UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Katherine Rivas

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 07-7-2014

Agency: VA

Patient Initials: R.S

Age: 65 years old

Admission Date: 06-03-2013

Gender: Male

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Autonomic Dysreflexia

Level of Education: Bachelors Degree

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Military

Diabetes type I, PTSD, Anxiety,

COPD, Skin Cancer

Number/ages children/siblings: 1 Daughter/42 years old/1 Brother

(deceased)

Hypotension, Neurogenic Bladder, Neurogenic

Bowel, Collapsed Lung
Insomnia, MRSA, Quadriplegic

Served/Veteran: Yes, Vietnam Era

Code Status: Full Code

Living Arrangements: Lives with wife. Both live in Fort Myers

Advanced Directives: Yes

If no, do they want to fill them out? No
Surgery Date: May 2013 Wound Debridement on
left ischium.

Culture/ Ethnicity /Nationality: White/Caucasian/American

Religion: Baptist

Type of Insurance: Medicare

1 CHIEF COMPLAINT:
I just felt different and my head was killing me

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The client is a 65 year old American white male, who was admitted to facility on 6/3/13 with a throbbing headache,
difficulty breathing and abnormal vital signs. Client states he felt weak, short of breath and had a throbbing headache.
Client states the headache was constant and rated the headache an 8 out of 10. Nothing relieved or aggravated the
symptoms. Client states once he arrives to VA he was told his vital signs were abnormal and was consistent with his
history of autonomic dysreflexia due to his spinal cord injury. In November 2013, patient experienced a collapsed lung
and was placed on a ventilator

University of South Florida College of Nursing Revision August 2013

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

Brother

65

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Cancer

Asthma

79

Arthritis

Mother

Anemia

77

Environmental
Allergies

Father

Cause
of
Death
(if
applicable
)
M.I.

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Debridement of Sacral Wound
Excisional debridement of right ischial wound
Tracheostomy
Cystoscopy
Left Foot grafting
Right Trochanter wound debridement
Excision Left Ischial Ulcer

Age (in years)

Date
1/2014
11/2013
10/2013
02/2013
03/2012
102011
10/1989

N/A

Sister

N/A

relationship

N/A

relationship

N/A

relationship

N/A
Comments: Include date of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations: Dates unknown
Routine adult vaccinations for military or federal service: Dates unknown
Adult Diphtheria (Date) : unknown
Adult Tetanus (Date) : unknown
Influenza (flu) (Date)December 2013

YES

University of South Florida College of Nursing Revision August 2013

NO

Pneumococcal (pneumonia) (Date): U

Have you had any other vaccines given for international travel or
occupational purposes? U
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Talwan

Type of Reaction (describe explicitly)

Rash and Hallucinations

Medications

N/A
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)
Mechanics of the disease: Autonomic Dysreflexia or A.D occurs when a noxious stimulus is introduced to the body
below the level of spinal cord injury. This can be caused with something small such as an overfull bladder. The stimulus
sends nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion at the level of
injury (Osborn, 2014). Since these electrical impulses cannot reach the brain, a reflex is activated that increases activity
of the sympathetic portion of the ANS, autonomic nervous system. This then leads to a spasm and a narrowing of the blood
vessels, which causes a rise in the blood pressure. (Osborn, 2014).
Risk Factors: Anyone with a spinal cord injury is at risk because their sensation is diminished and they feel when there is
a stimulus that is irritating the body. Quadriplegic and paraplegics are at highest risks and this includes individuals with
any disease that can cause this such as ALS patients.
Clinical manifestations: There are many manifestations that can be observed besides a spike in blood pressure and a low
pulse. Theres also pounding headache, sweating above the level of injury, nasal congestion, restlessness
Blood pressure greater than 200/100, flushed face, nausea cold, clammy skin below level of spinal injury (Osborn, 2014).
The main treatment: The first thing to do would be to remove the stimulus causing the irritation to the skin. It can be a
wrinkle in a sheet, or just emptying the bowel or bladder (Osborn, 2014). If the patient is supine immediately sit the
patient up also loosen any clothing, assess blood pressure, if the patient has an indwelling catheter make sure there are no
kinks (Osborn, 2014). If it is fecal impaction, nurse must digitally remove feces from the anus. By removing the stimulus
the blood pressure should return to normal limits if not this can be life threatening and cause death.
Prognosis: Educating the family and patient about symptoms of AD and causes can help save a life. If stimuls is removed
in time and caught early, patients have a low mortality rate. However, if it is not caught in time the patient can go into
hypovolemic shock and die (Osborn, 2014).
References
Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014).Nursing Management of Patients with Neurological
Disorders. Medical Surgical Nursing: Preparation for Practice (). Upper Saddle River, New Jersey: Pearson Education, Inc.

