UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Robinson Mejia

 1 PATIENT INFORMATION
Patient Initials: MP Age: 46
Gender: Female
Primary Language: Spanish
Level of Education: College
Occupation (if retired, what from?): Architect
Assignment Date: 07/19/17
.
Agency: St. Joseph Hospital Bay Care
Admission Date: 06/29/17
Marital Status: Married Primary Medical Diagnosis: Colonic
Obstruction, Intestinal Obstruction
Other Medical Diagnoses: (new on this
admission)

Number/ages children/siblings: 2 daughters ( aged 17 and 21),

one brother, one sister

Served/Veteran: No Code Status: None

If yes: Ever deployed? Yes or No
Living Arrangements: Own a one story house, lives with Advanced Directives: Yes, Living Will
husband and daughters. If no, do they want to fill them out?
Surgery Date: 07/05/17 Procedure: Ileostomy
RLQ
Culture/ Ethnicity /Nationality: Cuban/Spanish, Hispanic
Religion: Pentecostal Type of Insurance: Private health insurance

 1 CHIEF COMPLAINT: “I started feeling fullness in my stomach and a sharp intense abdominal pain
Wednesday (06/28/17), the pain was so intense that I rushed into the ER.”

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital
course of stay)
The patient started feeling fullness in her stomach and a sharp abdominal pain the morning of 06/28/17, the
patient had nausea and constant vomiting when she rushed to the ER. The patient reported before admission a
constant pain in her entire abdomen, the pain was from dull to sharp with a severity of 10 from a 0 to 10 scale.
06/29/17 the patient had a colonoscopy procedure with results stating unsuccessful to pass through structure.
The patient had an Ileostomy RLQ Wednesday 07/07/17 to relieve the colonic obstruction. Thursday 07/06/17
the patient feels low pain and constant abdominal discomfort from passing gases. The pain is related to
discomfort with a severity of 2 in a 0 to 10 pain scale. The patient is aggravated with certain movements, while
the pain is relieved when treated with pain medication and reposition. The pain is currently being treated with
Dilaudid. The patient currently has hypokalemia from the fluid loss, being treated with potassium chloride.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
07/02/17 Ileostomy RLQ- colonic obstruction
2 years ago Cervical cancer- patient received chemotherapy and radiation.
17 years ago Bilateral Tubal Ligation- Tylenol for pain, no heavy lifting
Current GERD- treated with omeprazole once daily
Age (in years)

Trouble
Environmental
2

Health

Stomach Ulcers
Bleeds Easily

Hypertension
MI,
Alcoholism
Cause

Glaucoma
FAMILY

Kidney
Diabetes
Arthritis

Seizures
Anemia

Asthma

Problems

Problems
Cancer
of Allergies

Tumor
Stroke
etc.)
Gout
MEDICAL

(angina,
Death

Heart

Mental
HISTORY (if

DVT
applicab
le)
8
Father X X X X X X X
7
8
Mother X X X
5
5
Brother X
2
4
Sister X X X
3
relationship
relationship
relationship

 1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations U
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? U
Influenza (flu) (Date) Is within 1 years? U
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state “U” for the patient not knowing date received

