UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Taylor Kelly

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 11/17/15

Agency: VA-SBN

Patient Initials: J.S.F

Age: 69

Admission Date: 10/24/15

Gender: M

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Stage 3 pressure ulcer of the sacral region: L89.153

Primary Language: English

Level of Education: Some college

Other Medical Diagnoses: (new on this admission)

Occupation: Retired

No new diagnoses

Number/ages children/siblings: 1 daughter, 34 yoa; 1 brother 65

yoa
Served/Veteran: Yes

Code Status: Full Code

Living Arrangements: Lives at home with wife

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: None scheduled

Culture/ Ethnicity /Nationality: Caucasian

Religion: Catholic

Type of Insurance: Medicare, Humana

1 CHIEF COMPLAINT:
Stage 3 pressure ulcer of the sacral region. The patient was brought into the hospital with complaints of a progressing
discomfort of pressure ulcer on his sacrum.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The patient was admitted on 10/24/15 with worsening discomfort of the sacral region due to a decubitus ulcer (stage 3).
The wound care team has been notified and have performed wound care daily since the patients admission. The patient
has a history of hypertension, COPD, and chronic foot ulcers in which resulted in his most recent surgery that was a
bilateral below the knee amputation in August of 2015. The patient also has a history of end stage renal disease and
receives dialysis treatments three days per week which insinuates his hemodialysis-associated hypotension.
The patient currently experiences obstructive sleep apnea in which is treated with oxygen 3L/min via nasal cannula, and
BiPAP machine while sleeping.

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

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

N/A

Diabetes

65

Cancer

Brother

Bleeds Easily

Pneumonia

Asthma

81

Arthritis

Mother

Anemia

86

Environmental
Allergies

Father

Cause
of
Death
(if
applicable)
MI

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
CHF
COPD
Chronic foot ulcers
ESRD
Unilateral right below the knee amputation
A-fib
Bilateral below the knee amputation

Age (in years)

Date
2001
2011
03/2014
2015
06/2015
08/2015
08/2015

Comments: Include date of onset- Patient was unsure

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria 07/14/2014
Adult Tetanus 07/14/2014
Influenza (flu) 09/24/2015
Pneumococcal (pneumonia) 07/14/2014
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

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NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Niaspan

Type of Reaction (describe explicitly)

Hives, weakness

Medications

None
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)
End stage renal disease significantly decrease the function of kidneys, leading to renal failure. Factors the increase the risk
of developing end stage renal disease include hypertension, diabetes mellitus, obesity, smoking, high cholesterol, and a
family history of kidney disease. End stage renal disease can be diagnosed through a series of blood and urine test
determining the function of the kidney and the ability to filter out toxins ("End Stage Renal Disease (ESRD)"). Treatment

for end stage renal disease includes hemodialysis treatments varying on the progression of the disease. The
hemodialysis treatment, filters out the blood of excess fluid and electrolytes that would normally be excreted
through the urine.

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

Concentration (mg/ml)

Route PO

Dosage Amount 3.125 mg

Frequency BID

Pharmaceutical class beta blocker

Home

Hospital

or

Both

Indication Hypertension
Side effects/Nursing considerations: Bradycardia, fatigue, blurred vision, and angioedema. Do not stop this medication abruptly.
Name midodrine (ProAmatine)

Concentration

Dosage Amount 10 mg

Route PO

Frequency TID

Pharmaceutical class vasopressors

Home

Hospital

or

Both

Indication Hemodialysis-associated hypotension

Side effects/Nursing consideration: Supine HTN, bradycardia, head pressure/fullness. Frequently monitor supine and sitting BP, make sure patient takes this
medication while receiving hemodialysis.
Name epoetin (Epogen)
Route

Concentration 1000 units

IV

Dosage Amount 1 mL

Frequency M, W, F (dialysis)

Pharmaceutical class erythropoiesis stimulating agents (ESA)

Home

Hospital

or

Both

Indication Hemodialysis, reduction in RBCs

Side effects/Nursing considerations: Stroke, MI, thromboembolic events, H/A. Monitor BP before and during therapy, monitor WBCs and platelet counts.
Name oxycodone (Oxecta)

Concentration

Dosage Amount 5 mg

University of South Florida College of Nursing Revision August 2013

Route PO

Frequency PRN w/ severe pain

Pharmaceutical class opiod agonist

Home

Hospital

or

Both

Indication Pain
Side effects/Nursing considerations: Respiratory depression, orthostatic hypotension, sedation, dizziness. Assess patients pain level 30 minutes after
administration, monitor BP and respirations.

