UNIVERSITYOFSOUTHFLORIDA

COLLEGEOFNURSING
FUNDAMENTALPATIENTASSESSMENTTOOL

Student:TiffanyTran
.

AssignmentDate:06/21/16

1PATIENTINFORMATION
PatientInitials:SJ Age:39

Agency:TampaGeneralHospital

Gender:Male

PrimaryMedicalDiagnosis:SickleCell
Anemia

MaritalStatus:Single

PrimaryLanguage:English
LevelofEducation:AssociatesdegreefromDeVry
University
Occupation(ifretired,whatfrom?):FieldServiceTechnician

AdmissionDate:06/19/16

OtherMedicalDiagnoses:(newonthis
admission)SickleCellCrisis

Number/ageschildren/siblings:Nochildren.4youngersisters
(Patientunawareoftheirages)
Served/Veteran:
Ifyes:Everdeployed?YesorNo

CodeStatus:Fullcode

LivingArrangements:LivesaloneinBrandon(apartment)

AdvancedDirectives:No
Ifno,dotheywanttofillthemout?:No
SurgeryDate:N/AProcedure:N/A

Culture/Ethnicity/Nationality:American(Patientdenies
identifyingwithanyotherculture)
Religion:Patientdeniesidentifyingwithanyreligion

TypeofInsurance:Aetna

1CHIEFCOMPLAINT:Istartedhavingpainandknewitwasmysicklecellanemia.Itriedtodealwithit
athomewithmyoxycodone,butitgotworseandworse,soIcamehere.
3HISTORYOFPRESENTILLNESS:(BesuretoOLDCARTthesymptomsinadditiontothehospital
courseofstay)Patientwasadmittedon06/19/16withsicklecellcrisis,whichbeganon06/14/16.Patient
reportedgeneralbackpain,jointandanteriorchestpain.Patientreportedconstantandthrobbingpainthatwas
sometimesaggravatedwithandsometimesrelievedbymovement.Heattemptedtotreatathomewith5mg
oxycodone,bid.Uponadmission,hewastreatedwith2mghydromorphonePRNq3h,aswellas2unitsofRBC
transfused.Patientstillreportspainlevel8persisting.
2PASTMEDICALHISTORY/PASTSURGICALHISTORYIncludehospitalizationsforanymedical
illnessoroperation;includetreatment/managementofdisease
Date
OperationorIllness
Year1979
Dxwithsicklecellanemia(2yearsold)
Year1979
Dxwithheartmurmurwhilehospitalizedforsicklecellcrisis/anemia
Year1989
Hospitalizedwithpneumonia
University of South Florida College of Nursing Revision September 2014

Father
Mother
Brother
Sister

U
n
k
5
5
N
/
A
3
1

Tumor

Stroke

StomachUlcers

Seizures

MentalHealth
Problems

Hypertension
Problems
Kidney

Gout
DVTetc.)
(angina,MI,
HeartTrouble

Glaucoma

Diabetes

Cancer

BleedsEasily

Asthma

Anemia
Arthritis

Environmental
Allergies

Cause
of
Death
(if
applicab
le)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age(inyears)

Patientsdeniesfurthermedicalorsurgicalhistory.

Relationship
:Maternal 7
Grandmothe 0
r
relationship
relationship
Comments:Includeageofonset
Patientdeniesknowingagesofonsetforhisfamilysmedicalhistory.

1IMMUNIZATIONHISTORY
(MaystateUforunknown,exceptforTetanus,Flu,andPna)
YES
Routinechildhoodvaccinations
Routineadultvaccinationsformilitaryorfederalservice
AdultDiphtheria(Date:U)
AdultTetanus(Date:U)

Iswithin10years?
Influenza(flu)(Date:N/A)

Iswithin1years?
Pneumococcal(pneumonia)(Date:U)

Iswithin5years?
Haveyouhadanyothervaccinesgivenforinternationaltravelor
occupationalpurposes?PleaseList
Ifyes:givedate,canstateUforthepatientnotknowingdatereceived
1ALLERGIES
ORADVERSE
REACTIONS
Medications

NAMEof
CausativeAgent

NO

TypeofReaction(describeexplicitly)

University of South Florida College of Nursing Revision September 2014

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

NKDA

Patientdeniesmedicationallergies

Alcohol

Caninciteasicklecellcrisisandpatientreportsheusuallybecomes
hospitalized

5PATHOPHYSIOLOGY:(includeAPAreferenceandintextcitations)(Mechanicsofdisease,riskfactors,
howtodiagnose,howtotreat,prognosis,andincludeanygeneticfactorsimpactingthediagnosis,prognosisor
treatment)
Sicklecellanemiaisaninherited,autosomalrecessivedisease.Apatientwiththisdiseasewillhaveaffectedred
bloodcellsthataresickled,haveincreasedadhesiveness,anddonoteffectivelycarryhemoglobinand,thus,do
noteffectivelycarryoxygen.Patientswithsicklecellanemiawillhavestretchesofratherhigh(ornormal)
functioninginspiteofthechronicanemia.Theseperiodsofhighfunctioningwillbeinterspersedwithperiods
ofheightenedand,sometimes,intensepainduetoocclusionofbloodvesselswiththesickledredbloodcells
knownassicklecellcrisesorvasoocclusivecrises.Duringthesecrises,patientsbecomeischemicatthesitesof
occlusion,whichgenerallyincludethechest,back,andextremities.Althoughcrisescanoccurwithouttriggers,
certaineventssuchasinfections,extremelycoldweather,orevendehydrationcanincitetheepisodes.Oncethe
crisishasbegun,thetreatmentisgenerallysupportive,intermsofpainmanagementandrestoringhemoglobin
levels.Patientswillgenerallyreceiveopioidandnonopioidanalgesicsforpainaswellasredbloodcellsin
ordertoreplacetheirhemoglobinandcompensateforthevolumeofsickledcellspresent.Episodestendtolast
9to11days,withthepainintensitypeakingaroundday3anddecreasingaroundday6or7.Theseepisodes,
however,canpotentiallybecomplicatedwiththepatientsinadequateneutrophilreactions,leavingthem
susceptibletoinfections.
5MEDICATIONS:[IncludebothprescriptionandOTC;hospital,home(reconciliation),routine,andPRN
medication(ifgiveninlast48).Givetradeandgenericname.]
Name:diphenhydramine(Benadryl)
Concentration:N/A
DosageAmount:25mg
Route:IV
Frequency:2timesdailyPRNfortransfusion
reactionandq6hPRNitching
Pharmaceuticalclass:Antihistamine
HomeHospitalorBoth
Indication:Usedforitching
Adverse/Sideeffects:Drowsiness,dizziness,anticholinergiceffects
Nursingconsiderations/PatientTeaching:Patientreportsanyexcessivedrowsinessordizziness.Riseslowly
orwithstandbyassistance
Name:docusatesodium(COLACE)
Concentration:N/A
DosageAmount:100mg
Route:Oral
Frequency:2timesdaily
Pharmaceuticalclass:Stoolsoftener
HomeHospitalorBoth
Indication:Usedtohelprelieveconstipationfromopioidanalgesicsandlackofambulationduringsicklecell
crisishospitalization
Adverse/Sideeffects:GIdistress,rectalirritation,throatirritation,bittertasteinmouth
Nursingconsiderations/PatientTeaching:Donotuseinconcurrencewithmineraloil.Reportanyrectal
University of South Florida College of Nursing Revision September 2014
3