 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Medications Morphine Unknown
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 Peanuts Hives, tightening of the throat
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)
Hypokalemia is a potassium deficiency which develops when the serum potassium concentration falls below
3.5 mEq/L (Huether & McCance, 2012). Factors for developing hypokalemia include reduce intake of
potassium, increased entry of potassium into cells, increased losses of body potassium, and dietary deficiency
of potassium. In the case of the patient, the patient has a deficiency in potassium since the patient has been in
IV fluids since 06/29/17 NPO, the patient also had loss of body fluids by vomiting and gastric loss due to the
ileostomy. Losses of potassium from body stores are usually caused by gastrointestinal and renal disorders
such as diarrhea, intestinal drainage tubes or fistulas, and laxative abuse (Huether & McCance, 2012).
Vomiting or continuous gastric suctioning often associated with potassium depletion is caused by potassium
loss in gastric fluid and principally due to renal compensation for volume depletion and the metabolic alkalosis
that occurs from sodium, chloride, and hydrogen ion losses. The loss of fluid and sodium stimulates the
secretion of aldosterone, which in turn causes renal losses of potassium (Huether & McCance, 2012). Renal
potassium losses occur with increased secretion of potassium by the distal tubules and magnesium deficit
increases renal potassium secretion and promotes hypokalemia. There are a few hereditary defects in
potassium transport such as Bartter and Gitelman syndrome can cause hypokalemia. The clinical manifestation
of hypokalemia occurs in relation to the rate of potassium depletion. Mild losses of potassium are usually
asymptomatic. Severe loss of potassium can result in neuromuscular and cardiac manifestations.
Neuromuscular excitability decreases, causing skeletal muscle weakness, smooth muscle atony, cardiac
dysrhythmias, glucose intolerance and impaired urinary concentrating ability. The body can accommodate to
slow losses of potassium allowing less severe neuromuscular changes. Loss of smooth muscle tone is
manifested in constipation, intestinal distention, anorexia, nausea, vomiting, and paralytic ileus which were all
present in the patient (Huether & McCance, 2012). The cardiac effect of hypokalemia is related to the changes
in membrane excitability. Potassium contributes to the repolarization phase of the action potential,
hypokalemia delays ventricular repolarization. Treatment of hypokalemia involves an estimation of total body
potassium losses and correction of acid-base imbalances. Individuals should be encouraged to eat foods rich in
potassium to prevent further potassium loss. The patient should also receive a maximal safe rate of intravenous
replacement of potassium of 20 mEq/hr at a maximal concentration of 40 mEq/L since potassium is irritating
to blood vessels (Huether & McCance, 2012). The serum potassium level values should be monitored until
normakalemia is achieved.

 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 enoxaparin (Lovenox) Concentration 10 mg= 0.1 ml Dosage Amount 40 mg
Route subcut Inj Frequency 1xdaily
Pharmaceutical class antithrombotics Home Hospital or Both
Indication Prophylaxis of deep vein thrombosis due to the ileostomy surgery.
Adverse/ Side effects anemia, hemorrhage, fever/ bleeding gums, coughing up blood, difficulty with breathing

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and swallowing, dizziness headache, paralysis, red or black tarry stool.
Nursing considerations/ Patient Teaching monitor for bleeding, anemia, thrombocytopenia, diarrhea, and
nausea.

Name Magnesium sulfate Concentration 2g= 50mL Dosage Amount 2g

Route IVPB Frequency once 7/6/17
Pharmaceutical class mineral/electrolyte Home Hospital or Both
Indication To prevent or treat magnesium deficiency in patients receiving total parenteral nutrition.
Adverse/ Side effects difficult breathing, swelling of face, lips, tongue, or throat/ feeling of passing out,
sweating, anxiety, cold feeling, flushing, weak or shallow breath, extreme drowsiness, numbness around mouth.
Nursing considerations/ Patient Teaching Monitor renal function, its excreted almost entirely by the kidneys.
Infuse over 2 hours, rate 25 mL/hr total volume of 50mL.

Name metoprolol (lopressor) Concentration 2.5 mg= 2.5 mL Dosage Amount 2.5 mg
Route IV, inj Frequency every 6 hours
Pharmaceutical class beta blockers Home Hospital or Both
Indication Hypertension, Angina pectoris, Management of stable, symptomatic heart failure.
Adverse/ Side effects fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, bronchospasm,
constipation, diarrhea, gastric pain, nausea, vomiting, rash, drug induced lupus syndrome.
Nursing considerations/ Patient Teaching: Hold for SBP less than 100 mmHg, hold for DBP less than 60
mmHg, hold for HR less than 50 bpm. Teach patint how to check pulses. Advise patient to change position
slowly.

Name pantaprazole (Protonix) Concentration Dosage Amount 40 mg

Route IV, inj Frequency 1x daily
Pharmaceutical class proton-pump inhibitor Home Hospital or Both
Indication Erosive esophagitis associated with GERD
Adverse/ Side effects headache, diarrhea, abdominal pain, flatulence, hyperglycemia, bone fracture, vitamin B12
deficiency.
Nursing considerations/ Patient Teaching Assess patient for abdominal pain, occult blood stool, and gastric
aspirate. Advise patient to not drink alcohol or eat foods that cause an increase in GI irritation.