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? Renal dialysis diet
Analysis of home diet (Compare to My Plate and
Diet pt follows at home?
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Cereal, juice
Lunch: Ham sandwich, chips
Dinner: Hamburger, fries, salad
Snacks: Crackers
Liquids (include alcohol): Juice with breakfast, water with
meals
According to My Plate, the patient eats 1,897 calories per
day of his allotted 2,000. However, the patient eats elevated
levels of refined grains compared to the recommend diet.
Also, the patient only consumed about 75% of the
recommend vegetables, only 60% of recommended protein,
and 50% of fruits recommended. My Plate recommends
eating three cups of dairy daily, whereas the patient only
ate 5% of the recommendation. The patients needs to focus
on switching the refined grains with more complex/whole
wheat choices

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
- Wife and daughter
How do you generally cope with stress? or What do you do when you are upset?
- I enjoy spending time with my family, talking to friends on the phone, and watching TV.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
- Feeling anxious and overwhelmed at times about recent amputation.

+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? N/A
Are you currently in a safe relationship? Yes

University of South Florida College of Nursing Revision August 2013

 4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Intimacy vs. Isolation

Autonomy vs. Doubt & Shame

Initiative vs. Guilt
Industry
Generativity vs. Self absorption/Stagnation
Ego Integrity vs.

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:

The patient reflects back on their life and either feels that it was meaningful (integrity) or does not feel satisfied
with their life accomplishments (despair) (Hearn et al., 2012).

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

The patient generally exhibits signs of integrity; he enjoys his time with his family and has an overall positive
attitude, even though he states that he feels overwhelmed at times.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

It seems that the patients developmental stage of life has be slightly affected by his illness. However, the patient
has efficient coping skills in which protect him from feeling despair about his condition.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
- Old age
What does your illness mean to you?
- The patient states that his illness is unfortunate and wishes that he was in better condition however, he is willing
to make the best of his situation.

+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? None
How long have you been with your current partner? 24 years
Have any medical or surgical conditions changed your ability to have sexual activity? Yes
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?
- The patient states that his religion is somewhat important to him.

Do your religious beliefs influence your current condition?

The patient believes that his beliefs do not influence his condition to worsen or get better.

+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)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

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

Has the patient ever tried to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
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
No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
- None

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: Shower at home
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
2/day
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?
2011
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: Hemodialysis (3x/week)

nocturia
dysuria
Anuric due to dialysis
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
1/year

Type: II

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:

2014

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

PND
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?
1/year
Date of last prostate exam?
2014
BPH
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal

10/2015

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

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

University of South Florida College of Nursing Revision August 2013

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: 69 year old
Height: 70 in.
male with no signs of distress Pulse: 82
Temperature: 97.8 F- Oral
Respirations: 18

Weight: 164 BMI: 23.65

Blood
Pressure: 105/56 (brachial)

Pain: 6

SpO2 : 95%
Is the patient on Room Air or O2: O2 3L/min via nasal cannula
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Patient bilateral below the knee amputations, able to perform most self care
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
Patient has stage 3 decubitus ulcer on sacrum

talkative
withdrawn

quiet
boisterous
aggressive
hostile

flat
loud

Peripheral IV site Type: Hep. Lock

Location: Right forearm
Date inserted: 10/23/15
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type: Tunneled chest catheter
Location: Right chest
Date inserted:
Fluids infusing?
no
yes - what?
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 3/ 3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- ~20 inches & left ear- ~20 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: WNL
Comments:
Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red

University of South Florida College of Nursing Revision August 2013

RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Clear- LUL, LLL

Diminished- RUL, RML, RLL

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th intercostal space, left midcalvicular line
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative (Amputee)

