UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kevin Jones

PATIENT ASSESSMENT TOOL .

Assignment Date: 11/12/15

Agency: USF

1 PATIENT INFORMATION
Patient Initials: EVB

Age: 56

Admission Date: 11/10/15

Gender: male

Marital Status: married

Primary Medical Diagnosis with ICD-10 code: E10

Primary Language: English

Diabetes type 1

Level of Education: High School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired Military

Lung abscess

Number/ages children/siblings: daughter 29, son 27

Served/Veteran: Persian Gulf War

Code Status: DNR

Living Arrangements: House with his wife

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: 11/11/15 Procedure: Lung biopsy

Culture/ Ethnicity /Nationality: Caucasian

Religion: NA

Type of Insurance: CareMark

1 CHIEF COMPLAINT:
-

It hurts to breathe
Im afraid to cough because of the biopsy

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient is a 56 year old male with history of type 1 diabetes, hypertension, and is a long time cigarette smoker. He
was admitted for a persistent cough that had a bloody tinge. The initial consult with the doctor resulted with them
thinking that it may be lung cancer so they ordered a lung biopsy on a spot they saw on the xray. The results of the
biopsy came back that it wasnt cancer, but just an abscess. His main problem today is from the pain of the biopsy which
he describes as sharp when he breathes too deeply or coughs. The pain is located at the site of the biopsy at the base of
the right lung. The pain is aggravated with deep inspiration and is slightly relieved with rest. He hasnt treated it yet with
anything. He rated his pain as a 7 out of 10 on a 1-10 scale.

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
Date
Unknown
4/22/12
11/11/15

Father

67

Mother

80

Grandpa

75

Grandpa

83

Grandma

88

Grandma

65

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable
)
MI

Alcoholism

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Type 1 diabetes
Hypertension
Lung abscess

Cancer

Comments: Include date of onset

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 (U)
Adult Tetanus (U)
Influenza (flu)(U)
Pneumococcal (pneumonia) (U)
Have you had any other vaccines given for international travel or
occupational purposes? Please List- Unknown

YES

University of South Florida College of Nursing Revision August 2013

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Penicillin

Type of Reaction (describe explicitly)

Hives

Medications

NKD
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)
A lung abscess is a collection cavity of necrotic lung tissue and pus resulting from pyogenic bacteria. Risk factors for lung
abscess are periodontal disease, risk for aspiration, large bacterial burden, airway obstruction, immunocompromised.
Diagnosis in this case came after the biopsy of the lung. You can treat it with antibiotics, postural drainage, or pulmonary
physiotherapy. Prognosis depends on the patients other comorbidities, but is generally good and usually clears up after
treatment. (Nursing Central, 2015)

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

Concentration: 25mg

Route: PO

Dosage Amount: 50mg

Frequency: Q Daily

Pharmaceutical class: Beta Blocker

Home

Hospital

or

Both

Indication: High Blood Pressure

Side effects/Nursing considerations: Hypotension, Bradycardia
Name: hydromorphone (Dilaudid)

Concentration: 1mg/1ml

Route: IVP

Dosage Amount: 1mg

Frequency: Q Daily

Pharmaceutical class: Narcotic

Home

Hospital

or

Both

Indication: Pain
Side effects/Nursing considerations: physical dependence, respiratory depression, bradychardia, urinary retention, constipation, sedation, hypotension, dizziness
Name: ciprofloxacin (Cipro)

Concentration: 200 mg/100ml D5W

Route: IV

Dosage Amount:200 mg

Frequency: Q 6 hours

Pharmaceutical class: fluoroquinolones

Home

Hospital

or

Both

Indication: Infection
Side effects/Nursing considerations: Elevated ICP, Seizures, Hepatotoxicity, Tendon Rupture
Name: enoxaparin (Lovenox)

Concentration: 40mg/0.4mL

Dosage Amount: 40mg/0.4mL

University of South Florida College of Nursing Revision August 2013

Route: Subcutaneous Injection

Frequency: Q Daily

Pharmaceutical class: Antithrombotic

Home

Hospital

or

Both

Indication: Prophylaxis for hospitalization

Side effects/Nursing considerations: Bleeding, anemia, erythema at injection site
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

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?
diabetic
Analysis of home diet (Compare to My Plate and
Diet pt follows at home?
diabetic
Consider co-morbidities and cultural considerations):
24 HR average home diet:
His diet was found on MyPlate to be fairly healthy.
Breakfast: 2 eggs scrambled, bacon
He was good in all food categories outside of fruits which
he admits that he doesnt like. He does need to watch the
Lunch: Turkey Sandwich, Lays potato chips
empty calories especially with the fact that he is a type 1
diabetic. While I was talking to him you could really tell
Dinner: Steak, green beans
that he has a good grasp of his diabetes and knows the
proper diet to follow. (MyPlate, 2015)
Snacks: NA
Liquids (include alcohol): water, juice, milk, coffee
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.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
My wife
How do you generally cope with stress? or What do you do when you are upset?
I talk with my wife, and smoke my cigarettes