Name piperarillin (tazabactam) Concentration Dosage Amount 3.375 g

Route IVPB Frequency every 6 hours
Pharmaceutical class extended spectrum
Home Hospital or Both
penicillin
Indication appendicitis and peritonitis.
Adverse/ Side effects seizures, confusion, dizziness, headache, insomnia, lethargy, diarrhea, constipation, nausea,
vomiting, bleeding, pain in IV site, hypersensitivity reactions.
Nursing considerations/ Patient Teaching Infuse over 30 minutes rate of 100mL/hr. Total volume 50 mL
Dextrose 5%in water. Assess patient for infection, monitor bowel function, assess skin reactions. Advice patient
to report any skin reaction, fever, and diarrhea.

Name Potassium chloride Concentration 40 mg = 2 tabs Dosage Amount 40mg

Route PO, tabs Frequency every 2 hours (interval) 2 doses
Pharmaceutical class potassium supplement. Home Hospital or Both
Indication treatment of hypokalemia
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Adverse/ Side effects confussion, ECG changes, abdominal ain, diarrhea, flatulence, nausea, vomiting, GI ulcers,
irritation at IV site, paresthesia.
Nursing considerations/ Patient Teaching Infuse slowly. Advise patient to avoid salt substitutes or low salt
milk, encourage a potassium diet, monitor side effects.

Name Dextrose 5% with 0.45% NaCl Concentration Dosage Amount 1000 mL

Route IV, inj Frequency rate 125 mL/hr, infuse over 8 hr.
Pharmaceutical class glucose supplement Home Hospital or Both
Indication replace lost fluids and provide carbohydrates to the body.
Adverse/ Side effects severe burning, pain, or swelling around IV needle, upset stomach, sweeling in your hands
and feet, fever, ongoing cough, high blood sugar, headache, memory loss, hallucination, fainting, seizure, shallow
breathing, low potassium, anxiety, sweating, pale skin, fast or uneven heart rate.
Nursing considerations/ Patient Teaching Total volume 1,000 mL, Assess hydrogen status of patient, assess
nutritional status, function of gastrointestinal tract, monitor IV site, monito lab results for an increase in serum
glucose level. Advise diabetic patient to monitor their glucose levels .

Name Dilaudid PCA 0.2 mg/mL Concentration 1mg= 1mL Dosage Amount 0.2 mg
Route IV, Inj Frequency 7 min, one hour limit
Pharmaceutical class opiod agonist Home Hospital or Both
Indication controls moderate to severe pain.
Adverse/ Side effects confusion, sedation, dizziness, dysphoria, floating feeling, hallucinations, headache,,
unusual dreams, blurred vision, diplopia, respiratory repression, hypotension, bradycardia, constipation, dry
mouth, nausea, vomiting, urinary retention, flushing, sweating, physical dependency, tolerance.
Nursing considerations/ Patient Teaching HYDROmorphone, Assess BP, pulse, and respiration before and
periodically during administration, assess bowel function routinely, assess pain, and assess risk for opioid
addiction. Advice patient how and when to take pain medication, advice patient that hydromorphone is a drug
with known abuse potential. Advice patient to avoid driving until known response to drug, and avoid concurrent
use of alcohol. To prevent atelectasis, advice the patient to turn, cough, and breathe deeply every two hours.

Name ketorolac (Toradol) Concentration 30 mg= 1 mL Dosage Amount 50mg

Route IV, inj Frequency every 6 hours
Pharmaceutical class pyrroziline carboxylic acid Home Hospital or Both
Indication PRN short term management of pain
Adverse/ Side effects drowsiness, abnormal thinking, dizziness, euphoria, headache, increase lacrimation, nasal
discomfort, throat irritation, stroke, edema, pallor, vasodilation, diarrhea, dry mouth, dyspepsia, GI pain, nausea,
increase liver enzymes, oliguria, Stevens-Johnsons syndrome, prolonged bleeding, injection site pain, paresthesia,
and anaphylaxis.
Nursing considerations/ Patient Teaching Assess for rash periodically, assess pain prior to 1-2 hour following
administration, monitor labs results since it may cause increase in potassium concentration. Advice patient to
avoid driving until known response to drug, avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen,
without consulting health care professional, and report any rash, itching, visual disturbances, tinnitus, weight
gain, edema, black stools, headaches, or influenza-like syndrome.