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name Acetaminophen Tab
Route PO

Concentration (mg/ml) 650 mg tab

Dosage Amount (mg) 650 mg

Frequency PRN

University of South Florida College of Nursing Revision August 2013

Pharmaceutical class Antipyretic

Indication As needed for fever > 100.4 or pain
Side effects/Nursing considerations Hepatoxity
Name Gabapentin

Home

Hospital

or

Concentration 200 mg

Route PO

Pharmaceutical class Anticonvulsant

Home

Frequency
Hospital

Both

Dosage Amount 200 mg

or

Both

Indication PO BID for burning pain

Side effects/Nursing considerations Depression/Suicidal thoughts
Name Albuterol Solution

Concentration

Route Inhale
Frequency Daily
Pharmaceutical class Adrenergics
Home
Hospital
or
pIndication Lung expansion rotocol per Respiratory Therapy while inpatient
Side effects/Nursing considerations Chest Pain/ Palpatations
Name Vancomycin

Concentration 500 mg

Dosage Amount 1 vial

Both

Dosage 500 mg

Route IV
Frequency twice a day
Pharmaceutical class Anti infective
Home
Hospital
or
Both
Indication Use cautiously in those with hearing impairments
Side effects/Nursing considerations: Ototoxicity , N/V, hypotension, rashes, nephrotoxicity
Name Guaifenesin tablet

Concentration 400 mg

Dosage Amount 400mg

Route PO
Frequency twice a day
Pharmaceutical class Expectorant
Home
Hospital
or
Both
Indication Use cautiously if cough longer than a week
Side effects/Nursing considerations dizziness, headache, nausea, diarrhea, stomach pain,
Name Diazepam

Concentration 10 mg

Dosage 10 mg

Route PO
Frequency twice a day
Pharmaceutical class : Benzodiazepines
Home
Hospital
or
Both
Indication contraindicated in those with sleep apnea and pts with myasthenia gravis
Side effects/Nursing considerations dizziness, drowsiness and lethargy. Can also cause rashes, constipation

References
Deglin, J.H., Vallerand,A. H., & Sanoski, C. (2009). Daviss Drug Guide for Nurses (13 th ed). Philadelphia, Penn: F.A.
Davis

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular Diet
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? Regular Diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Grains: 6 ounce equivalents
(1 ounce equivalent is about 1 slice
bread; 1 ounce ready-to-eat cereal;
or cup cooked rice, pasta, or
cereal)
Breakfast: Cereal with 2% Milk and cranberry juice
Vegetable 2 cups
(1 cup is 1 cup raw or cooked
vegetables, 2 cups leafy salad greens,
or 1 cup100% vegetable juice)
Lunch: Grilled Cheese sandwich with Ham and
Cranberry juice and Lays chips.

Fruits: 2 cups
(1 cup is 1 cup raw or cooked fruit,
cup dried fruit, or 1 cup 100% fruit juice

Dinner: Grilled chicken, green Beans and a salad or

mashed potatoes

Dairy: 3 cups
(1 cup is 1 cup milk, yogurt, or
fortified soy beverage; 1 ounces
natural cheese; or 2 ounces

Snacks: Lays Chips or Melon.