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I was anxious about the biopsy but Im relieved now

+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?_____Yes___ Have you ever been hit punched or slapped? ___Yes___________
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? ________NA___________
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:
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
patients age group: This stage is characterized by the need to pursue close personal relationships. Not just romantically but close
friend relationships are very important as well. If the person isnt able to cultivate these relationships it can lead them towards
isolation. (Treas, Wilkinson, 2014)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is in the Isolation vs. Intimacy stage, and is more on the side of intimacy. He says that he spends
most of his days with his wife trying to find things to keep busy. He is a very social person, and throughout my
conversation with him he was very friendly and willing to answer any questions I had, I really enjoyed the conversation.

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

His disease process seems like it may possibly test his resolve but honestly I dont see it doing that because he is such
a calm and self-aware person.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Smoking for so long
What does your illness mean to you?
I know its a consequence of smoking for so long, and Im ok with that

+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?______NA__________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ______I dont know___________________
Are you currently sexually active? _____Yes___________________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?_______12 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

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?
____ Id say a little ______________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_____ No_____________________________________________________________________________________________
______________________________________________________________________________________________________

+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 17

thru

present

Pack a day
If applicable, when did the
patient quit? Still smoking

Pack Years: 39
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? no

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

For how many years?

(age

17

thru

present

If applicable, when did the patient quit?

NA
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
Maybe in the war

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 NA SPF:
Bathing routine: 1X per day
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
1 x/day
Routine dentist visits
NA x/year
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? NA
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:O positive
Other:

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

5 x/day

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
Type: 1
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - bloody
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 11/10/15
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? NA
Date of last prostate exam? NA
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

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: AOx3
Temperature: 98 (oral)

Height: 73 in
Pulse: 77 BPM
Respirations: 18

Weight: 180lb BMI: 24

Pain: 7, Right lung
Blood
Pressure: 130/88, R. arm cuff
(include location)

SpO2: 98%
Is the patient on Room Air or O2: Room Air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
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

Peripheral IV site Type:

Hep Lock
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Fluids infusing?
no
yes - what?

talkative
withdrawn

Location: Right AC
Location:
Location:

quiet
boisterous
aggressive
hostile

flat
loud

Date inserted: 11/10/15

Date inserted:
Date inserted:

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 2 /2 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 12 inches & left ear- 12 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

University of South Florida College of Nursing Revision August 2013

10

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:
thin
Amount: scant
CR - Crackles
Color: blood tinge
RH Rhonchi
Pt uses accessory muscles to assist in breathing
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5 intercostal L mid. axillary
Heart sounds: S1 S2 Regular
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

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3
Brachial: 3
Radial: 3
Femoral: 3 Popliteal: 3
DP: 3
PT: 3
No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

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: amber
Previous 24 hour output:
N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance
CVA punch without rebound tenderness
Last BM: (date 11 / 11 / 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 __5_____ RLE

& __5_____ in LLE

[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, no pain, pallor, paralysis or parathesias

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:

Biceps: 2

Brachioradial: 2

Patellar: 2

Achilles:

Ankle clonus:

negative Babinski:

negative

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):

Lab
Hemoglobin- (normal is
<12g/dL)

Hematocrit(normal is about 34%50%)

Glucose- (normal is 65110mg/dL)

Dates
11/11/15-10.2g/dL
11/12/15- 10.1g/dL

Trend
These two values are on
the low side, but they
arent really trending in a
direction.

11/11/15- 30.3%
11/12/15-30.3%

These two values are on

the low side, but they are
the same so no trend is
occurring.

11/11/15-140, 120
mg/dL
11/12/15-160, 200
mg/dL

White blood cell count

(normal is 4500-10000
WBC/ mcL)

11/11/15- 11500
11/12/15- 11930

The values are slightly

scattered throughout the
two days, Im assuming
from the procedure. But
they were on the high
side when I was there
These values show that
there has been an increase
in the number of white
blood cells from one day
to the next

Analysis
These values are below
the normal range.
Looking back at his
previous labs from other
visits, this seems to be the
range at which his body is
accustomed to, so it
doesnt seem to be a big
problem for him.
These values are below
the normal range.
Looking back at his
previous labs from other
visits similar to his
hemoglobin level, this
just seems to be where his
body lives.
The most current value is
elevated from the normal
range, He wasnt paying
much attention to his diet
on this day he admitted.
These values are above
the normal range. Even
though it wasnt a giant
increase in the number of
white blood cells, his lab
values to point to the fact
that his body is mounting

an immunologic response
to something.

