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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kristine Martin

FUNDAMENTAL PATIENT ASSESSMENT TOOL


.
1 PATIENT INFORMATION
Patient Initials:
Gender:

S.L.G

Female

Assignment Date: 11/05/2014


Agency: TGH

Age: 49

Admission Date: 9/27/2014

Marital Status: Divorced

Primary Medical Diagnosis: Diabetic Ketoacidosis

Primary Language: English


Level of Education: Some college

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Entrepreneur

None

Number/ages children/siblings: 4 children (31, 30, 26, 23) , brother


(40), sister (50)
Served/Veteran: Army
If yes: Ever deployed? No

Code Status: Full code

Living Arrangements: Lives alone, no environmental hazards. Has


no problem remembering to take medication.

Advanced Directives: No
If no, do they want to fill them out? Unsure
Surgery Date:
N/A
Procedure: N/A

Culture/ Ethnicity /Nationality: African American


Religion: Christian

Type of Insurance: Has insurance- type unknown

1 CHIEF COMPLAINT: Patient stated she came into the hospital because she was experiencing diabetic
ketoacidosis. Patient stated she is always in the hospital for either DKA or a mental health reason.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient was admitted on 9/27/14 for DKA (with a blood glucose level of 430), which is recurrent since 1993. P/t states it
gets worse when she lets her sugars get to high, nothing relieves her symptoms except hospitalization, has no related
factors and tries to treat by maintaining her blood glucose levels. Plan of care for hospitalization is stabilizing blood
glucose levels. Patient also presents with depression (which has led to several suicide attempts), anxiety, esophageal
ulcers, chronic back pain related to deteriorating vertebral disk., and MRSA bacteremia.

University of South Florida College of Nursing Revision September 2014

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease

Father

69

Mother

72

Brother

40

Sister

50

Operation or Illness

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

Gout

(angina,
MI, DVT
etc.)
Heart
Trouble

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable)

Environmental
Allergies

Cholecystectomy
Mental health instability
Treatment: Baker act, prescribed Xanax and antidepressant (medication name unknown)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Date
2001/2002
Date Unknown
(several)

relationship
relationship
Relationship- Aunt

U
Comments: Brother suffers from alcoholism beginning at the age of 16; age of mental health problem onset is unknown
Sister has been experiencing seizures since birth. Aunts date of stroke is unknown.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received- patient is unsure of
dates vaccines were received.
University of South Florida College of Nursing Revision September 2014

1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

None

N/A

None

N/A

Medications

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)
Diabetic ketoacidosis is a complication related to a deficiency of insulin and increased levels of insulin counter-regulatory
hormones including catecholamines, cortisol, glucagon, and growth hormone (Huether and McCance, 2012.) When
insulin levels are deficient, lipolysis is enhanced resulting in an increased amount of nonesterified fatty acids delivered to
the liver, thus causing increased gluconeogenesis. Gluconeogenesis, the production of glucose from the breakdown of
fatty acids, contributes to hyperglycemia and the production of ketone bodies, the byproducts of fat breakdown, at a rate
that exceeds peripheral use (Huether and McCance, 2012.) As the ketone bodies accumulate, pH levels drop, resulting in
metabolic acidosis. Symptoms of diabetic ketoacidosis include Kussmaul respirations, postural dizziness, central nervous
system depression, ketonuria, anorexia, nausea, abdominal pain, thirst and polyuria (Heuther and McCance, 2012.)
According to the American diabetes association (2014), the criteria for the diagnosis of DKA are a serum glucose level of
>250 mg/dl, a serum bicarbonate level of <18 mg/dl, a serum pH of <7.30, the presence of an anion gap, and the presence
of urine and serum ketones. Those at risk for diabetic ketoacidosis include individuals with type 1 diabetes, given that
they do not produce insulin, as well as those who are unaware they have diabetes. Treatment of DKA include symptom
management as well as getting the blood glucose levels under control. Those diagnosed with DKA can make a full
recovery, however if DKA is unresolved, the individual is at risk for falling into a diabetic coma or even death. (DKA
&Ketones, 2014)