Protein: 5 ounce equivalents

(1 ounce equivalent is 1 ounce lean
meat, poultry, or seafood; 1 egg; 1 Tbsp
peanut butter; cup cooked beans or
peas; or ounce nuts or seeds)
When comparing clients diet to that recommended by My
Plate I think he needs to increase his protein intake because he
has three wounds and protein will help heal them. He can
increase his vegetables and fruit and decrease his salt intake. He
can replace chips with melons because its his favorite fruit or
green beans. He drinks a lot of water already, but he can also
have a variety of fruit juices or Orange juice because it contains
vitamin C, which is good for his immune system.

Liquids (include alcohol): Low Fat Milk, Iced water or

cranberry juice 1 and no alcohol

Use this link for the nutritional analysis by comparing the patients 24
HR average home diet to the recommended portions, and use My
Plate as reference.

References
ChooseMyPlate.gov. (2014, January 1).ChooseMyPlate.gov.
Retrieved July 7, 2014, fromhttp://www.choosemyplate.gov

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? His wife
How do you generally cope with stress? or What do you do when you are upset?
Client states when he is stressed he calls or tells his wife and she is understanding.

University of South Florida College of Nursing Revision August 2013

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life): Client states he
Did suffer from PTSD for years but he no longer has that problem. The VA helped me through that process and he no
longer feels depressed so he just takes it day by day. Client also states
Some mornings are better than others, but denies feelings of anxiety or depression.
+2 DOMESTIC VIOLENCE ASSESSMENT
Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are safe.
Have you ever felt unsafe in a close relationship? ____No___________________________________________________
Have you ever been talked down to?__No_____________ Have you ever been hit punched or slapped? __No________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
______________No______________ If yes, have you sought help for this? ______________________
Are you currently in a safe relationship? Yes. Client states I come from different times, we didnt do that stuff.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons
developmental stage for your
Clients age group: This stage occurs during late adulthood from age 65 through the end of life. During this
period of time, people reflect on the life they have lived and come away with either a sense of fulfillment from a
life well lived or a sense of regret over a life misused (Osborn, 2014) Successfully completing this phase means
looking back with few regrets and a general feeling of satisfaction (Osborn, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
I believe my patient is in the ego integrity phase because although his life has changed a lot in the last year
due to the ventilator, the client still shows some feelings of general satisfaction. His wife visits him every
weekend and that helps motivate him. He also shared many good stories about his life which sounded to me like
he has no regrets but just wants to be closer to his family.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of
life: I think this hospitalization has had a major impact on my clients developmental stages because when he
came to the VA a year ago, he was supposed to be discharged right away. However, due to complications with his
autonomic dysreflexia and a surgery that went wrong, he has now been hospitalized for a year. This means he has
been away from his family, because they live an hour away and also he will be leaving with more problems than
he came in with. Client is aware that this is a major burden on his wife and states he wishes he would have
never came in the first place. This has caused my patient to feel despair sometimes instead of feeling
completely satisfied. The client however is very hopeful and has had a positive attitude these last few months.
References
Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). The Biophysical and Psychosocial Aspects of
Nursing. Medical Surgical Nursing: Preparation for Practice (). Upper Saddle River, New Jersey: Pearson
Education, Inc.
University of South Florida College of Nursing Revision August 2013

+3 CULTURAL ASSESMENT:
What do you think is the cause of your illness? Client states that because he is a quadriplegic little things can cause his
body to have autonomic dysreflexia.

What does your illness mean to you? Client states it is something he has dealt with his whole life so he is used to it.

+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? ____No__________________________________
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? N/A
How long have you been with your current partner?_______40 years________________
Have any medical or surgical conditions changed your ability to have sexual activity? Quadriplegia and being on a
ventilator
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? No

University of South Florida College of Nursing Revision August 2013

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

What importance does religion or spirituality have in your life?

Client states his religion does not play a major impact in his life.
Do your religious beliefs influence your current condition?

No, not really

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)
Cigarettes
20 cigarettes per day

Yes
For how many years? 7 years
Age 18 thru 25
If applicable, when did the
patient quit? 30 years ago

Pack Years: 7
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? Yes

2. Does the patient drink alcohol or has he/she ever drank alcohol?
No
What?
How much? (give specific volume)

For how many years?