bleedingordiarrhea
Name:famotidine(PEPCID)
Concentration:N/A
DosageAmount:20mg
Route:IV/PO
Frequency:2timesdaily
Pharmaceuticalclass:histamineH2receptor
HomeHospitalorBoth
antagonist
Indication:UsedtoprotectpatientsGItractfromdistress(secondarytomedicationswhilehospitalized)
Adverse/Sideeffects:Headache,agitation,hypersensitivity
Nursingconsiderations/PatientTeaching:Havepatientmonitorforhypersensitivity/adversereactionsand
reportimmediately
Name:folicacid(FOLVITE)
Concentration:N/A
DosageAmount:1mg
Route:PO
Frequency:daily
Pharmaceuticalclass:Erythropoiesisagent
HomeHospitalorBoth
Indication:Usedtohelpsynthesisoferythrocytes
Adverse/Sideeffects:Hypersensitivityreactions
Nursingconsiderations/PatientTeaching:Havepatientmonitorforhypersensitivityreactionsandreport
immediately
Name:heparinflush(HepLock)

Concentration:100unit/mL
DosageAmount:5mL
injection500units
Route:IV
Frequency:flushPRN
Pharmaceuticalclass:Anticoagulant
HomeHospitalorBoth
Indication:UsedtoflushMediportif/whentherearenoIVfluidsbeinginfused
Adverse/Sideeffects:Severelackofplatelets,uncontrolledbleeding
Nursingconsiderations/PatientTeaching:Havepatientmonitorforbruisingorunexpected/uncontrolled
bleeding
Name:HYDROmorphone(dilaudid)
Concentration:N/A
DosageAmount:2mg
Route:IV
Frequency:q3hPRN
Pharmaceuticalclass:Opioidanalgesic
HomeHospitalorBoth
Indication:Usedtocontrolpainfromsicklecellcrisis
Adverse/Sideeffects:Respiratorydepression,sedation,apnea,lightheadedness,dizziness,GIdistress,euphoria,
drymouth,pruritus
Nursingconsiderations/PatientTeaching:Informpatientofsedativeeffectsandpotentialorthostatic
hypotension.Riseslowlyorwithstandbyassistance
Name:ondansetronHCl(Zofran)
Concentration:4mg/2mL
DosageAmount:4mg
Route:IV
Frequency:q6hPRNnauseaandvomiting
Pharmaceuticalclass:Selective5HT3receptor
HomeHospitalorBoth
antagonist
Indication:Usedtopreventnauseaandvomitingsecondarytomedicationsduringhospitalization
Adverse/Sideeffects:Diarrhea,constipation,headache,fever,dizziness,drowsiness/sedation
Nursingconsiderations/PatientTeaching:Riseslowlyorwithstandbyassistance.Reportanymentalstatus
University of South Florida College of Nursing Revision September 2014

alteration.
Name:oxyCODONE(Roxicodone)
Concentration:N/A
DosageAmount:5mg
Route:PO
Frequency:q4hPRN
Pharmaceuticalclass:Opioidanalgesic
HomeHospitalorBoth
Indication:Usedtocontrolpain(breakthroughpain)fromsicklecellcrisis
Adverse/Sideeffects:Respiratorydepression/arrest,circulatorydepression,cardiacarrest,hypotension,
headache,pruritus,dizziness,insomnia
Nursingconsiderations/PatientTeaching:Informpatientofsedativeeffectsandpotentialorthostatic
hypotension.Riseslowlyorwithstandbyassistance
Name:polyethyleneglycol3350
Concentration:N/A
DosageAmount:17g
(MiraLax)
Route:PO
Frequency:2timesdaily
Pharmaceuticalclass:Osmoticlaxative
HomeHospitalorBoth
Indication:Usedtohelprelieveconstipationfromopioidanalgesicsandlackofambulationduringsicklecell
crisishospitalization
Adverse/Sideeffects:Loose,watery,andtoofrequentstools.GIdistress,rectalbleeding
Nursingconsiderations/PatientTeaching:Havepatientmonitorandreportrectalbleedingordiarrhea
Name:0.45%NaClinfusion
Concentration:0.45%NaCl
DosageAmount:150mL/hour
infusion
Route:IV
Frequency:Continuous
Pharmaceuticalclass:Hypotonicsalinesolution HomeHospitalorBoth
Indication:Usedtomaintainpatienthydrationduringsicklecellcrisisandhospitalizationaswellastomaintain
patencyofIVlineinMediport
Adverse/Sideeffects:IrritationatIVsite,hypervolemia,infiltrationofIVsite,erythema
Nursingconsiderations/PatientTeaching:TeachpatienttomonitorIVsiteforswelling,erythema,andreport
anypainorIVsitechanges.

