UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Alyssa Escobar |

|Fundamental Patient Assessment Tool . |Assignment Date: 7/11/2014 |

| ( 1 PATIENT INFORMATION |Agency: Sarasota Memorial Hospital |

|Patient Initials: WEA |Age: 69 |Admission Date: 7/10/2014 |

|Gender: Male |Marital Status: Widower |Primary Medical Diagnosis with ICD-10 code: |

| | |Right knee osteoarthritis – M17.11 |

|Primary Language: English | |

|Level of Education: Some college |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): Retired from insurance agent | |

|Number/ages children/siblings: Daughter – 44, Son – 40; Brother – 66 | |

| | |

|Served/Veteran: Yes |Code Status: Full |

|Living Arrangements: Patient claims “daughter lives with me” |Advanced Directives: |

| |If no, do they want to fill them out? |

| |Surgery Date: 7/10/2014 Procedure: Right total knee arthroplasty |

|Culture/ Ethnicity /Nationality: White | |

|Religion: Baptist |Type of Insurance: Disability/self-pay |

|( 1 CHIEF COMPLAINT: |

|Patient states, “I have had right knee pain for a while, so I went to see what I could do about after trying over the counter stuff and the doctor said I should |

|have surgery”. |

|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |

| |

|O – 1 year of more ago, got worse in January |

| |

|L – right knee |

| |

|D – pain is on and off |

| |

|C – Pain is 8/9; stabbing pain |

| |

|A – hurts more when it is bent |

| |

|R – Celebrex, Ben Gay, and a cane helped him before surgery |

| |

|T – no other treatments were tried |

| |

| |

( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation (my patient was really drowsy so he couldn’t remember everything)

|Date |Operation or Illness |

|2001 |Diverticulitis |

|Unknown |Hernia (surgery) |

|Unknown |Hemorrhoids (severe blood loss) |

|Unknown |4 different finger surgeries |

|Unknown |2 times left rotator cuff |

|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

| |Patient states mother died of ovarian cancer and denies everything else. |

| |Patient states he does not know anything about his brother’s health because they haven’t talked in quite a long time. |

|( 1 immunization History |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) UNKNOWN |Yes |No |

|Routine childhood vaccinations | | |

|Routine adult vaccinations for military or federal service UNKNOWN DATE | | |

|Adult Diphtheria (Date) UNKNOWN DATE | | |

|Adult Tetanus (Date) 2013 | | |

|Influenza (flu) (Date) REFUSES | | |

|Pneumococcal (pneumonia) (Date) 2012 | | |

|Have you had any other vaccines given for international travel or occupational purposes? Please List PT | | |

|states he doesn’t remember names | | |

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |Niacin |Pt states he gets flushed and it feels like there are pins and needles all over his body |

|( 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) |

|Osteoarthritis (OA), also known as degenerative joint disease, happens in the synovial joints where there is loss of articular cartilage but bone keeps forming. |

|This can cause bone spurs and pieces of the bone may break off and irritate the capsule. There is also inflammation and thickening of the joint capsule from this. |

|This is most commonly found in the hips, hands, wrists, knees, feet and spine and is more prevalent in those 40 years old and older. There is no specific cause at |

|this time but is seen more in those who put more stress on their bodies, like athletes and obese people. |

|In OA, articular cartilage is broken down by cytokines and anabolic growth pathways with enzymatic destruction of proteoglycans and collagen fibers. Signs and |

|symptoms include pain, stiffness, enlargement, swelling, tenderness, limited range of motion, muscle wasting, partial dislocation, and deformity. These symptoms |

|can be one and off but unrelieved at night. To find out if you have OA, a healthcare provider may order a CT scan, arthroscopy, MRI but are not usually needed |

|because it is easy to detect. Some treatments may include rest to improve symptoms, use of a cane, losing weight, and use of anti-inflammatory drugs and |

|analgesics. With this kind of treatment, symptoms can still get worse. Surgery is another option that will improve range of motion and deformities and will help |

|long term. |

Huether, S. E., & McCane, K. L. (2012). Osteoarthritis. In V. Brashers & N. Rote (Eds.), Understanding pathophysiology (p. 997-998). St. Louis, Missouri: Mosby, Inc.

