UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Patra Cain |

|Patient Assessment Tool . |Assignment Date: 2/12/2014 |

| ( 1 PATIENT INFORMATION |Agency: SMH/UD/USF |

|Patient Initials: B.K. |Age: 86 |Admission Date: 2/9/2014 |

|Gender: female |Marital Status: widowed |Primary Medical Diagnosis with ICD-10 code: |

|Primary Language: English |S82 |

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

|Occupation (if retired, what from?): retired; engineer | |

|Number/ages children/siblings: | |

|2 sisters, 2 daughters, and 1 son. | |

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|Served/Veteran: no |Code Status: Full |

|Living Arrangements: lives alone but has home health assistance |Advanced Directives: yes |

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

| |Surgery Date: Procedure: |

|Culture/ Ethnicity /Nationality: white/Caucasian | |

|Religion: Roman Catholic |Type of Insurance: Medicare, Blue Cross |

|( 1 CHIEF COMPLAINT: |

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|“Right leg pain” |

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

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|Patient was trying to make breakfast and twisted her ankle trying to move her walker around a chair and fell down |

|resulting in a right ankle fracture. Patient was having continuous sharp pain in her right ankle and did not take any |

|medications for pain until arrived at the hospital and had her leg raised. |

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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation

|Date |Operation or Illness |

|70 years ago |appendectomy |

|50 years ago |c-section |

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|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

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|( 1 immunization History |

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

|Routine childhood vaccinations | | |

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

|Adult Diphtheria (Date) | | |

|Adult Tetanus (Date) sometime this year | | |

|Influenza (flu) (Date) September 2013 | | |

|Pneumococcal (pneumonia) (Date) September 2013 | | |

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

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

|REACTIONS |Causative Agent | |

|Medications |Penicillin |unknown |

| |iodine |Chest tightness |

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|Other (food, tape, latex, dye, |Corn and broccoli |Unknown |

|etc.) | | |

| |Fish |Unknown |

| |Oats |Unknown |

| |Rice |unknown |

|( 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) |

|This patient had a right ankle fracture. According to McCance and Huether (2012), fracture healing can be done in a direct way which means it is done with |

|surgical mean. Healing requires integration of cells, signaling pathways, and |

|carious molecules. Direct healing is when the repair of a broken bone is done surgically. No callus formation occurs with |

|direct bone healing. |

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|Reference: |

|McCance, K. L., and Huether, S. E. (2012). Understanding Pathophysiology 5th edition. St. Louis, MO: Mosby Inc. |

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

|Name carvedilol |Concentration (mg/ml) 6.25mg |Dosage Amount (mg) 6.25mg |

|Route PO |Frequency BID |

|Pharmaceutical class beta blocker |Home Hospital or Both |

|Indication HTN, HF, left ventricular dysfunction after MI |

|Side effects/Nursing considerations dizziness, fatigue, weakness, diarrhea, bradycardia, Steven-Johnson syndrome, pulmonary edema |

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|Name losartan |Concentration 50mg |Dosage Amount 50mg |

|Route PO |Frequency once daily |

|Pharmaceutical class angiotensin II receptor blocker |Home Hospital or Both |

|Indication HTN |

|Side effects/Nursing considerations diarrhea, angioedema, hypotension |

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|Name aspirin |Concentration 81mg |Dosage Amount 81mg |

|Route PO |Frequency once daily |

|Pharmaceutical class salicylates |Home Hospital or Both |

|Indication osteoarthritis, mild to moderate pain |

|Side effects/Nursing considerations GI bleed, nausea, abdominal pain, indigestion |

|Name famotidine |Concentration 20mg |Dosage Amount 20mg |

|Route PO |Frequency BID |

|Pharmaceutical class histamine h2 antagonist |Home Hospital or Both |

|Indication ulcers |

|Side effects/Nursing considerations confusion, aplastic anemia, agranulocytosis, dizziness, constipation |

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|Name lovenox |Concentration 40mg |Dosage Amount 40mg |

|Route subq |Frequency once daily |

|Pharmaceutical class antithrombotics |Home Hospital or Both |

|Indication prevent blood clots |

|Side effects/Nursing considerations bleeding, anemia, constipation, dizziness, HA, n/v, hold if platlet count ................
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