5NUTRITION:Includetypeofdiet;24HRaveragehomediet,andyournutritionalanalysiswith
recommendations.
Dietorderedinhospital?Regular
Analysisofhomediet(ComparetoMyPlateand
Dietpatientfollowsathome?Regular
Considercomorbiditiesandculturalconsiderations):

University of South Florida College of Nursing Revision September 2014

24HRaveragehomediet:

Breakfast:1Peanutbutter/jellysandwichonrefined
grain

Asevidencedbythegraphabove,thepatientsdietis
imbalanced.Heconsumesanabundanceofproteinand
fruit(includingbothfruitandjuice)aswellassome
refinedgrains,butdoesnotconsumevegetablesor
dairy.Hisexcessofcandy,juiceandsoda
consumptionmakeitsothathisaveragedailycaloric
consumptionexceedshistargetof2000calories(2427
calories).Inadditiontovegetablesanddairy,the
patientisunderhisdailytargetforiron.Inregardsto
hissicklecellanemia,itisimperativeforhimto
consumeanadequateamountofiron.Furthermore,it
iscrucialforhimtoproperlyhydrateinorderto
maintainthepatencyofhisbloodvessels.Thepatient
wouldneedtoincreasehisironintake(whichcouldbe
donebyincorporatingvegetablesintohisdiet)aswell
asmaintainingproperhydrationwithwater,
preferably.

Lunch:1fruitcocktailcupand1largefriedchicken
breast
Dinner:2cupsBeefstew(homemade)
Snacks:Candy(8Twizzlersticks,16gummybears)
Liquids(includealcohol):5cupswater,1CocaCola
(regular),2cupsapplejuice,3mugssweettea

University of South Florida College of Nursing Revision September 2014

Usethislinkforthenutritionalanalysisbycomparing
thepatients24HRaveragehomediettothe
recommendedportions,anduseMyPlateasa
reference.

1COPINGASSESSMENT/SUPPORTSYSTEM:

(thesearepromptsdesignedtohelpguideyour
discussion)
Whohelpsyouwhenyouareill?:Patientstatesthatnoonehelpshimwhenheisill,ashedoesnotrequesttheir
help.Headvisesthathismotherhelpshimwhenheaskshertodoso.
Howdoyougenerallycopewithstress?orWhatdoyoudowhenyouareupset?:Patientstatesthathedistracts
himselfwithvideogamesortelevision.

Recentdifficulties(Feelingsofdepression,anxiety,beingoverwhelmed,relationships,friends,sociallife):
Patientdeniesfeelingsofdepressionoranxiety,butcontinuestostatethathehasnosociallifeanddeclares
himselfterminallysingle/alone.Patientreportsthathedoesnotunderstandwhyheisnotabletofindor
maintainarelationship.

+2DOMESTICVIOLENCEASSESSMENT
Considerbeginningwith:Unfortunatelymany,children,aswellasadultwomenandmenhavebeenor
currentlyareunsafeintheirrelationshipsintheirhomes.Iamgoingtoasksomequestionsthathelpmeto
makesurethatyouaresafe.
Haveyoueverfeltunsafeinacloserelationship?
__No___________________________________________________
Haveyoueverbeentalkeddownto?_20yearsagoinhighschool_Haveyoueverbeenhitpunchedorslapped?
_20yearsagoinhighschool_
Haveyoubeenemotionallyorphysicallyharmedinotherwaysbyapersoninacloserelationshipwithyou?
_No_______________________________________Ifyes,haveyousoughthelpforthis?
_N/A___________________
Areyoucurrentlyinasaferelationship?Patientiscurrentlysingle.

4DEVELOPMENTALCONSIDERATIONS:
Eriksonsstageofpsychosocialdevelopment: Trustvs.

Mistrust

Autonomyvs.

University of South Florida College of Nursing Revision September 2014

Doubt&Shame
7

Initiativevs. Guilt Industryvs. Inferiority Identityvs. RoleConfusion/Diffusion Intimacy

vs. Isolation Generativityvs. Selfabsorption/Stagnation EgoIntegrityvs. Despair
Checkoneboxandgivethetextbookdefinition(withcitationandreference)ofbothpartsofEricksons
developmentalstageforyour
patientsagegroup:Basedonthepatientsagegroup,heisintheIntimacyvsIsolationstageofpsychosocial
development.Thisstageofhislifeisdefinedbyhisabilitytopursueandmaintainintimaterelationshipswith
otherpeople.Atthispointinhisdevelopment,thepatientisexperiencingloneliness,isolationanddepression.
Heisunabletoachieveintimacyinrelationshipsandisbeginningtofeelterminallysingle.Ifhewere
succeedinginthisstageofhislife,hewouldbecomfortableinrelationshipsandfeelsafeinthecompanyof
others.
Describethestageyourpatientisinandgivethecharacteristicsthatthepatientexhibitsthatledyoutoyour
determination:Mypatientdemonstratessignsofisolation,asheisunabletosuccessfullypursueandmaintain
intimacywithothers.Hecontinuouslyexpressesfeelingsofterminalsinglehoodandisolation.Heexpresses
confusionastohowtoacquireandmaintainrapport,letaloneatrue,intimaterelationshipwithanotherperson.
Describewhatimpactofdisease/conditionorhospitalizationhashadonyourpatientsdevelopmentalstageof
life:Patientstatesthathissicklecellanemiaisalargepartofwhatmakeshimfeelisolatedandhebelievesthat
itisalargepartofthereasonheissingle.
+3CULTURALASSESSMENT:
Whatdoyouthinkisthecauseofyourillness?:Patientstatesthatheunderstandsthecauseofhisillnessis
purelygenetic.