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

|Name Acetaminophen (Tylenol) |Concentration (mg/ml) |Dosage Amount (mg) 650 mg |

|Route PO |Frequency Q6H |

|Pharmaceutical class Nonopioid analgesic/antipyretic |Home Hospital or Both |

|Indication Mild pain, fever |

|Side effects/Nursing considerations hepatotoxicity, renal failure, neutropenia |

| |

|Name Atorvastatin (Lipitor) |Concentration |Dosage Amount 20 mg |

|Route PO |Frequency QHS |

|Pharmaceutical class hmg coa reductase inhibitor/lipid-lowering agent |Home Hospital or Both |

|Indication adjunctive management of primary hypercholesterolemia and mixed dyslipidemia; primary prevention of coronary heart disease |

|Side effects/Nursing considerations abdominal cramps, constipation, diarrhea, flatus, heartburn |

| |

|Name Cefazolin |Concentration |Dosage Amount 2 gm |

|Route IVPB |Frequency Q8H – stop after 2 doses |

|Pharmaceutical class first gen cephalosporin/anti-infective |Home Hospital or Both |

|Indication prophylaxis |

|Side effects/Nursing considerations phlebitis at IV site, rash, diarrhea, nausea, vomiting |

|Name Celecoxib |Concentration |Dosage Amount 200 mg |

|Route PO |Frequency Once daily |

|Pharmaceutical class cox 2 inhibitors |Home Hospital or Both |

|Indication relief of signs and symptoms of osteoarthritis, managing acute pain |

|Side effects/Nursing considerations dizziness, abdominal pain, rash |

| |

|Name Pregabalin |Concentration |Dosage Amount 100 mg |

|Route PO |Frequency BID |

|Pharmaceutical class nonopoid analgesics/gamma aminobutyric acid gaba |Home Hospital or Both |

|analogues | |

|Indication neuropathic pain assoc. with diabetic peripheral neuropathy |

|Side effects/Nursing considerations dizziness, drowsiness, edema, dry mouth |

| |

|Name Enoxaparin (Lovenox) |Concentration |Dosage Amount 40 mg |

|Route PO |Frequency Q24H |

|Pharmaceutical class antithrombotic |Home Hospital or Both |

|Indication prevention of venous thromboembolism, treatment of DVT, prevention of ischemic complications |

|Side effects/Nursing considerations bleeding, anemia, dizziness, headache |

| |

|Name Glyburide |Concentration |Dosage Amount 10 mg |

|Route PO |Frequency BID with meals |

|Pharmaceutical class sulfonylureas/antidiabetic |Home Hospital or Both |

|Indication control of blood sugar in type 2 diabtetes mellitus when diet therapy fails |

|Side effects/Nursing considerations photosensitivity, hypoglycemia |

| |

|Name Lisinopril |Concentration |Dosage Amount 20 mg |

|Route PO |Frequency once daily |

|Pharmaceutical class ACE inhibitors |Home Hospital or Both |

|Indication management of hypertension |

|Side effects/Nursing considerations dizziness, hypotension, cough, chest pain |

| |

|Name Metformin |Concentration |Dosage Amount 500 mg |

|Route PO |Frequency BID |

|Pharmaceutical class biguanides/antidiabetic |Home Hospital or Both |

|Indication management of type 2 diabetes mellitus |

|Side effects/Nursing considerations abdominal bloating, diarrhea, nausea, vomiting |

| |

|Name Metroprolol |Concentration |Dosage Amount 25 mg |

|Route PO |Frequency BID |

|Pharmaceutical class beta blocker |Home Hospital or Both |

|Indication hypertension |

|Side effects/Nursing considerations fatigue, weakness, erectile dysfunction |

| |

|Name Insulin Human |Concentration |Dosage Amount Sliding scale |

|Route subcutaneous |Frequency sliding scale |

|Pharmaceutical class insulin |Home Hospital or Both |

|Indication lower blood sugar |

|Side effects/Nursing considerations hypoglycemia |

|Name Hydromorphone (Dilaudid) |Concentration |Dosage Amount 0.2 mg / mL |

|Route PCA pump |Frequency 6 doses per hours |

|Pharmaceutical class opioid agonist |Home Hospital or Both |

|Indication moderate to severe pain |

|Side effects/Nursing considerations confusion, sedation, dizziness, hypotension, constipation |