+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 on a diabetic diet. His vitals were all in normal ranges outside of his elevated blood
pressure which was 130/88. Right now he is allowed to do whatever activity he can tolerate, which has mostly
been walking around the war to avoid boredom. He currently doesnt have any more diagnostic tests scheduled
after yesterdays biopsy. He does have consults scheduled for the following: Respiratory, primary care, and social
services. And he has routine accuchecks before all meals.

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

1.Risk for infection related to invasive procedure.
2.Ineffective breathing pattern related to pain, as evidenced by use of accessory muscles to breathe.
3.Risk for anxiety related to new diagnosis, as evidenced by a feeling of apprehension caused by anticipation of danger.
4.Risk for sleep deprivation related to sleep-related painful erections.
5.Risk for constipation related to opioid pharmaceuticals.

 15 CARE PLAN
Patient Goals/Outcomes
Patient will remain free from signs
and symptoms of infection

Maintain a warm and dry

environment

Long term:
Patient will achieve and maintain a
white blood cell count and
differential within normal limits

Nursing Diagnosis: Risk for infection related to invasive procedure.

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Teach patient signs and symptoms
If the patient can identify when
of infection
something is going wrong with
their body, care will be delivered in
a much more timely manner
Maintain a clean environment
If the exposure to antigens is
minimized the risk for infection is
as well
Utilize practices of infection
Aseptic technique has been shown
control
to lower the incidence of infection
in the hospital
Make sure that the patient
When the patient has a good
understands the importance of a
knowledge base as to why
good healing environment
something is important they are
more likely to stick with it
Keep materials necessary at the
If the materials are within reach, it
bedside of the patient
makes keeping the environment
dry and warm much easier

Patient will implement strategies to

keep using the teaching he receives

The teaching is good, but unless he

follows the instructions daily the
goal will not be met

Evaluation of Goal on Day care is

Provided
Have patient reiterate the teaching
back to nurse.
Make sure that the room is kept
clean and surfaces are wiped down
when they get dirty
Be sure to always use proper
technique and dont use shortcuts.
Have the patient repeat the teaching
so you know they understand it
Every time you walk in the room
you can check to make sure it is
dry and warm, and that the
materials are still in the room as
well
Talk with the patient to make sure
he understands the importance of
the teaching, and help him come up
with strategies to stick with the
teaching

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
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Ineffective breathing pattern related to pain, as evidenced by use of accessory muscles to breathe.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Demonstrate a breathing pattern
Use of incentive spirometer
The incentive spirometer may
Check to make sure that patient
that supports blood gas results
make the pain worse, but it will
uses the incentive spirometer
within the clients normal
keep him from developing further
regularly
parameters
complications like pneumonia
Utilization of pain medicine
By reducing the pain level, the
Make sure that the medicine
patient will be able to breathe a
reduces his pain to a tolerable level
little more comfortably
that allows him to breathe easier
Teach patient to understand the
If the patient understands some of
Patient will be able to explain what
importance of proper ventilation
the possible consequences he is
causes proper ventilation as well as
less likely to keep using the
some possible consequences of
ineffective pattern
improper ventilation
Identify and avoid specific factors
Teach patient to identify possible
If the patient knows what sets off
Have patient make a list of things
that exacerbate episodes of
triggers
the episodes he is more likely to
that trigger his ineffective breathing
ineffective breathing patterns
avoid those triggers
pattern to worsen
Come up with a plan to avoid these If he has a way to avoid the
Have the patient explain his plan to
triggers
triggers they can no longer effect
avoid possible triggers
his health
Long Term:
Report ability to breathe
Continued use of incentive
If the incentive spirometer is used
Make a schedule with the patient to
comfortably
spirometer
throughout his recovery, he will
use at home to track when to use
have a much faster recovery with
the incentive spirometer
less set backs
Teach healing process of specific
If the patient understands the
Have the patient explain a
problem
healing process and knows that at
timetable that it should take to fully
some point it will get better he can recover and feel comfortable
have hope and see his recovery
breathing again
through

 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
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

15 CARE PLAN
Patient Goals/Outcomes

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References

Evaluation of Interventions on
Day care is Provided

 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
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

References
ChooseMyPlate.gov. (2015, February 1). Retrieved July 15, 2015

Nursing Central from Unbound Medicine. (2015, July 1). Retrieved July 15, 2015.

Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning (p. 145).
Philadelphia, PA: F.A. Davis Company.