Whatdoesyourillnessmeantoyou?:Patientstatesthathissicklecellanemiatakesatollonhispsychological
wellbeing.Hestatesthathefeelsisolatedfromothers,especiallyconsideringthefactthathisfoursistersdonot
sufferfromsicklecellanemialikehedoes.Headvisedheisthefirstofhisfamilythatsuffersfromthefull
blownanemia(andisnotjustacarrier).Patientstatesthat,becauseofhisdiagnosis,hefeelsheisunwillingto
havechildrenandexposethemtohisillnessandpotentiallytoillnessoftheirown.
+3SEXUALITYASSESSMENT:(thefollowingprompts

mayhelptoguideyourdiscussion)
Considerbeginningwith:Iamaskingaboutyoursexualhistoryinordertoobtaininformationthatwill
screenforpossiblesexualhealthproblems,theseareusuallyrelatedtoeitherinfection,changeswithaging
and/orqualityoflife.Allofthesequestionsareconfidentialandprotectedinyourmedicalrecord
Haveyoueverbeensexuallyactive?
______Yes___________________________________________________________
Doyoupreferwomen,menorbothgenders?
______Women________________________________________________
Areyouawareofeverhavingasexuallytransmitted
infection?_____No_______________________________________
Haveyouorapartnereverhadanabnormalpapsmear?
_____N/A____________________________________________Haveyouoryourpartnerreceivedthe
Gardasil(HPV)vaccination?_____N/A(toooldwhenitbecameavailable)______

University of South Florida College of Nursing Revision September 2014

Areyoucurrentlysexuallyactive?_____No____________________Ifyes,areyouinamonogamous
relationship?__N/A_______________Whensexuallyactive,whatmeasuresdoyoutaketopreventacquiringa
sexuallytransmitteddiseaseoranunintendedpregnancy?_____Condoms______________________
Howlonghaveyoubeenwithyourcurrentpartner?
_____N/A________________________________________________
Haveanymedicalorsurgicalconditionschangedyourabilitytohavesexualactivity?
___No_______________________
Doyouhaveanyconcernsaboutsexualhealthorhowtopreventsexuallytransmitteddiseaseorunintended
pregnancy?___No_____________________

University of South Florida College of Nursing Revision September 2014

1SPIRITUALITYASSESSMENT:(includingbutnotlimitedtothefollowingquestions)
Whatimportancedoesreligionorspiritualityhaveinyourlife?
Patientstatesthatreligionandspiritualitydonothaveanyinfluenceinhislife.Headvisesheattendedchurch
asachild,butnolongerdoes.Patientdeniesmeditationas
well.______________________________________________________________________
Doyourreligiousbeliefsinfluenceyourcurrentcondition?
__N/A____________________________________________________________________________________
_________________
__________________________________________________________________________________________
____________
+3SMOKING,CHEMICALUSE,OCCUPATIONAL/ENVIRONMENTALEXPOSURES:
1.Doesthepatientcurrently,orhashe/sheeversmokedorusedchewingtobacco?YesNo
Ifso,what?:
Howmuch?(specifydailyamount) Forhowmanyyears?0years
Deniestobacco,hookah,vaporuse
(agethru)
Ifapplicable,whendidthe
patientquit?N/A

PackYears:0
Doesanyoneinthepatientshouseholdsmoketobacco?
Ifso,what,andhowmuch?N/A(livesalone;parents
didnotsmoke)

Hasthepatientevertriedtoquit?N/A
Ifyes,whatdidtheyusetotrytoquit?N/A

2.Doesthepatientdrinkalcoholorhashe/sheeverdrankalcohol?YesNo
What?Beer
Howmuch?1glass
Forhowmanyyears?
Volume:8oz
(age:37thru:37)
Frequency:Once/lifetime
(allergic)
Patientonlydrankalcoholone
timebecausehehadanallergic
Ifapplicable,whendidthepatientquit?
reactionandwashospitalizedfora
sicklecellcrisis.
3.Hasthepatienteverusedstreetdrugssuchasmarijuana,cocaine,heroin,orother?YesNo
Ifso,what?N/A
Howmuch?N/A
Forhowmanyyears?N/A
(agethru)
Isthepatientcurrentlyusingthese
drugs?YesNo

Ifnot,whendidhe/shequit?

N/A

4.Haveyouever,orareyoucurrentlyexposedtoanyoccupationalorenvironmentalHazards/Risks
Patientstatesnoknownenvironmentaloroccupationalhazards/risks.