5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name: Oxycodone/oxycontin

Concentration

Dosage Amount: 30mg

Route: Oral

Frequency 3x

daily- patient usually takes only 1 daily when

needed
Pharmaceutical class Opioid

agonist
Home
Hospital
or
Both
Indication: moderate to severe pain
Adverse/ Side effects: confusion, sedation, dizziness, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred
vision, diplopia, miosis, respiratory depression, orthostatic depression, constipation, dry mouth, choking, GI obstruction, N/V,
urinary retention, flushing, sweating, physical/psychological dependence.
Nursing considerations/ Patient Teaching: how/when to take medication, advise p/t to change positions slowly, warn medication may
cause dizziness- p/t may need help ambulating.
Name: Xanax/alprazolam

Concentration

Dosage Amount: 2mg

Route: oral

Frequency: 3x

Pharmaceutical class: benzodiazepine


Indication: GAD,

Home

Hospital

daily

or

Both

panic disorder, anxiety assoc. with depression

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects: Dizziness,

drowsiness, lethargy, confusion, mental depression, blurred vision, constipation, diarrhea, N/V,
weight gain, rash, physical/psychological dependence.
Nursing considerations/ Patient Teaching: Take as directed- do not skip or double dose, do not stop abruptly, may cause drowsinessavoid driving until medication response is known, avoid drinking grapefruit juice, avoid use of other CNS depressants such as
alcohol, remind p/t this drug does not cure problem.
Name: Humalog/

insulin lispro

Concentration: 100units/mL

Route: Injection

Dosage Amount: sliding

Frequency: with

Pharmaceutical class: pancreatics

Home

Hospital

or

scale

meals
Both

Indication: control

of hyperglycemia in type 1 and 2 DM


lipodystrophy, pruritis, erythema, swelling, allergic reactions
Nursing considerations/ Patient Teaching: proper administration technique, explain this medication does not cure diabetes, emphasize
importance of diabetic diet, instruct p/ts on symptoms of hypoglycemia, direct patient to carry source of sugar .
Adverse/ Side effects: Hypoglycemia,

Name: Ambien/zolpidem

Concentration

Dosage Amount: 10mg

Route: Oral

Frequency: 1

Pharmaceutical class: imidazapyridine

Home

Hospital

tablet every night


or

Both

Indication: insomnia
Adverse/ Side effects: daytime

drowsiness, dizziness, abnormal thinking, agitation, amnesia, sleep-driving, diarrhea, N/V,


anaphylaxis, physical/psychological dependence
Nursing considerations/ Patient Teaching: do not take unless able to stay in bed for a full night (7-8 hours), go to bed immediately after
taking, may cause daytime drowsiness or dizziness so p/t should avoid driving until effects are known ,caution that sleep-driving
may occur, notify provider is symptoms of anaphylaxis occur, avoid use of alcohol and other CNS depressants.
Name: Cogentin/benztropine

Concentration

Dosage Amount: 1mg

Route: Oral

Frequency: daily

Pharmaceutical class: anticholinergic

Home

Hospital

or

Both

Indication: drug-induced

extrapyramidal effects
Adverse/ Side effects: confusion, depression, dizziness, headache, sedation, weakness, blurred vision, dry eyes, arrhythmias,
hypotension, tachycardia, palpitations, constipation, dry mouth, nausea, urinary retention, decreased sweating
Nursing considerations/ Patient Teaching: take as directed, take missed dose ASAP up to two hours before the next dose, taper dose when
discontinuing, may cause drowsiness/dizziness- p/t should avoid driving unless side effects are known, inform p/t that frequent
mouth rinsing, good oral hygiene and sugarless gum or candy can help with dry mouth; caution p/t to change positions slowly,
avoid overheating as this medication reduces sweating, avoid taking antacids or antidiarrheals with 1-2 hours of taking
medication.
Name: Heparin/

hep-lock

Concentration: 5000units/mL

Route: Subcutaneous

Dosage Amount: 1

Frequency: 2x

Pharmaceutical class: antithrombotics

Home

Hospital

mL

daily

or

Both

Indication: prophylaxis
Adverse/ Side effects: drug-induced

hepatitis, alopecia with long term use, rashes, bleeding, heparin-induced thrombocytopenia,
anemia, pain at injection site, fever, hypersensitivity
Nursing considerations/ Patient Teaching: report any symptoms of unusual bleeding or bruising immediately, avoid IM injections and
activities leading to injury, use a soft toothbrush, be careful while shaving, inform provider of medication regimen prior to
surgery
Name: Valium/

diazepam

Concentration

Dosage Amount: 10mg

Route: oral

Frequency: nightly

Pharmaceutical class: benzodiazepine

Home

Hospital

or

Both

Indication: adjunct

in the management of anxiety


Adverse/ Side effects: dizziness, drowsiness, lethargy, depression, slurred speech, headache, paradoxical dance, blurred vision,
respiratory depression, hypotension, constipation, diarrhea, N/V, weight gain, rashes, physical/psychological dependence