Name diphenhydrAMINE (Benadryl) Concentration 12.5 mg= 0.25 mL Dosage Amount

Route IV, inj Frequency every 4 hours
Pharmaceutical class antihistamine Home Hospital or Both
Indication PRN itching, sneezing

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Adverse/ Side effects drowsiness, dizziness, headache, paradoxical excitation, blurred vision, hypotension,
anorexia, dry mouth, constipation, nausea, dysuria, urinary retention, photosensitivity, chest tightness, and
wheezing.
Nursing considerations/ Patient Teaching Assess degree of nasal stuffiness, rhinorrhea, and sneezing. Advice
patient to avoid driving until known response to drug, use frequent oral rinses to minimize effect of dry mouth,
use sunscreen, and don’t use alcohol.

Name ondansetron (Zofran) Concentration 4mg= 2mL Dosage Amount 4mg

Route Iv, Inj Frequency every 4 hours
Pharmaceutical class 5-HT3 anragonist Home Hospital or Both
Indication PRN prevention of nausea/vomiting
Adverse/ Side effects serotonin syndrome, headache, dizziness, drowsiness, fatigue, weakness, constipation,
diarrhea, abdominal pain, dry mouth, extrapyramidal reaction, and Stevens Johnson syndrome.
Nursing considerations/ Patient Teaching Assess patient for nausea, vomiting, abdominal pain, and bowel
sounds before administration of drug. Monitor ECG in patients with hypokalemia. Advise patient to report
irregular heartbeat, serotonin syndrome, or involuntary movement of eyes, face, or limbs.

Name omeprazole Concentration Dosage Amount 20mg

Route oral Frequency 1x daiy
Pharmaceutical class proton-pump inhibitor Home Hospital or Both
Indication GERD/ maintenance of healing in erosive esophagitis.
Adverse/ Side effects dizziness, drowsiness, fatigue, headache, chest pain, abdominal pain, acid regulation,
diarrhea, constipation, flatulence, nausea, vomiting, hypomagnesium, itching, rash, allergic reactions.
Nursing considerations/ Patient Teaching Assess patient routinely for abdominal pain, gastric aspirate, monitor
bowel function, monitor lab results for hypomagnesium. Advise patient to avoid driving until known response to
medication, advoid alcohol, and NSAIDs to prevent GI irritation.

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

Breakfast: 1 cup of coffee, 1 cup of milk, 1 serving of As the “My Plate” shows, the patient is eating the
plantain chips, 2 slices of bread, 2 slices of cheese proper amounts of vegetables, fruits, and protein,
however, she needs to increase her dairy and her
refined grain intakes. Since the patient had a recent

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 ileostomy procedure, she needs to slowly gradually
advance her diet as ordered by her physician. She
needs to eat two slices of whole wheat bread instead of
white bread and trade the white rice for 1 cup of
brown rice to balance her refined grains. To improve
her dairy intake, the patient should eat 1 cup of yogurt
and have 1 more slices of cheese. The daily calorie
limit for the patient is 2000 total calories per day, she
eats around 2201 calories per day, exceeding 201
calories. The patient needs to be active at least 150
minutes per week to compensate the extra calories
intake. If the patient continues to be hypokalemic, she
should continue to eat potatoes and substitute some of
her vegetables for more potassium rich vegetables
such as winter squash, sweet potatoes, and white
beans.

Lunch: 6oz grill chicken breast, 1 cup of white rice, 1

cup of beans, and 1 cup of mixed vegetables

Dinner: 1 cup of kale salad, 1 cup of broccoli, 1 baked

potatoes, 6oz grill tilapia fish

Snacks:1 dark chocolate bar

Liquids (include alcohol): 1 liter of water, 2 cups of

fruit shake, 1 cup of almond milk

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your
discussion)
Who helps you when you are ill?
Family, friends, coworkers, church

How do you generally cope with stress? or What do you do when you are upset?
Pray, Christian music, cleans the house, visits the ocean, takes walks with family.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Stress over father recent stroke, anxiety over past cervical cancer and worried of future cancers.