|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |

|Diet ordered in hospital? Carb complex diet |Analysis of home diet (Compare to “My Plate” and |

|Diet patient follows at home? None |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: | |

|Breakfast: Nothing | |

| | |

|Lunch: Hot dog from Race Trac gas station | |

| | |

|Dinner: House salad with ranch, country fried steak, broccoli with butter | |

| | |

|Snacks: None | |

| | |

|Liquids (include alcohol): Water, occasional Pepsi | |

| | |

|[pic] |The patient does not seem to follow a carbohydrate complex or diabetic diet at |

|[pic] |home. He eats whatever he wants and doesn’t seem to manage his intake of |

|[pic] |different macronutrients in any way. |

| |According to his regular day, he eats 569 empty calories out or 1373 calories per|

| |day. He eats too much saturated fat per day and consumes too much sodium per day |

| |which is not good for his hypertension or hyperlipidemia. |

| |His daily food group targets need to be worked on. He needs five more ounces of |

| |grain in his diet which can be achieved by him eating breakfast. He could eat |

| |toast, cereal, or oatmeal. He could eat a little more vegetables by including a |

| |vegetable in his lunch like carrots or another salad. According to the patient’s |

| |daily intake he isn’t receiving any dairy products. He could drink milk at some |

| |point or have yogurt with his breakfast or lunch. It seems most people intake too|

| |much protein and this is the case for him as well. He needs to cut down about 1.5|

| |ounces. |

| |He needs to have a more balanced diet overall for his diabetes to try to manage |

| |it along with the medications and insulin. This could help use less of those. |

| |Carbohydrates and sugars need to be watched for this diet. Lean protein and fresh|

| |fruits and vegetables are encouraged. |

| (2014). Food Tracker. Retrieved from |

| |

| |

|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? Daughter |

|How do you generally cope with stress? or What do you do when you are upset? |

|Patient states “I tell when I am upset”. |

|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) – None |

| |

| |

|+2 DOMESTIC VIOLENCE ASSESSMENT |

|Have you ever felt unsafe in a close relationship? No |

| |

|Have you ever been talked down to? Yes Have you ever been hit punched or slapped?  Patient states he has been by his Dad |

| |

|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? No |

| |

|Are you currently in a safe relationship? No, not in relationship |

| |

|( 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: |

|“Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, |

|bitterness, and despair.” |

|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |

|The patient is sure not bitter about anything, he doesn’t seem to have any despair and doesn’t talk about regrets. He just doesn’t seem like a grumpy and miserable|

|old man. He seems fulfilled by the years he spent in the military and the years he spent with his wife and taking care of her while she was sick. I can tell he |

|misses his wife, but the way he talks about his daughter, granddaughter, and grandson, I can tell he is proud to have them and be a part of their life. He talks |

|about how he is remodeling his house by himself and is very proud of that. I feel like he is definitely satisfied with his life so far. |

|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |

|He doesn’t seem let down by this surgery at all. He was remodeling his house even when his knee was hurting before the surgery. I don’t think it has affected his |

|ego at all. He thinks of it as he will be in a better position afterwards. |

| |

|Cherry, Kendra. (2014). Psychology. Erikson’s Psychosocial Stages Summary Chart. |

|Retrieved from |

| |

| |

|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” |

|Military – marching and everything that went along with it for so long |

|What does your illness mean to you? Nothing |

| |

|+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 |

|Are you aware of ever having a sexually transmitted infection? Patient states “I don’t have one” |

|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?  No |

|When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?  Foam spermicide |

|How long have you been with your current partner? Partner died in December, hasn’t had one since |

|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 |

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

What importance does religion or spirituality have in your life?

Patient states “it is very important”.

Do your religious beliefs influence your current condition?