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10

5.ForVeterans:Haveyouhadanykindofservicerelatedexposure?
N/A
10REVIEWOFSYSTEMSNARRATIVE
GeneralConstitution(OLDCARTanythingcheckedabove)
Howdoyouviewyouroverallhealth?:Patientstateshebelieveshissicklecellanemiaisgenerallycontrolled
andthatheisluckyasthisishisfirstcrisisinalmost3years.
Integumentary:Patienthasintactskinthatisdry,warmandappropriateforhisethnicity.Hedeniesproblems
withwounds,erythema,edema,rashes,hives,andnails.
HEENT:Patientreportsblurryvisionwhenreadingexcessivelyandstatesthatherequiresglassestobothread
andsee.Patientdeniesproblemswithear,nose,throat,tonsils,orheadachesandmigraines.PatientdeniesHxof
glaucomaandcataracts.
Pulmonary:Patientdeniesdyspneaandcough.PatientalsodeniesHxofasthma,bronchitis,tuberculosis,
environmentalallergies,oremphysema.
Cardiovascular:PatientdenieschestpainorHxofhypertension,hyperlipidemia,chestpain/angina,myocardial
infarction,CAD/PVD,heartfailure,thrombus,rheumaticfever,arrhythmiasorhyperglycemia.Patientreports
historyofmurmur,whichwasdiagnosedatage2inconjunctionwithsicklecellanemia.
GI:Patientdeniesindigestionorulcers,nausea,vomiting,diarrhea,hemorrhoids,pancreatitis,jaundice,colitis,
appendicitis,irritablebowelsyndrome,orhepatitis.Patientreportshislastbowelmovementwaspriorto
hospitalizationon06/19/16andthatitwasformedandnormalforhim.Patientreportsregularityofbowel
movementsathome2timesdaily.Besideshisopioidinducedconstipation,patientdeniesHxofGIdistressor
issues.
GU:PatientdeniesdysuriaorHxofkidneystonesorurinarytractinfections;however,hereports
concentrated/darkyellowurineduetohisdehydration.
Women/MenOnly:Patientdeniesfindingmassesuponselfpalpationoftesticles.Patientdenieshaving
prostateexamsorcolonoscopy.PatientdeniesBPH,urinaryretention,orinfectionofgenitalia.
Musculoskeletal:Patientdeniestingling,weaknessornumbnessinextremities.PatientdeniesHxoffractures,
gout,arthritis,orosteomyelitis.
Immunologic:PatientdeniesHxofchillswithsevereshaking,nightsweats,fever,HIVorAIDS,lupus,
rheumatoidarthritis,sarcoidosis,tumors,anaphylaxisorlymphadenopathy.
Hematologic/Oncologic:Patientreportsdiagnosisofsicklecellanemiaat2yearsofage.Patientreportshehas
hadseveral(unknownnumber)bloodtransfusionsfromage2andoninordertoaddresshissicklecellcrises.
PatientdeniesHxofcancer.
Metabolic/Endocrine:PatientdeniesHxofdiabetes,hypothyroidorhyperthyroid,osteoporosisorintolerance
tohotorcold.
CentralNervousSystem:PatientdeniesHxofmigraines,headachesorstroke,CVA,dizziness,seizures,ticks
ortremors,encephalitisormeningitis.
MentalIllness:PatientdeniesHxofmentalillness,includingbipolardisorder,schizophrenia,oranxiety.
PatientdeniesHxofdepression.
ChildhoodDiseases:Patientstateshismainchildhoodillnesswassicklecellanemia(diagnosedage2)andthat
theonlyotherproblemheencounteredwaschickenpoxatage15.Patientdeniesmeasles,mumps,polio,scarlet
feverandasthma.
Isthereanyproblemthatisnotmentionedthatyourpatientsoughtmedicalattentionforwithanyone?:
No
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11

Anyotherquestionsorcommentsthatyourpatientwouldlikeyoutoknow?
No

10PHYSICALEXAMINATION:
Generalsurvey_Patientislethargic,butappropriate.Heisdisheveled,butunabletobatheduetopainfrom
sicklecell
crisis.______________________________________________________________________________________
_______
Height_511____Weight__88.6kg____BMI_27.9_______Pain(includeratingandlocation)_8;Located
inback(generalbackpain),jointsandanteriorchest_Pulse__95___BloodPressure(includelocation)_117/73
(88)(leftupperarm)__________________________________Temperature(routetaken)__98.6
(oral)___________
Respirations__17__________SpO2_94%____________RoomAirorO2__Room
air_________________________
OverallAppearance_Patientislethargic,disheveled,anduncomfortable.Heshiftscontinuouslytotrytofind
comfortableposition(betweensittingupinbedandlying
back)._______________________________________________________
OverallBehavior_Patientisappropriate,butislethargic.Hefallsasleepmidsentencewhenansweringquestions
duringPAT
interview._________________________________________________________________________________
Speech_Patientsspeechisnotslurredorinappropriate,however,hefallsasleepmidsentencewhenanswering
interviewquestionsforthePAT.
________________________________________________________________________________
MoodandAffect_Patientreportsfeelingisolatedandalone.Patientappearsflat,withdrawnanddepressed
regardingthesicklecellcrisisresultinginhishospitalization.
__________________________________________________________________
Integumentary_Warm,dry,intact,appropriatecolorforethnicity(black).Sacrumandcoccyxintact.Nails
withoutclubbing,capillaryrefill<3seconds,norashesorlesions,hairevenlydistributedandabsentofvermin.
Skinturgoriselastic.
IVAccess_Mediportwasaccessedon06/19/16(rightchest).
_________________________________________________
HEENT_Facialfeaturessymmetric,nopaininsinusregion,TMJ.PERRLA,sclerawhiteandconjunctiveclear,
eyebrows,eyelids,orbitalareaandeyelashessymmetricandwithouttenderness,pupilsize3mm.peripheral
visionintact.Earssymmetricandwithoutlesions.Narespatentandwithoutlesionsordischarge.Airwaypatent.
Mucusmembranesintact,pinkandmoist.
Pulmonary/Thorax_Clearsounds,equalbilaterally.Noshortnessofbreath.Respirationsregularandunlabored,
chestexpansionsymmetric,andwithoutsputumproduction.
Cardiovascular_S1&S2auscultated,murmurauscultated(confirmedhistorywithpatient).Noheaves,lifts,
thrills,orJVD.Regularrhythm.Calfpainisbilaterallynegative,radialandpedalpulsesbilaterallyequal.No
bruitswereauscultated.
GI_Abdomenisprotuberant,bowelsoundsarehypoactive.LBMwas06/19/16(Sunday,priorto
admission)___________
GU_Nodysuriaorretention.Patientiscontinentandurinatinginurinalorinbathroom.Patienthasbathroom
University of South Florida College of Nursing Revision September 2014

12

privilegeswithstandbyassistance.Urineisconcentratedanddarkyellow.Genitaliawasnotassessedaspatient
waslethargic,butorientedanddeniesproblems.
Musculoskeletal_FullROMinupperandlowerextremities.Radialandpedalpulses:2+.5/5strengthinupper
andlowerextremities.Vertebralcolumnwithoutkyphosisorscoliosis.Patientdeniestinglingornumbnessin
upperandlowerextremities.
NeurologicalLethargic/orientedx4.PERRLA.Facialsymmetryintact.Sensationtopainandtouchintact.
10PERTINENTLABVALUESANDDIAGNOSTICTESTRESULTS(includepertinentnormalsaswell
asabnormals,includerationaleandanalysis.Listdateswithalllabsanddiagnostictests):

Lab
Redbloodcells(RBC)

Dates

2.19

(06/20/2016)

2.76

(06/21/2016)

Normal(4.26.2million/mm3)

Hemoglobin(Hgb)
6.9

(06/20/2016)

8.3

(06/21/2016)

Normal(13.517.5g/dL)
Hematocrit(Hct)
18.7

(06/20/2016)

