due to hematoma.
Patients renal function is being monitored by Dr. S.
Patient will have a psychiatry consult for anxiety.

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

1. Impaired physical mobility, related to pain and weakness in weight-bearing extremities as associated with bilateral
knee surgery, as evidenced by verbalization of pain and need for assistance with ambulation.
2. Risk for Peripheral neurovascular dysfunction related to orthopedic surgery.

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 15 CARE PLAN
Nursing Diagnosis: Impaired physical mobility, related to pain and weakness in weight-bearing extremities as associated with bilateral knee surgery, as
evidenced by pain scale of 7-10 and need for assistance with ambulation.

Patient
Goals/Outco
mes
Patient will
ambulate with
rolling walker
to and from
the bathroom
with
supervision
during the
shift.

Patient will
report pain
scale of 3/10
throughout
shift.

Nursing Interventions to Achieve Goal

1. Before activity, observe for and, if
possible, treat pain with massage, heat
pack to affected area, or medication.
Ensure that the client is not over
sedated.
2. *Obtain any assistive devices needed for
activity, such as gait belt, weighted vest,
walker, cane, crutches, or wheelchair,
before activity begins.
3. *Increase independence in ADLs,
encouraging self-efficacy and
discouraging helplessness as the client
gets stronger.
1. Assess pain level in a client using valid and
reliable self-report pain tool, such as the 010 numerical pain rating scale.
2. Assess the client for pain presence
routinely at frequent intervals, often at the
same time as vital signs are taken, and
during activity and rest. Also assess for
pain with interventions or procedures likely
to cause pain.
3. Obtain a prescription to administer an
opioid analgesic if indicated, especially for
moderate to severe pain.

Rationale for Interventions

Provide References
1. Pain limits mobility and is often
exacerbated by movement. (Ackley &
Ladwig, 2011, p. 550)
2. Assistive devices can help increase
mobility. Yeom, Kellery & Fleury,
2009 (as cited by Ackley & Ladwig,
2011, p. 551)
3. Providing unnecessary assistance
with transfers and bathing activities
may promote dependence and a loss
of mobility. (Ackley & Ladwig, 2011,
p. 551)
1. The first step in pain assessment is to
determine if the client can provide a
self-report. Ask the client to rate pain
intensity or select descriptors of pain
intensity using a valid and reliable
self-report pain tool. Breivik et al,
2008; Ming Wah, 2008 (as cited by
Ackley & Ladwig, 2011, p. 601)
2. Pain assessment is as important as
physiological vital signs and pain is
considered the fifth vital sign.
Acute pain should be reliably
assessed both at rest (important for
comfort) and during movement
(important for function and decreased

University of South Florida College of Nursing Revision September 2014

Evaluation of Goal on Day Care is

Provided

1. Patients pain addressed with prope

medication before needing to
ambulate.
2. Patient has assistive devices
available. Gait belt is used for
transfers. Wheelchair is available a
well as walker. Patient ambulated t
the bathroom with use of walker an
supervision.
3. Patient was able to brush his teeth
dress upper extremities without
assistance. Patient still needs
assistance dressing lower extremiti
1. Patients pain was initially reporte
as a 7 at beginning of shift. After
medication was given patient
reported pain of 3/10.
2. Patients pain was assessed with vi
signs. Prior to physical therapy the
patient was assessed for pain and
reported pain of 3/10.
3. Patient is taking opioid medication
manage moderate to severe pain.

19

3.
Patient will
increase
muscle
strengthening
activities that
involves the
lower
extremities
during
hospital stay.

1. *Consult with physical therapist for

further evaluation, strength training, gait
training, and development of a mobility
plan.
2. If the client is immobile, perform
passive ROM exercises at least twice a
day unless contraindicated; repeat each
maneuver three times.

1.

2.

Patient will
ambulate
without
assistance by
time of
discharge

1. Do not routinely assist with transfers or

bathing activities unless necessary.
2. Help the client achieve mobility and
start walking as soon as possible if not
contraindicated.
3. *Consult with physical therapist for
further evaluation, strength training, gait

1.