Pulses bilaterally equal: 2+ normal
Apical pulse: 2+ Carotid: 2+ Brachial: 2+ Radial: 2+ Femoral: 2+ Popliteal: Amputee DP: Amputee PT: Amputee
No temporal or carotid bruits
Edema: 0- none
Location of edema:
Extremities warm with capillary refill less than 3 seconds (upper, and above the knee only)

GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color:
Previous 24 hour output: Anuric due to dialysis
Foley Catheter
Urinal or Bedpan
Bathroom Privileges with assistance
CVA punch without rebound tenderness
Last BM: (date 10/22/15)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at 5 RUE, 5 LUE, 4 RLE (above the knee) & 4 LLE (above the knee)
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable (upper), no pain, pallor, paralysis or parathesias

University of South Florida College of Nursing Revision August 2013

Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: +2

Biceps: +2

Brachioradial: +2

Patellar

Achilles:

Ankle clonus: positive negative Babinski: positive negative

Unable to perform Rombergs, gait assessment, Babinski, or ankle clonus due to bilateral BKA.

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.
Lab
Serum Potassium
5.2
5.6 H
5.9 H
54.6
5.7 H

Dates
11/10 @ 0400
11/09 @ 1145
11/09 @ 0400
11/08 @ 0400
11/07 @ 0400

Trend
The patients serum
potassium levels are
generally unstable, and
slightly elevated.

Analysis
The instability of the
patients serum potassium
levels can be attributed to
the frequent dialysis
treatments, and the
inability of the patients
body to naturally regulate
electrolyte levels.

The patients hemoglobin

levels are significantly
low and are continuing to
decrease.

The amount of
hemoglobin affects the
patients bloods carrying
capacity of oxygen.
Therefore the patients
ability to use oxygen
efficiently is
compromised.

Normal (3.5 to 5.5)

Hemoglobin
9.5 L
9.7 L
9.7 L
9.8 L
10.3 L

11/09 @ 0400
11/08 @ 0400
11/07 @ 0400
11/06 @ 0400
11/05 @ 0400

Normal (13.5 to 17.5)

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
-

Diet: Renal dialysis diet

Accuchecks: Two times daily
University of South Florida College of Nursing Revision August 2013

Scheduled hemodialysis (3x/week)

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

1. Excess fluid volume related to compromised regulatory mechanisms (decreased kidney function), as evidence by
altered electrolyte levels, and edema in the peritoneum.
2. Impaired skin integrity related to altered metabolic state and circulation, reduced activity and mobility, and
accumulation of toxins in the skin, as evidence by stage three decubitus sacral ulcer and end stage renal disease.

3. Impaired physical mobility related to loss of lower extremities below the knee, pain/discomfort, decreased muscle
strength, and dialysis treatments.
4. Ineffective breathing pattern related to increased abdominal pressure restricting diaphragmatic excursion, rapid
infusion of dialysate, pain, and discomfort, as evidence by use of 3L/min of oxygen via nasal cannula and BiPAP
machine while sleeping.

University of South Florida College of Nursing Revision August 2013

 15 CARE PLAN
Nursing Diagnosis: Excess fluid volume related to compromised regulatory mechanisms (decreased kidney function), as evidence by altered
electrolyte levels, and edema in the peritoneum.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care
Goal
Provide References
is Provided
Short Term:
1. Relieve fluid from peritoneum and
other excess fluids Q shift.

2. Continue to improve electrolyte

imbalance Q shift.

Long Term:
1. Patient should receive out patient
hemodialysis without interruption
after discharge.

1. Perform aspiration of the

peritoneum as ordered, and allow
patient to receive timely hemodialysis
treatments.

1. Routine dialysis treatments and

peritoneal draining will help relieve
excess fluid from the patient, and will
help restore electrolyte levels.

1. The goal was met. The patient

2. Actively monitor the patients

electrolyte levels, and assess the
patient for signs and symptoms of
fluid volume excess and electrolyte
imbalance. Consult the provider for
hyperkalemia treatment.