22.6

(06/21/2016)

Normal(3950%)
Whitebloodcells(WBC)
9.84

(06/20/2016)

9.61

(06/21/2016)

Normal(510thousand/mm3)

Trend
Uponadmission,the
patientsRBCswere
belownormalrange.
After2unitsofRBCs
weretransfusedon
06/20/16andearly
06/21/16,thepatients
RBCsarestillbelow
normalrange,but
trendingupward.
Uponadmission,the
patientsHgbwasbelow
normalrange.After2
unitsofRBCswere
transfused,thepatients
Hgbisstillbelownormal
range,butistrending
upwardaswell.
Uponadmission,the
patientsHctwasbelow
thenormalrangeaswell.
After2unitsofRBCs
weretransfused,the
patientsHctalsobegan
trendingupward.
Uponadmission,the
patientsWBCswerein
thehighnormalrange.
Althoughthetrendwas
somewhatlower,the
changewasminimal.

Analysis
RBCsareaffected
(sickled)inthispatients
diseaseand,thus,during
acrisis/episode,itis
expectedforthepatients
RBCstobebelownormal
range.

Hgblevelsaredirectly
relatedtotheRBCcount
and,thus,itisexpected
fortheHgblevelstotrend
upwardalongwiththe
RBCs.
Hctmeasuresthe
proportion/percentageof
RBCsinwholeblood.As
asicklecellcrisisaffects
thepercentageofRBCs
present,itisexpectedthat
thepatientsHctwillbe
lowasherecoversfrom
hiscrisis.
WBCsrepresentthe
numberofinfection
fightingcells.Although
withinthenormalrange,
thenumberofWBCsis
highenoughthatthey
shouldbemonitored
closelyincasethepatient

University of South Florida College of Nursing Revision September 2014

13

Plateletcount
243

(06/20/2016)

260

(06/21/2016)

Normal(150400thousand/mm3)

Uponadmission,the
patientsplateletcount
waswithinnormalrange
andwasmaintained
aroundthesamerange.

isintheprocessof
developinganinfectionor
inflammation.
Assicklecellanemia
affectsRBCsandnot
platelets,itwasexpected
thatthepatientsplatelet
countbewithinnormal
rangedespitehiscurrent
sicklecellcrisis.

+2CURRENTHEALTHCARETREATMENTSANDPROCEDURES:(Diet,vitals,activity,scheduled
diagnostictests,consults,accuchecks,etc.Alsoproviderationaleandfrequencyifapplicable.)
06/20/161437:Type&crossmatch(ifgivingRBCs/wholeblood)
06/20/161437:Prep&transfuse2unitsRBC(06/20/1619462140:417.5mL)(06/21/1600440300:315mL)
06/20/160749:NICECG2D(Mitralmildregurgitation;Latriummildlydilated;LventricleEjection
fracture6065%,systolicnormal;Atrialseptumaforamenovalecannotbeexcluded)
06/20/160024:Placedontelemetrymonitoring
06/20/160023:Inpatientconsultstocardiologyandhematology
06/19/161718:BMP,CBCwithdifferential,VTEprophylactic,pulseoximetry,O2nasalcannula2L,vitals
Q4,painassessmentQ4,regulardiet,activityupwithassistance
06/19/161553:EDconsultstointernalmedicineandhematology
06/19/161243:EKG12leadstat
06/19/161237:CBCandautomateddifferentialwithreflex,CMP,reticulocytecount,U/A,POCTBedside
troponin,TroponinI,XRChestPAandLateral(CXR:normal)
8NURSINGDIAGNOSES(actualandpotentiallistedinorderofpriority)
1.Acutepainr/ttissuehypoxiaasevidencedbypatientreportofpainlevel8after2mgHYDROmorphone.

2.Impairedphysicalmobilityr/tpainasevidencedbypatientsrefusaltoambulatearoundunitduetopainlevel
8after2mgHYDROmorphoneanddifficultywalking/standing.

University of South Florida College of Nursing Revision September 2014

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15CAREPLAN
NursingDiagnosis:Acutepainr/ttissuehypoxiaasevidencedbypatientreportofpainlevel8after2mgHYDROmorphone.
PatientGoals/Outcomes
NursingInterventionstoAchieve
RationaleforInterventions
EvaluationofGoalonDayCare
Goal
ProvideReferences
isProvided
Patientwilluseaselfreportpain
1.Determineifthepatientis
1.Determininglocation,temporal 1.Thepatient'spainwasevaluated
tooltoidentifycurrentpain
experiencingpainatthetimeofthe aspects,painintensity,
uponinitialmeetingandinterview.
intensityandestablishacomfort
initialinterview.Ifpainispresent, characteristics,andtheimpactof
TheOLDCARTSassessmenttool
functiongoalatbeginningofthe
conductanddocumenta
painonfunctionandqualityoflife wasusedtoevaluatepatient'spain.
shift.
comprehensivepainassessment
arecriticaltodeterminethe
2.DuringOLDCARTS,patient
andimplementorrequestordersto underlyingcauseofpainand
identifiedhispainlevelas8outof
implementpainmanagement
effectivenessoftreatment.This
10.
interventionstoachievea
initialassessmentincludesallpain 3.Patientreportedthatacomfort
satisfactorylevelofcomfort.
informationthatthepatientcan
functiongoalforthedaywouldbe
Componentsofthisinitial
provideandprovidesdataforthe
tobeanythingbelowan8outof
assessmentincludelocation,
developmentoftheindividualized 10.
quality,onset/duration,temporal
painmanagementplan.
profile,intensity,aggravatingand 2.Selfreportisconsideredthe
alleviatingfactors,andeffectsof
singlemostreliableindicatorof
painonfunctionandqualityoflife. painpresenceandintensity.
2.Assesspainintensitylevelina
3.Therelationshipbetweenpain
patientusingavalidandreliable
levelandfunctionalgoalsshould
selfreportpaintool,suchasthe0 beamajorfocusofthe
10numericalpainratingscale.
developmentofindividualizedpain
3.Askthepatienttoidentifya
managementplans.
comfortfunctiongoal,apainlevel,
onaselfreportpaintool,thatwill
allowtheclienttoperform
necessaryordesiredactivities
easily.Thisgoalwillprovidea
basistodetermineeffectivenessof
painmanagementinterventions.
Patientwilldescribe
1.Askthepatienttodescribeprior 1.Obtaininganindividualizedpain 1.Patientreportedthathemanages
pharmacologicaland
experienceswithpain,
historyhelpstoidentifypotential
hischronicpainassociatedwith
nonpharmacologicalmethodsthat effectivenessofpainmanagement factorsthatmayinfluencethe
sicklecellanemiaathomewith
University of South Florida College of Nursing Revision September 2014