(age

thru

If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
If so, what?
Marijuana
How much?
For how many years? 4
(age 20
thru
24
)
Once a day
Is the patient currently using these drugs?
Yes No

If not, when did he/she quit?

30 years ago

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Client states he has been exposed to Agent Orange and some pesticides

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
x/day
x/year

Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other:

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision August 2013

REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

Client states he has gained 10 lbs in the last year and it due to mostly being in his bed.
Integumentary:
On inspection of the skin I did notice 3 pressure ulcers, 2 on his left trochanter and 1 on his
sacrum. On his left trochanter there is a stage 3 pressure ulcer, 2 cm in width, 1 cm in length, and
1 cm in depth with mild yellow exudate. The other area on the left trochanter is a stage 1 pressure
ulcer, 2 by 2cm. The one on the sacrum is a stage three pressure ulcer 3 cm in width and 3 cm in
length and 1 cm in depth with no exudate. Client denies any other changes in appearance of skin
or problems with nails. I didnt observe any dandruff or psoriasis. Client has no rashes or hives.
Besides the pressure ulcers, no other skin infection was noted. Client states he does use sunscreen
when he is outside, SPF35. I educated client about the importance of applying sunscreen on his
ears as well. Client does receive care from staff while in the hospital every morning. Client is
bathed while in bed and receives one shower a week. At home, his wife bathes him.

HEENT:
Client does wear corrected eye lenses. He denies having cataracts or glaucoma. Client
wears two hearing aids because he does have difficulty hearing, from both ears. Client
denies ear infections, sinus pains or infections. Client does not have a history of nose
bleeds or post nasal drip. Client has assistance for brushing his teeth, once a day and
denies having oral infections or dental problems. Last visit to the dentist was one year ago
and last vision screening was 4 months ago and he gets his vision tested twice a year.
Pulmonary:
Client denies difficulty breathing, client is on a ventilator. Client has had a productive
cough with white sputum for a week. Client gets suctioned as needed. Client does not
have a history of asthma, emphysema or tuberculosis. Client has and has had pneumonia
about 4 times. Client denies environmental allergies. Last chest x-ray was yesterday to
Rule out pneumonia.
Cardiovascular:
Client does have a history of hypotension and is taking medication. Client denies having
hyperlipidemia, or complaints of angina. Client does not have history of myocardial
infarction, CAD, PVD or thrombus. Client does have a heart murmur and has a history of
atrial fibrillation. Last EKG was three weeks ago.
GI:
Client has not had constipation, nausea or vomiting. He had diarrhea for the past 2 days.
Stool is watery and dark in color. Amount is medium. Client denies having irritable bowel,
GERD or cholecystitis, Client does have a history of stomach ulcers. Client has not had
blood in the stool or hemorrhoids. Clients history is negative for hepatitis, pancreatitis,
colitis or yellow jaundice. Client hasnt had appendicitis or any abdominal abscess. Last
colonoscopy was years ago.
GU:
Client has a supra pubic foley catheter inserted and denies dysuria. Client has not had
hematuria or polyuria. Client states hes never had kidney stones. He also denies having
bladder or kidney infections.

University of South Florida College of Nursing Revision August 2013

10

Women/Men Only:
Client denies having infection of male genitalia or prostate. Client states last prostate
exam was 1 year ago. Client does not have history of BPH or urinary retention.
Musculoskeletal:
Client states he has both legs and both arms when he was younger. Client has weakness
bilaterally secondary to being a quadriplegic. Client denies having pain that morning.
Client has had gout before, last time was 3 years ago. Client denies history of
osteomyelitis and arthritis.
Immunologic:
Client currently does not have a fever, this morning it was 97.8 degrees. Client has not has
night sweats. Client denies history of HIV, RA or lupus. Client has not had enlarged lymph
nodes or a life threatening allergic reaction.
Hematologic/Oncologic:
Client does not have history of anemia. Client does not bleed or bruise easily. Client has
never had a blood transfusion. Client does have history of Basal Cell Carcinoma lesions
(2x) on his face but were removed using a chemical peel and MOHS surgery. Blood type is
B Positive.
Metabolic/Endocrine:
Client has diabetes Type I and it is controlled. He denies any thyroid problem or
osteoporosis.
Central Nervous System:
Client does not have history of CVA. Client has had dizziness recently and severe
headaches. Client thinks it might be due to autonomic dysreflexia. Client denies having
seizures, tremors or meningitis. Client history is negative for encephalitis.
Mental Illness:
Client denies feeling depressed or anxious. Client has no history of schizophrenia or
bipolar disorder. Client does state he has insomnia.
Childhood Diseases:
Client had chicken pox at the age of 10. Client also states he has had mumps and measles
when he was younger but cannot recall what age. History negative for polio, or scarlet
fever.