+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.”
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Have you ever felt unsafe in a close relationship?
___No____________________________________________________

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? The patient is currently married to her husband, the father of her
daughters.

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame
Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role Confusion/Diffusion 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 Erickson’s
developmental stage for your
patient’s age group:

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
My patient is experiencing at her 46 years of age the Erikson’s psychosocial development stage of generativity
vs. stagnation. For the generativity stage, during middle adulthood which ranges from 40 to 64 years of age,
individuals tend to establish their careers, settle down in their relationships, have their own families, and realize
there is a bigger picture. During this stage, the individual gives back to society by raising children, being
productive at work, and becoming involved with the community (Thyer, Dulmus, & Sowers, 2012). The patient
shows characteristics of Erikson’s generativity since she was proud of talking about her career as an architect,
about her husband and her daughters always being together, and how she is a part of her church. The patient
uses her career to give back to the community.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of
life:
The patient feels more connected to her family, career, and church during her hospitalization since she is
constantly being visited by family members, co-workers, and friends from her church. The patient feels capable
of overcoming this illness to continue her daily life.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
Stress from the past cervical cancer, and her father’s recent stroke.

What does your illness mean to you?

Things happen for a reason, most things in life have a solution. She is positive of her outcome.

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+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?
__Male__________________________________________________
Are you aware of ever having a sexually transmitted
infection? ___No_______________________________________
Have you or a partner ever had an abnormal pap smear?
____Yes_____________________________________________ 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? ____Bilateral Tubal Ligation for unintended
pregnancy, none for STDs____

How long have you been with your current partner?___25

years__________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity?
___No___________________

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?
_Great importance, the patient is very spiritually, she states that she has a close relationship with God and the
church.
__________________________________________________________________________________________
____________
Do your religious beliefs influence your current condition?
__Yes, the patient states that God has a purpose for her condition, she says that his illness is just another stage
of her life that she is going to overcome and learn from.
__________________________________________________________________________________________
____________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No X
For how many years? X
If so, what? How much?(specify daily amount)
years
(age thru )
If applicable, when did the
Pack Years:
patient quit?
Does anyone in the patient’s household smoke tobacco? Has the patient ever tried to quit?
If so, what, and how much? 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 X
What? How much? For how many years?
Volume: (age thru )
Frequency:
If applicable, when did the patient quit?
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No X
If so, what?
How much? For how many years?
(age thru )
Is the patient currently using these
If not, when did he/she quit?
drugs? Yes No
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks

5. For Veterans: Have you had any kind of service related exposure?

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

The patient is middle aged female adult, she is dressed and acts appropriate for the occasion, the patient is alert
and interacts with her family in the room. The patient shows symtoms of fatigue. The patient hasn’t eaten
anything orally since 06/29/17, she is currently in a clear liquid diet. The patient ambulates with minimal
assistance, she walks, uses the restroom, and sits on a chair to watch television.

Integumentary: The patient has clean, dry, pink skin and nails. The patient has a clean ileostomy RLQ in the
abdomen with no redness, swelling or tenderness on the surrounding skin. The patient has mild edema. The
patient doesn’t have any bruising, fungal infections, hives, and rashes. The patient showers daily.
HEENT: The patient uses glasses to read. The patient doesn’t have glaucoma, cataracts, ear infections, nose
bleeds, oral infections, or dental problems. The patient has all her original teeth, she practices dental hygiene
after every meal.
Pulmonary: The patient is breathing unlabored with no coughing present. The patient denies asthma, bronchitis,
emphysema, and pneumonia.
Cardiovascular: The patient has hypokalemia due to the loss of body fluids, she is being monitored in TELE
since she is at risk of possible dysrhythmia from electrolyte imbalance. The patient has no chest pain or vascular
problems.
GI: The patient had previous history of nausea, vomiting, constipation, and other gastrointestinal problems.
Currently she is experiencing abdominal discomfort and passing gases. Mild distention.
GU: The patient is urinating normally. No past history of GU problems.
Musculoskeletal: The patient has sensation, strength, and ROM in all her extremities symmetrically. She can
move around the room with minimal assistance.
Immunologic: The patient denies any past immunologic issues.
Hematologic/Oncologic: The patient doesn’t have any past or present hematologic illness. The patient denies
bleeding and bruising easily. The patient had a previous cervical cancer and received chemotherapy and
radiation.
Metabolic/Endocrine: The patient denies any history of diabetes, osteoporosis, adrenal gland disorder, thyroid
cancer, seizures, ticks, tremors, or severe headaches.
Central Nervous System: The patient is conscious, speaks clearly, denies any history of problems with sight,
hearing, taste, smell, sensation, voluntary and involuntary problems. The patient is also not showing any
problems with movement and balance.
Mental Illness: The patient is awake, alert, oriented, and engaged. The patient denies any history of depression,
anxiety, bipolar, schizophrenia, obsessive compulsive disorder, PTSD, or any other mental disorder.
Childhood Diseases: The patient denies any childhood disease.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone? NO