15

canbeusedtohelpachieve
comfortfunctiongoalbyendof
shift.

interventions,responsesto
analgesicmedications,including
occurrenceofsideeffects,and
concernsaboutpainandits
treatment.
2.Determinethepatient'scurrent
medicationuse.Obtainanaccurate
andcompletelistofmedications
theclientistakingorhastaken.
3.Obtainaprescriptionto
administeranonopioidanalgesic
formildtomoderatepainandan
opioidanalgesicifindicatedfor
moderatetosevereacutepain.
4.Teachandimplement
nonpharmacologicalinterventions
whenpainisrelativelywell
controlledwithpharmacological
interventions.

patient'swillingnesstoreportpain,
aswellasfactorsthatmay
influencepainintensity,the
patient'sresponsetopain,anxiety,
andpharmacokineticsof
analgesics.Painmanagement
regimensmustbeindividualizedto
theclientandconsidermedical,
psychological,andphysical
condition;age;leveloffearor
anxiety;clientgoalsand
preference;andpreviousresponse
toanalgesics.
2.Accuratemedication
reconciliationcanpreventerrors
associatedwithincorrect
medications,dosages,omissionof
componentsofthehome
medicationregimen,drugdrug
interactions,andtoxicitythatcan
occurwhenincompatibledrugsare
combinedorwhenallergiesare
present.Thishistorywillprovide
theclinicianwithanunderstanding
ofwhatmedicationshavebeen
triedandwereorwerenoteffective
intreatingthepatient'spain.
3.Nonopioids,suchas
acetaminophenandNSAIDs,are
firstlineanalgesicsforthe
treatmentofmildandsome
moderateacutepain.Opioidsare
firstlineanalgesicsforthe
treatmentofmoderatetosevere
acutepain.

University of South Florida College of Nursing Revision September 2014

oxycodone5mgoncedaily,
sometimestwicedaily.Hereported
that,duringasicklecellcrisis,
however,itisgenerallynecessary
forhimtobehospitalizedand
HYDROmorphone2mgIVis
employedtomanagehisacutepain,
withoxycodone5mgavailablefor
breakthroughpain.
2.Patientreportedthathisathome
medicationsincludedonly
oxycodone5mgPRNforpain.
3.Theproviderprescribed
HYDROmorphone2mgq3hPRN
forseverepain(710)aswellas
oxycodone5mgforbreakthrough
pain.
4.Patientwaseducatedaboutthe
benefitsofusinghotpacks,in
additiontotheprescribedpain
medications,onaffectedareasin
ordertohelpdilatehisblood
vessels,allowingthesickledRBCs
tonavigatehiscirculatorysystem
moreeasily.

16

Patientwillreportthatpain
managementregimenachieves
comfortfunctiongoalwithoutside
effectsbyendofhospitalstayand
athome.

1.Administersupplemental
analgesicdosesasorderedtokeep
thepatient'spainlevelatorbelow
thecomfortfunctiongoal.
2.Assessthepatientforpain
presenceroutinely;thisisoften
doneatthesametimeaswhena
fullsetofvitalsignsisobtained,
andduringactivityandrest.Also
assessforpainwithinterventions
orprocedureslikelytocausepain.
3.Reviewthepatient'spain
flowsheetandmedication
administrationrecordtoevaluate
effectivenessofpainrelief,
previous24houropioid
requirements,andoccurrenceof
sideeffects.

4.Paincausescognitive
impairment.Nonpharmacological
interventionsshouldbeusedto
supplement,notreplace,
pharmacologicalinterventions.
1.AnorderforPRNsupplemental
analgesicdosesbetweenregular
dosesisessentialinproviding
comprehensivepainmanagement.
2.Painassessmentisasimportant
asphysiologicalvitalsigns.Acute
painshouldbereliablyassessed
bothatrest(importantforcomfort)
andduringmovement(important
forfunctionanddecreasedpatient
riskofcardiopulmonaryand
thromboembolicevents).
3.Systematictrackingofpainisan
importantfactorinimprovingpain
managementandmaking
adjustmentstopainmanagement
regimen.Ifpainisconstant,
analgesicsshouldbeadministered
aroundtheclock.Ifapreviousdose
wassafebutineffective,obtainan
ordertoincreasethedoseby25%
to50%foramoderateeffectand
by50%to100%foragreater
effect.

University of South Florida College of Nursing Revision September 2014

1.Patientreceived
HYDROmorphoneq3hPRNfor
hispainandwaseducatedtoutilize
hisoxycodone5mgfor
breakthroughpain.Initially,patient
refusedtousetheoxycodone,
statingthathedidnotbelieveit
wouldbeefficaciousduetohis
severeacutepain;however,hewas
willingtotryitforbreakthrough
painaftereducation.
2.Patientwasassessedforpain
every2hours,aswellas
immediatelybeforeandwithinan
hourafterreceivinganalgesics.He
continuedtoreportpainlevelof8
throughouttheshift.
3.Patient'spainflowsheetwas
reviewedfromthedayof
admissionthroughthecurrentshift
andheconsistentlyreportedlevel
89painintensity.Itwasnotedon
theMAR,however,thatpatienthad
notbeenacceptingoxycodone5mg
inadditiontohis
HYDROmorphone2mginorderto
helpwithmanaginghis
breakthroughpain.Educated
patientpromptlyonthebenefitof
utilizingbothanalgesicsin
17

conjunction.