Patient states “God doesn’t do anything to punish us”.

|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |

| If so, what? |How much?(specify daily amount) |For how many years? years |

| | |(age thru ) |

| | | |

|Pack Years: | |If applicable, when did the patient quit? |

| | | |

|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? |

| |

| |

|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No ONCE |

| What? Crown Roya |How much? (give specific volume) |For how many years? |

| |180 mL |(age 21 thru 21 ) |

| | | |

| If applicable, when did the patient quit? 21 | | |

| |

| |

|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |

| If so, what? |

| |How much? |For how many years? |

| | |(age thru ) |

| | | |

| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |

| | | |

| | | |

|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks? No |

( 10 Review of Systems Narrative

|General Constitution (OLDCART anything checked above) |

|Pt’s perception of health: Patient thinks he is pretty healthy because he can still do his house remodeling |

| |

|Integumentary: Patient complains of hives/rash on the back of the knees occasionally from sweating. Patient says he bathes once a day. |

|HEENT: Patient uses reading glasses. Patient has difficulty hearing and has hearing aids but doesn’t always use them. Patient got hearing aids 6 months ago. Patient|

|has had dental issues resulting in teeth being pulled. Patient claims he brushes his teeth once a day. Patient says he only goes to the dentist when he needs to. |

|Patient has regular vision screenings and last one was in November 2013. |

|Pulmonary: Patient says he has difficulty breathing because he has COPD and was diagnosed 2 years ago. Patient states he has a chronic productive cough which |

|started about 3 years ago. Last chest x-ray was 7/9/2014. |

|Cardiovascular: Patient was diagnose with hypertension and hyperlipidemia 7 years ago. His last EKG screening was 7/10/2014. |

|GI: Patient states he gets nauseated in the car because he gets car sick. Patient states he had severe hemorrhoids in 1983 and lost 10 pints of blood and had to |

|have blood transfusion. Patient states he had diverticulitis in 1996. Patient states he had a colonoscopy 5 years ago. |

|GU: Patient states he has had kidney stones before but doesn’t remember when. Patient says he urinates about 4 times per day. |

|Men Only: Patient states he has annual prostate exams. Patient says his last one was June 2014. |

|Musculoskeletal: Patient claims he had weakness in 1990 when he was at work and fell against a door. Patient claims he has arthritis in his knees. |

|Immunologic: Patient has no immunologic complaints. |

|Hematologic/Oncologic: Patient said he bleeds easily and that it started about 5 years ago. Patient states he had blood transfusions in 1996 because of his sever |

|hemorrhoids. |

|Metabolic/Endocrine: Patient claims he has had type 2 diabetes mellitus for 7 years. |

|Central Nervous System: Patient claims he gets dizziness occasionally from his blood pressure medication. |

|Mental Illness: Patient states no issues with mental illness. |

|Childhood Diseases: Patient states he got chicken pox at age 6 because his mother exposed him to it so he would get it and get it over with. |

|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 Patient is drowsy and has trouble walking and transferring because of his right total knee arthroplasty. Patient is talkative but sometimes barely |

|understandable because of his drowsiness. Patient is alert and oriented x 3. Nothing with patient looks out of the ordinary for his current condition. |

|Height 6ft 4in Weight 235 lbs BMI 28.71 Pain (include rating and location) 8/9 – right knee Pulse 64 Blood Pressure (include location) 154/87 right arm Temperature |

|(route taken) 97.7 degrees Fahrenheit oral |

|Respirations 16 SpO2 96 room air |

|Overall Appearance Patient is clean, hair combed, dressed appropriate for the setting and temperature, maintains eye contact, and displays an obvious handicap in his|

|right knew r/t right total knee arthroplasty surgery. |

|Overall Behavior Patient is awake, calm, relaxed, interacts well with others, judgment is intact. |

|Speech Speech is clear but sometimes unclear because the patient is very drowsy. |

|Mood and Affect Patient is pleasant, cooperative, cheerful, talkative. |

|Integumentary Patient’s skin is warm, dry, intact. Skin turgor is elastic. Patient has no rashes, lesions or deformities. Nails are without clubbing. Capillary |

|refill is ................
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