2.

client risk of cardiopulmonary and

thromboembolic events. Breivik et al,
2008 (as cited by Ackely & Ladwig,
2011, pp. 601-602)
Opioids are indicated for the
treatment of moderate to severe pain.
(Ackley & Ladwig, 2011, p. 603)
A review of interventions to enhance
mobility found that prescribing a
regimen of regular physical activity
that includes both aerobic exercise
and muscle strengthening activities is
beneficial to minimizing impaired
mobility; use exercise diary or log to
improve adherence to mobility
enhancement recommendations.
Develop mobility enhancement
programs that are specific to gender,
ethnicity, and are culturally
appropriate. Yeom, Kellery & Fleury,
2009 (as cited by Ackley & Ladwig,
2011, p. 550)
Inactivity rapidly contributes to
muscle shortening and changes in
periarticular and cartilaginous joint
structure. The formation of
contractures starts after 8 hours of
immobility. Fletcher, 2005 (as cited
by Ackley & Ladwig, 2011, p. 551)
The nursing staff may contribute to
impaired mobility by helping too
much. Encourage client
independence. Fauci et al, 2008 (as
cited by Ackley & Ladwig, 2011, p.
553)
Early mobilization for acute limb

University of South Florida College of Nursing Revision September 2014

1. Patient works with physical therap

daily to increase muscle strength an
improve mobility.
2. Physical therapy includes passive
ROM exercises with the patient da

1. The patient still requires minimal t

moderate assistance with some
activities. Patient can mostly dress
himself and perform most ADLs
without assistance.
2. The patient is allowed full mobility
self-tolerated. Walker use is
20

training, and development of a mobility

plan.

injuries generally resulted in

improved function, less pain, and
earlier return to work and sports.
Ebell, 2005 (as cited by Ackley &
Ladwig, 2011, p. 551)
3. A review of interventions to enhance
mobility found that prescribing a
regimen of regular physical activity
that includes both aerobic exercise
and muscle strengthening activities is
beneficial to minimizing impaired
mobility; use exercise diary or log to
improve adherence to mobility
enhancement recommendations.
Develop mobility enhancement
programs that are specific to gender,
ethnicity, and are culturally
appropriate. Yeom, Kellery & Fleury,
2009 (as cited by Ackley & Ladwig,
2011, p. 550)

encouraged.
3. The patient is working with physic
therapy daily to increase strength,
improve gait. His mobility plan thu
far is to complete all activities as
tolerated by the patient. He is able
ambulate with supervision. By
discharge he should be without
assistive devices.

Include a
minimum of
one
Long term
goal per care
plan
University of South Florida College of Nursing Revision September 2014

21

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

- Patient will be discharged to home. His wife will be caring for him after discharge. He has 5 steps to enter, single floor home in St. Pete. Patient may need a
walker to help with ambulation to steady him while recovering. Physical therapy should be continued to promote strength training in lower extremities, this m
be done on an outpatient basis. The patient should be counseled on a diet to promote wound healing and to help with anemia. Advise patient to keep all
necessary follow up appointments regarding joint replacements as well as renal function with his regular specialist. Patient will be on warfarin for 1 month
following surgery, advise to keep follow up lab appointments.
Medication adherence should be followed as prescribed; patient states he has supplemental drug coverage to help with the cost of prescriptions.

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22

References
Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.
Funaki, B. (2006). Inferior Vena Cava Filter Insertion. Seminars in Interventional Radiology, 23(4), 357-360.
doi:10. 1055/s-2006-957026
Huether, S. E., & McCance, K. L., (2012). Alterations of Hematologic Function. In V. L. Brashers & N. S. Rote
(Eds.), Understanding Pathophysiology (5th ed.) pp. 526-534. St. Louis, MO: Mosby Elsevier.
Malone, P. C., & Agutter, P. S. (2008). The aetiology of deep venous thrombosis: A critical, historical and
epistemological survey. Dordrecht: Springer. Retrieved from
http://usf.catalog.fcla.edu.ezproxy.hsc.usf.edu/sf.jsp?st=dvt+&ix=kw&fa=language_facet
%3AEnglish&V=D&S=0081436030198672&I=2#top
Treas, L. S., & Wilkinson, J. M., (2014). Basic Nursing. Concepts, Skills & Reasoning. Philadelphia, PA: F. A.
Davis

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