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

University of South Florida College of Nursing Revision August 2013

11

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

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12

10 PHYSICAL EXAMINATION:
General survey: Client is Alert and Oriented x 3.
Height __5 feet_6 inches____Weight___165 Lbs_______ BMI __25____ Pain (include rating and location) 4, around neck.
Pulse__84_____ Blood Pressure (include location)__Left Arm_114/84_____Temperature (route taken) Oral 98.7
Respirations____18________ SpO2 ____99_____________ Room Air or O2_________Room Air__________________
Overall Appearance: Client is clean, hair combed and dresses appropriate in gown. Client is well groomed.
Overall Behavior: Awake and relaxed. Client makes eye contact with judgment intact.
Speech: Clear and crisp diction.
Mood and Affect: Clients mood is cooperative and friendly. Non-combative.
Integumentary: Client has three pressure ulcers. Two on left trochanter and one on sacrum. On his left trochanter there is a
stage 3 pressure ulcer, 2 cm in width, 1 cm in length, and 1 cm in depth with mild yellow exudate. The other area on the left
trochanter is a stage 1 pressure ulcer, 2 by 2cm. The one on the sacrum is a stage three pressure ulcer 3 cm in width and 3 cm
in length and 1 cm in depth with no exudate. Client does have ointments ordered by provider and does receive
Mist therapy every day from registered nurses.
IV Access: PIC Line located in right arm, with no signs of infections or infiltration.
HEENT: Facial features are symmetric, no pain in sinuses. Trachea is midline and thyroid is not enlarged. Client had no
palpable lymph nodes. Sclera is white and conjunctiva is clear with no exudate. Pupils were PERRLA. Ears are symmetric
without lesions. Nose is without lesions. Lips and buccal mucosa is pink and moist. Clients dentition is intact, no problems
noted.
Pulmonary/Thorax: Client had some wheezes on auscultation and a productive cough with moderate white mucus. Nurse was
notified of this.
Cardiovascular: No heaves, no lifts noted and PMI felt at 5 th intercostal space mid-clavicular line. S1 and S2 were heard, no
murmur auscultated. No edema in upper or lower extremities. No JVD noted. All pulses were 2 plus bilaterally. Capillary
refill is less than 3 seconds.
GI: Normo-active bowel sounds heard in all four quadrants. Abdomen soft and slightly distended. No organomegaly
GU: . Client has suprapubic catheter with no redness around area. Input was 1100 Output is 1300. Urine color is dark yellow
with no blood. Last BM was that morning, small semi-liquid stools, medium brown in color. Genitalia is clean without
discharge. Assessed during morning care with clients consent.
Musculoskeletal: Limited ROM in all extremities due to spinal injury. Strength is 0-absent in all extremities. No crepitus or
scoliosis.
Neurological: Client is alert, awake and oriented times 3. Sensation is not intact in lower extremities due to spinal injury.
Unable to assess all cranial nerves, Rombergs or gait due to clients condition.
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, Xrays, 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.