2. The patients decreased kidney

function allows for excess electrolytes
and fluids to build up, by relieving this
the patients overall health and
comfort will increase.

2. The goal was met. The patients

vitals and lab values were monitored
frequently for sudden changes. The
patient remained stable, and
continuous hyperkalemia was reported
to the physician.

1. Assess the patients ability to

receive transport to dialysis
treatments, consult social services if
needed.

1. Because of the patients diagnosis

of end stage renal disease, it is critical
that the patient receive his scheduled
dialysis treatments three times per
week.

1. Patient was provided with education

about his dialysis treatments, it was
confirmed that the patients wife is
able to take him to his appointments.

received hemodialysis for four

hours, and was transferred back to
the unit in which the patient was
aspirated the previous day.

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:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
*F/U appts: Dialysis out patient
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Patient receives meds through VA.
Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Impaired skin integrity related to altered metabolic state and circulation, reduced activity and mobility, and
accumulation of toxins in the skin, as evidence by stage three decubitus sacral ulcer and end stage renal disease.
Patient Goals/Outcomes
Short Term:
1. Patient will experience a wound
that measurably decreases in size
and has increased granulation
tissue every 7 days per
assessment.

Nursing Interventions to
Achieve Goal

Rationale for Interventions

Provide References

Evaluation of Goal on Day Care

is Provided

1. Specialized nurse will provide

appropriate wound care daily
using the prescribed topical
mediations.

1. Keeping the wound free from

infection and excess pressure will
allow the wound to heal faster.

1. The goal was met. The wound

was treated by the wound care
nurse, using the prescribed
mediations.

2. Prevent recurrent infection in

wound everyday.

2. Daily wound care with use of

medicated packing supplies and
anti-infective medications.
Monitor the site of tissue damage
once daily for changes in color,
swelling, warmth, or signs of
further infection.

2. If the wound is able to stay free

of infection and fewer
complications will occur, allowing
for increased healing time.

2. The goal was met. The wound

was treated by the wound care
nurse, using the prescribed
mediations. The patients wound
did not exhibit any signs of
infection (redness, swelling, pain,
necrotic tissue).

3. Compliance with hemodialysis

treatment and increased mobility
on days not actively receiving
hemodialysis.

3. Transfer patient to dialysis,

promote mobility when patient
returns.

3. Allowing the patient to receive

timely dialysis treatments, will
help remove toxin build up.
Increased mobility will promote
healing.

3. The goal was met. The patient

received hemodialysis for four
hours, and was transferred back to
the unit in which the patient
received education and
encouragement to become more
mobile on his off-days of dialysis.

1. Provide appropriate wound care

daily, and provide patient
education on wound healing.
Consult physical therapy.

1. Proper wound care and mobility 1. The goal is unmeasurable at this

will help increase the rate of
time.
healing.

Long Term:
1. Regain integrity of tissue and
skin surface in at least1 month,
and increase mobility gradually.

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:

SS Consult
*Dietary Consult: Nutrition education is needed to manage ESRD.
*PT/ OT: PT is needed in order to keep patient active and decrease fall risk.
Pastoral Care
Durable Medical Needs
*F/U appointments: Wound care
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No Patient receives meds through VA.
Rehab/ HH
Palliative Care

References
End Stage Renal Disease (ESRD). (2015). Retrieved November 17, 2015, from
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age_renal_disease_esrd_85,P0147
Food Tracker. (n.d.). Retrieved November 17, 2015, from https://www.supertracker.usda.gov/foodtracker.aspx
Hearn, S., Saulnier, G., Strayer, J., Glenham, M., Koopman, R., & Marcia, J. (2012). Between Integrity and
Despair: Toward Construct Validation of Erikson's Eighth Stage. Journal Of Adult Development, 19(1),
1-20. doi:10.1007/s10804-011-9126-y
Long-term mortality and risk factors for development of end-stage renal disease in critically ill patients with and
without chronic kidney disease. (2015). Critical Care, 191-12 12p. doi:10.1186/s13054-015-1101-8
Unbound Medicine, Inc. and Vallerand, Sanoski, Deglin & Mansell. (2015). Daviss Drug Guide
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