NursingDiagnosis:Impairedphysicalmobilityr/tpainasevidencedbypatientsrefusaltoambulatearoundunitduetopainlevel8after2mg
HYDROmorphoneanddifficultywalking/standing.
PatientGoals/Outcomes
NursingInterventionstoAchieve
RationaleforInterventions
EvaluationofGoalonDayCare
Goal
ProvideReferences
isProvided
Patientwillverbalizelesspainwith 1.Beforeactivity,observeforand, 1.Painlimitsmobilityandisoften 1.Patientbeganutilizingboth
physicalactivity.
ifpossible,treatpainwithmassage, exacerbatedbymovement.
medicationandheatpackstohis
heatpacktoaffectedarea,or
2.Somepatientschoosenotto
affectedareasinordertotryto
medication.Ensurethatthepatient movebecauseofpsychological
minimizepainbeforeandafterhis
isnotoversedated.
factorssuchasfearoffallingor
physicalactivity.
2.Assessthepatientforcauseof
pain.
2.Patient'simpairedmobilitywas
impairedmobility.Determine
physical;asitwasduetothepain
whethercauseisphysical,
hewasexperiencingfromhissickle
psychological,ormotivational.
cellcrisis.
Patientwillverbalizefeelingof
increasedstrengthandabilityto
move.

1.IncreaseindependenceinADLs,
encouragingselfefficacyand
discouraginghelplessness,asthe
clientgetsstronger.
2.Begindischargeplanningas
soonaspossiblewithapersonal
healthnavigator(e.g.nursecare
coordinator)toassessneedfor
homesupportsystems,assistive
devices,andcommunityorhome
healthservices.

1.Providingunnecessary
assistancewithtransfersand
bathingactivitiesmaypromote
dependenceandalossofmobility.
Afunctionfocusedcare
interventiondemonstrateda
significanteffectonincreasing
outcomeexpectationsforexercise,
improvingfunctionalperformance
andincreasingtimespentin
exerciseandphysicalactivity.
2.Dischargebeginsupon
admission.Thegoalistoprovide
patientwitheverythingneededto
leavethehospitalsafelyandableto
functionathome.

University of South Florida College of Nursing Revision September 2014

1.Patientwasabletowalkwith
standbyassistance,thoughnot
withoutpain,totherestroom.He
did,however,declinethe
opportunitytowalkaroundtheunit
becausehestatedthathispainwas
toogreat.
2.Patientwasoutfittedwitha
walkertohelphimwhen
ambulatingaroundhisroom.

18

Patientwillperformactivitiesof
dailylivingeasilybytheendofthe
hospitalstayandathome.

1.Screenformobilityskillsinthe
followingorder:1)bedmobility;2)
supportedandunsupportedsitting;
3)transitionmovementssuchassit
tostand,sittingdown,and
transfers;and4)standingand
walkingactivities.
2.Assessthepatientforcauseof
impairedmobility.Determine
whethercauseisphysical,
psychological,ormotivational.
3.Monitorandrecordthepatient's
abilitytotolerateactivityanduse
allfourextremities;notepulserate,
bloodpressure,dyspnea,andskin
colorbeforeandafteractivity.

1.Assessforqualityofmovement,
abilitytowalkandmove,gait
pattern,ADLfunction,presenceof
spasticity,activitytolerance,and
activityorder.
2.Somepatientschoosenotto
movebecauseofpsychological
factorssuchasfearoffallingor
pain.
3.Usevalidandreliablescreening
proceduresandtoolstoassessthe
patient'sparticipationinexercise
healthscreeningandrisk
stratificationforexercisetesting
(low,moderateorhighrisk).

1.Patientwasabletomoveinhis
bedtoasittingpositionwithout
difficulty,butnotwithoutpain.
Patientwasabletowalkwith
standbyassistance,butreported
thatthemovementexacerbatedhis
pain.
2.Patient'simpairedmobilitywas
physical;asitwasduetothepain
hewasexperiencingfromhissickle
cellcrisis.
3.Patientwouldambulatetothe
bathroomwithassistanceofone
person,however,hewouldreturn
tohisbedwithdyspneaand
increasedpain.Patientreportedhe
preferredtourinateintheurinalat
bedsideifpossible.

2DISCHARGEPLANNING:(puta*infrontofanypteducationinabovecareplanthatyouwouldincludefordischargeteaching)
Considerthefollowingneeds:
SSConsult
xDietaryConsult
PT/OT
PastoralCare
DurableMedicalNeeds
xF/Uappointments
xMedInstruction/Prescription
areanyofthepatientsmedicationsavailableatadiscountpharmacy?xYesNo
Rehab/HH
PalliativeCare

University of South Florida College of Nursing Revision September 2014

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References
Ackley,B.J.,&Ladwig,G.B.(2014).Nursingdiagnosishandbook:Anevidencebasedguidetoplanningcare
(10thed.).MarylandHeights,MO:MosbyElsevier.
Huether,S.E.,&McCance,K.L.(2012).Alterationsofhematologicfunction.InV.L.Brashers&N.S.Rote
(Eds.),UnderstandingPathophysiology(pp.500534).StLouis,MO:ElsevierMosby.
MicromedexHealthcareSeries.(Version5.1)[Intranet].GreenwoodVillage,CO:ThomsonReuters
(Healthcare)Inc.
Natrajan,K.,&Kutlar,A.(2015).Disordersofhemoglobinstructure:Sicklecellanemiaandrelated
abnormalities.InK.Kaushansky,M.A.Lichtman,J.T.Prchal,M.M.Levi,O.W.Press,L.J.Burns,&
M.Caligiuri(Eds.),WilliamsHematology(9thed.).Retrievedfrom
http://accessmedicine.mhmedical.com.ezproxy.hsc.usf.edu/content.aspx?
bookid=1581&Sectionid=108061089.
UnitedStatesDepartmentofAgriculture.(2016,Jan7).Choosemyplate.Retrievedfrom
http://www.choosemyplate.gov/MyPlate

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