University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching: take

as directed, do not increase dose is less effective after a few weeks, may cause drowsinessdo not drive until side effect is known, avoid taking alcohol or other CNS depressants, notify provider is pregnancy is planned or
expected
Concentration

Name: Colace/docusate

Dosage Amount: 100mg

Frequency: daily
softeners
Home
Hospital
or
Both
Indication: prevent constipation
Adverse/ Side effects: throat irritation, mild cramps, diarrhea, rashes
Nursing considerations/ Patient Teaching: Laxatives should only be used short-term, encourage use of other forms of bowel regulation
such as fluid intake and exercise, do not use when abdominal pain, nausea, vomiting or fever is present
Route:

Oral

Pharmaceutical class: stool

Name: Neurontin/gabapentin

Concentration

Dosage Amount: 100mg

Route: oral

Frequency: 3x

Pharmaceutical class: mood

stabilizers

Home

Hospital

daily

or

Both

Indication: anxiety
Adverse/ Side effects: suicidal

thoughts, confusion, depression, dizziness, drowsiness, sedation, anxiety, abnormal vision, nystagmus,
hypertension, weight gain, anorexia, rhabdomyolysis, ataxia, altered reflexes. Hyperkinesia, multiorgan hypersensitivity
reactions, facial edema
Nursing considerations/ Patient Teaching: do not discontinue abruptly, do not take within 2hr of antacid, may cause
dizziness/drowsiness- advise p/t not to drive until effects are known, notify healthcare provider immediately if thought of suicide
, new or worse depression occurs, notify provider before surgery, noticare healthcare provider of abnormal muscle pain occurs
Name: Novolog/

insulin aspart

Concentration 1unit/mL

Route: subcutaneous

Dosage Amount: sliding

Frequency: 3x

Pharmaceutical class: pancreatics

Home

Hospital

scale

daily

or

Both

Indication: control

of hyperglycemia
Adverse/ Side effects: hypoglycemia, lipodystrophy, pruritis, erythema, swelling, allergic reactions including anaphylaxis
Nursing considerations/ Patient Teaching: instruct patient on proper technique, demonstrate technique for mixing insulins, explain that
this medication controls hyperglycemia but does not cure diabetes, instruct p/t proper technique for testing blood glucose, advise
p/t to notify provider if nausea, vomiting, or fever develops, if unable to eat regular diet, or if blood sugar levels are not
controlled, instruct patients on signs and symptoms of hypoglycemia, and hyperglycemia and what to do if they occur, advise p/t
to carry a source of sugar with them
Name: Lisinopril/prinivil

Concentration

Dosage Amount: 2.5mg

Route: Oral

Frequency: daily

Pharmaceutical class: ace

inhibitors
Home
Hospital
or
Both
of hypertension
Adverse/ Side effects: dizziness, fatigue, headache, weakness, cough, hypotension, chest pain, abdominal pain, diarrhea, nausea,
vomiting, impaired renal function, rashes, hyperkalemia, angioedema
Nursing considerations/ Patient Teaching: Take medication at the same time each day even when you are feeling well, avoid salt
substitutes, change positions slowly, may cause dizziness- do not drive until effects are known, notify health care provider if
rash, mouth sores, sore throat, fever, swelling of hands and feet, irregular heartbeat, chest pain, dry cough, hoarseness, or
difficulty breathing occurs. Encourage patient to comply with additional interventions for hypertension.
Indication: management

Name: Reglan/metoclopramide

Concentration: 100units/mL

Route: Subcutaneous
Pharmaceutical class: antiemetics

Dosage Amount: sliding

Frequency: 3x
Home

Hospital

scale

daily

or

Both

Indication: treatment

of post-surgical and diabetic gastric stasis


Adverse/ Side effects: drowsiness, extrapyramidal reactions, restlessness, neuroleptic malignant syndrome, anxiety, depression,
irritability, tardive dyskinesia, arrhythmias, hypertension, hypotension, constipation, dry mouth, gynecomastia, neutropenia,
leukopenia