Lab
K

Dates
4.0

3.4 L
Normal (3.5-5.2)

NA

135 L
139
Normal (136-145)

(06/30/2014)
(07/2/2014)

(06/30/2014)
(07/02/2014)

Trend
Low potassium can be
due to a side effect of the
medications he is taking
or due to his diarrhea.
These can cause an
electrolyte imbalance in
the body
Clients sodium can
change also due to
diuretics or as a side
effect of a mood

Analysis
Low potassium refers to a
lower than normal
potassium level in your
bloodstream. Potassium is
an electrolyte that is critical
to the proper functioning of
nerve and muscles cells,
especially heart muscle
cells.
Low blood sodium occurs
when you have an
abnormally low amount of
sodium in your blood or

University of South Florida College of Nursing Revision August 2013

13

medication he is taking.

CL

105
104
Normal (98-109)

(06/30/2014)
(07/02/2014)

CO2

24
21 L
Normal: (22-32)

(06/30/2014)
(07/02/2014)

BUN

19
20
Normal: 8-23

(06/30/2014)
(07/02/2014)

Normal-Liver is working
properly.

Creat

(06/30/2014)
(07/02/2014)

Kidneys are rapidly

excreting creatinine, more
tests should be done to
determine exact problem.

0.2 L
0.3 L
Normal: 0.8-1.3

Normal

Clients CO2 can be

decreasing due to an
uncontrolled disease. Client
was having some diarrhea
during this time and client is
on a ventilator.

when you have too much

water in your blood. Low
blood sodium is common in
older adults, especially
those who are hospitalized.
Chloride is an anion in the
human body needed for
metabolism. It also helps
keep the body's acid-base
balance. The amount of
serum chloride is carefully
controlled by the kidneys.
Low CO2 in the body
causes blood to be less
acidic. This condition is
caused by hyperventilation,
or excessive ventilation.
A BUN test measures the
amount of nitrogen in your
blood that comes from the
waste product urea. Urea is
made when protein is
broken down in your body.
Urea is made in the liver
and out of your body in the
urine.
Having a low level of blood
creatinine indicates nothing
more than an efficient and
effective pair of kidneys.

References below unable

to paste under this chart.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled
diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
I assisted the registered nurse perform AM care, by bathing the patient, changing his bed linens and assisting with
taking vital signs. Vital signs were: BP: 114/82 R18 P:88 02:99%. Client ordered lunch and I assisted in feeding
patient, he ate 80% of lunch. Client has a regular diet. Client has limited ROM and is on a ventilator due to spinal
injury so does not perform too many activities. He does like to go in his wheel chair for one hour and sit outside.
Client does receive breathing treatments and breathing exercises every morning from respiratory therapist. Client
has a consult tomorrow with a surgeon for a colostomy surgery.
References
Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014).Fluid, Electrolytes and Acid Base Balance. Medical
Surgical Nursing: Preparation for Practice (). Upper Saddle River, New Jersey: Pearson Education, Inc.

University of South Florida College of Nursing Revision August 2013

14

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

1. Risk for autonomic dysreflexia related to loss of autonomic nervous system control below the level of the cord injury as
evidenced by history of dysreflexia triggered by pressure.
2.
3.
4.
5.

University of South Florida College of Nursing Revision August 2013

15

 15 CARE PLAN
Nursing Diagnosis: (Which nursing diagnosis you are doing your care plan on goes here.)
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Client/family will be able to 1 Assess for causative agents that
respond to early signs and
can cause AD.
symptoms of autonomic
dysreflexia by tomorrow.
2. Educate individual and family
how to constantly assess patients
vital signs- Blood pressure, pulse,
pain
3. Teach family members how to
digitally remove fecal impaction

1. Being able to identify the cause

- Goal not met, Unable to evaluate
is vital in treating the patient and
during my shift
preventing further damage or
death.
2. Vital signs are the first indicative
of AD, since the client is unable to
assess for himself it is imperative
to teach the family to look for HTN
and low pulse.
3. Fecal impaction is the second
leading cause of AD, so it is vital
that family members can remove
this stimulus safely without
causing further harm.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Since the client is quadriplegic and is unable to care for himself I would discharge him to a facility that can attend to all his needs, including the
ventilator or I would educate the family about all the potential problems and new skills they need to learn.

Consider the following needs:

SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts **
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH **
Palliative Care for patient and for the family.