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

±10 PHYSICAL EXAMINATION:

General survey __The patient is an average female for her age and weight, _______________
Height _162.56 cm_____Weight__7468 kg___ BMI _28.3______ Pain (include rating and location) _2
abdomen____ Pulse_89____ Blood Pressure (include location)__105/64 upper left arm_Temperature (route
taken)_98.6o oral___
University of South Florida College of Nursing – Revision September 2014 11
Respirations_18_____ SpO2 _99___________ Room Air or O2__room air_______________
Overall Appearance_ symmetrical, clean, hair combed, no obvious abnormalities___________________
Overall Behavior__ Alert and oriented, no acute distress, behaved appropriate to setting, maintain eye contact,
engaged in conversation
Speech__ clear ________________
Mood and Affect__ cooperative, appropriate, normal judgement, pleasant, fatigue
_________________________
Integumentary__ skin warm, pink, dry, no lesions, no rashes, no deformities, skin turgor elastic; capillary refill
<3 seconds, no nail clubbing; hair evenly distributed, clean, no lesions.
__________________________________
IV Access__ left forearm______________________________________________________________
HEENT___ PERRLA, clear conjunctiva with no discharge, white sclera, symmetrical facial features, no pin in
sinus, no pain or clicking of TMJ, trachea midline, thyroid not enlarged, no palpable lymph nodes, symmetrical
eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands, peripheral vision intact, mild edema, no
tenderness on the face, EOM intact through 6 cardinal fields without nystagmus, whisper test heard on both sides
at the same time, ears symmetrical with no discharge, nose without lesions or discharge; lips, buccal mucosa,
floor of mouth, & tongue pink and moist without lesions. Teeth white and intact. _________
Pulmonary/Thorax__ Regular respiration and unlabored, chest expansion symmetric, lungs clear to auscultation
in all fields, percussion resonant throughout all lung fields, lung sounds are equal in both lungs _____
Cardiovascular___ No lifts, heaves, or thrills, no murmurs, regular heart sounds S1S2, regular rhythm, No JVD,
pulses bilaterally equal +3 radial and dorsalis pedis pulses, no temporal or carotid bruits, mild edema, extremities
warm with capillary refill less than 3 seconds. The patient is in TELE #94. ___________
GI__ Bowel sounds active x 4 quadrants; no bruits auscultated, stomach non-tender to palpation, percussion dull
over liver and spleen and tympanic over stomach and intestine, abdomen has mild distention, patient not
experiencing nausea or vomiting, last BM was in the morning at 11:20 am 07/06/17 liquid stool.
_____________________
GU____ Urine clear, normal, no pain, genitalia not assessed, patient alert, oriented, denies problems.
______________
Musculoskeletal__ Grip 5/5 on RUE, LUE, RLE, and LLE; Sensation 100% on RUE, LUE, RLE, and LLE;
Strength 5/5 on RUE, LUE, RLE, and LLE; ROM intact in all extremities without crepitus _______________
Neurological Patient awake, alert, oriented to person, place, time, and date, CN 2-12 grossly intact, sensation
intact to touch, pain, and vibration, DTR +2 in triceps, biceps, patellar, and Achilles. Patient has regular gait and
balance.

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

WBC: 4.8 - within normal range of 4.5-11 billion cells/L.