University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching: take

as directed, take missed dose as soon as remembered if not almost time for the next dose,
may cause drowsiness- do not drive until effect is known, avoid use of alcohol and other CNS depressants, inform about risk of
extrapyramidal effects, tardive dyskinesia and neuroleptic malignant syndrome- advise provider if symptoms occur.
Name: Protonix/pantoprazole

Concentration

Dosage Amount: 40mg

Route: oral

Frequency: Before breakfast and before dinner


pump inhibitors
Home
Hospital
or
Both
Indication: erosive esophagitis associated with GERD
Adverse/ Side effects: headache, pseudomembranous, abdominal pain, diarrhea, hypomagnesaemia, bone fracture
Nursing considerations/ Patient Teaching: take as directed for full course of therapy, avoid alcohol and products containing aspirin or
NSAIDS, report onset of black tarry stools, diarrhea or abdominal pain to healthcare provider, notify provider immediately if
rash, diarrhea, or abdominal cramping fever or bloody stools occur.
Pharmaceutical class: proton

Name: Seroquel/quetiapine

Concentration

Dosage Amount: 200mg

Route: oral

Frequency: nightly

Pharmaceutical class: antipsychotics

Home

Hospital

or

Both

Indication: depressive

disorders with bipolar disorder


Adverse/ Side effects: neuroleptic malignant syndrome, seizures, dizziness, extrapyramidal symptoms, tardive dyskinesia, ear pain,
rhinitis, pharyngitis, cough, dyspnea, peripheral edema, postural hypotension, pancreatitis, anorexia, constipation, dry mouth,
stevens-johnson syndrome, sweating, decreased hemoglobin, weight gain, hyperglycemia, hypothyroidism, rhabdomyolysis
Nursing considerations/ Patient Teaching: do not stop abruptly, inform patient of possibility of extrapyramidal symptoms and instruct
p/t to report symptoms immediately, change positions slowly, may cause drowsiness- do not drive until effects are known, avoid
extreme temperatures, notify professional about thoughts of suicide, new or worse depression, panic attacks, acting on
dangerous impulses, or other unusual changes in mood or behavior
Name: Carafate/sucralfate

Concentration

Dosage Amount: 1g

Route: oral

Frequency: 4x daily
protectants
Home
Hospital
or
Both
Indication: short-term management of duodenal ulcers
Adverse/ Side effects: dizziness, drowsiness, constipation, diarrhea, discomfort, pruritis, rashes, hyperglycemia, anaphylaxis
Nursing considerations/ Patient Teaching: continue therapy for 4-8 weeks even if feeling better, increased fluid intake and exercise may
prevent constipation.
Pharmaceutical class: GI

Name: Desyrel/trazodone

Concentration

Dosage Amount: 100mg

Route: oral

Frequency: nightly

Pharmaceutical class: antidepressants

Home

Hospital

or

Both

Indication: major depression


Adverse/ Side effects: suicidal

thoughts, confusion, dizziness, fatigue, hallucinations, headache, slurred speech, hypotension,


palpitations, tachycardia, dry mouth, altered taste, constipation, hematuria, N/V, rash, anemia, tremor
Nursing considerations/ Patient Teaching: may cause drowsiness and blurred vision- do not drive until effects are known, change
positions slowly, advise family to assess for changes in mood and behavior and look for thoughts of suicide, good oral hygiene
may reduce dry mouth, notify professional if signs of serotonin syndrome present, teach patients signs of serotonin syndrome.

University of South Florida College of Nursing Revision September 2014

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Diabetic 2000
Analysis of home diet
Diet patient follows at home? Regular- not diabetic
According to MyPlate, on a typical day, the patient is
24 HR average home diet:
completely lacking in vegetables, fruits and proteins and
Breakfast: 1 pack instant oatmeal
under the recommended amount of grains and dairy.
Because the patient is diabetic, her diet is not ideal for the
Lunch: doesnt usually eat lunch
management of her diabetes. Most of the patients diet is
grain-based and high in carbohydrates and is thus loaded
Dinner: 1 pack ramen noodles
with sugar. Since the patient has a history of poor glucose
management, it would be important to educate the patient
Snacks: Doesnt have an appetite for snacks
about foods that are appropriate in a diabetic diet to help in
her management of this disease. The patient is also
Liquids (include alcohol): 16oz water, 16oz coffee, 8oz
significantly below the recommended intake of calories,
orange juice if p/t is feeling hypoglycemic
which could be a major factor in her recent weight loss.
The patient should also be educated about the importance
of fruits, vegetables, and protein in her diet, as they provide
vitamins and minerals essential to the proper functioning of
the body.
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 a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? P/t states she has no support system to turn to for help when she is ill
How do you generally cope with stress? or What do you do when you are upset?
P/t states she copes by ignoring the stressors or events/thoughts that make her upset

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient has dealt with depression and anxiety since 1993. P/t states she has frequent suicidal thoughts and has been
hospitalized for attempted suicide (date unknown).
+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? _Yes _
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?