RBC: 3.16 (low) trillion cells/mcL – should be 3.6-5.4 mill/uL.
HGB: 9.3 (low) - should be 12-16 grams/dL.
HCT: 27.5 (low) - should be 37-47%.
MCV: 89.1 – within normal range of 80-100 fl.
MCH: 29.6 – within normal range of 26-32 pg/cell.
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 MCHC: 33.9 – within normal range of 31-36 Hb/cell.
Platelet: 254,000 - within normal range of 140,000 to 450,000 mmol.
Potassium: 2.7 (low) – range 3.5-5.1 mmol/L. Critical below 3.
Protein: 4.5 (low) – range 6.4-8.2 g/dL
Magnesium: 2.2 – range 1.6- 2.4 mg/dL
Sodium: 14.1 – range 136-145 mmol/L
Chloride: 104 – range 99-17 mmol/L
Carbon dioxide: 31 – range 21-32 mmol/L
Glucose: 131(high) – range 70-99 mg/dL.
BUN: 2 (low) – range 6-26 mg/dL
Colonoscopy 06/30/17 - unsuccessful to pass through structure/mass.

The patient WBC means the patient in not currently fighting an infection. The low RBC, HGB, and HCT means
the patient is suffering from anemia. The patient is not anemic, she may receive a blood transfusion. The patient
has normal MCV which means she has average red blood cell size and normal MCHC which means her red blood
cells carry the average amount of hemoglobin per red blood cell. Since the patient has a normal platelet range,
she is not at risk for clotting or bleeding.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
The patient is currently being treated with potassium chloride to improve the potassium levels since she has
hypokalemia. The patient potassium level is constantly being monitored. The patient is receiving teaching in how
to maintain, clean, and change the Ileostomy bag. The patient is being advice to walk frequently to improve her
mild edema. The patient is about to transition from clear liquid diet to full liquid diet and from PCA to PO pain
medication if tolerated. Patient pending a blood transfusion order. The patient’s potassium level is low, needs
potassium chloride to balance levels. The protein levels are low related to her low potassium intake and
inadequate nutrition. The patient has a colonoscopy 06/29/17 with results showing an unsuccessful to pass
through structure concluding in the patient getting an ileostomy. The patient’s heart continues to be monitored
with tele.

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

1. Decreased level of potassium serum (hypokalemia) related to oral dietary deficiency, excessive loss of
fluid and electrolytes as evidence by vomiting, loss of gastric fluid, distention, and lab results.

2. Mild body swelling (edema) related to inactivity, diuretics, and IV fluids as evidence by fluid retention,
and mild pitting edema.

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± 15 CARE PLAN
Nursing Diagnosis: Decreased level of potassium serum (hypokalemia) related to vomiting, loss of gastric fluid, dietary deficiency as evidence by
Patient Goals/Outcomes
The patient will not experience
hypokalemia.
fatigue and lab results
Nursing Interventions to Achieve
Goal
Monitor the potassium levels.
Continue to treat with potassium
chloride.
Advance diet to full liquid diet.
Transition to PO pain medication.
Teach potassium balance
nutritional diet.
Rationale for Interventions Evaluation of Goal on Day Care
Provide References is Provided
Until normakalemia is achieved to Potassium level slowly increasing,
prevent further decline of still below the critical care range of
potassium (Huether & McCance, 3 mmol/L.
2012).
Increase the level of potassium to
provide balance in serum content.
To slowly advance to oral diet,
increase potassium intake.
As tolerated by the patient, is
parallel with advancing the diet.
Prevent potassium levels to
decrease after discharge.

±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:
The patient is still not ready for discharge until her potassium levels are normal, the patient will be schedule with a dietary consult to manage her diet
to prevent hypokalemia. The patient is also receiving teaching regarding her ileostomy, how to maintain, clean, and change the bag.

University of South Florida College of Nursing – Revision September 2014 14

 Reference

Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology. (fifth, Ed.) St. Louis, Missouri:
Elsevior.
Thyer, B. A., Dulmus, K. N., & Sowers, K. M. (2012). Human Behavior in the Social Environment: Theories
for Social Work Practice. Hoboken: John Wiley & Sons.

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