University of South Florida College of Nursing Revision September 2014

__Yes__ If yes, have you sought help for this? ___Yes, has been to several domestic violence shelters__
Are you currently in a safe relationship? No- patient is single

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: During adulthood, we continue to build our lives, focusing on our career and family.
Those who are successful during this phase will feel that they are contributing to the world by being active in their home and
community. Those who fail to attain this skill will feel unproductive and uninvolved in the world. (Osborn et al., p215)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
my patient is in the Generativity vs. Self absoption/stagnation stage of development as defined by Erikson. My patient has failed
during this stage, as evidenced by the patients exclamation of her feelings of uninvolement in the world and her feeling as though she
has been unproductive with her life. These feelings are most likely intensified by, if not the result of, her depression. The patient
Stated that her feelings of uninvolment and unproductiveness have led to her attempts at suicide, as she feels as though she should not
be in this world if she isnt doing anything with her life.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
My patients depression has greatly impacted her developmental stage. Although she is in the correct stage for her age, she is
classified as failing this stage due to her feelings of unproductiveness and uninvolement in the world. If the patient were not
depressed, she may have a more positive view of her past- she could possibly see more of her accomplishments rather than only seeing
her failures. If she were able to focus on the positive aspects of her life, she may feel as though she has been a productive member of
society and feel more involved in the world. Unfortunately, due to her depression, her able to have a positive outlook is hindered, thus
causing her to be classified as failing in her stage of development.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?- p/t stated the cause of her illness is due to the abduction of her
children in 1993
What does your illness mean to you? p/t stated her illness means she has work to do on herself

+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? _Men________________________________________________________
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______________________ If yes, are you in a monogamous relationship?
_N/A- patient is single________ When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? __Condom____________________
How long have you been with your current partner?____N/A________________________________________________
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 September 2014

University of South Florida College of Nursing Revision September 2014

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


What importance does religion or spirituality have in your life?
_Religion plays a very important role in the patients life- she believes God is in control of her life _________
______________________________________________________________________________________________________
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? Cigarettes
How much?(specify daily amount)
0.5-1 pack per day

Yes
No
For how many years? X years
(age 16

thru

present

If applicable, when did the


patient quit? N/A

Pack Years: 33
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No- p/t lives alone

Has the patient ever tried to quit? Yes


If yes, what did they use to try to quit? Nothing

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Mixed drinks
How much?
Volume: 8oz-16oz (2 drinks)
Frequency: socially 2x per month
If applicable, when did the patient quit?

For how many years?


(age 16

thru

present

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
Marijuana
How much?
For how many years?
(age 16 thru
present
very little- couple puffs
Is the patient currently using these drugs?
Yes No

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks?
No
5. For Veterans: Have you had any kind of service related exposure? No

General Constitution
Recent weight loss or gain
How many lbs? Patient is unsure of exactly how much weight she lost
Time frame? Patient is unsure of time frame- maybe a year
Intentional? No
How do you view your overall health? Patient states she has a lot going on with her health, specifically her mental health and
diabetes management. Patient states she needs to be in a better place mentally and needs to work on regulating her blood glucose.

University of South Florida College of Nursing Revision September 2014

General Constitution (OLDCART anything checked above)


How do you view your overall health? Patient states she has a lot going on with her health, specifically her mental health and
diabetes management. Patient states she needs to be in a better place mentally and needs to work on regulating her blood glucose.

Integumentary: Patient denies changes in appearance of skin, problems with nails, dandruff, psoriasis, hives or
rashes and skin infections. Patient does not use sunscreen and bathes 2 times per day.
HEENT: Patient has dental problems, including a partial tooth/implant (date of implant unknown). Patient
denies difficultly seeing, cataracts or glaucoma, difficultly hearing, ear infections, sinus pain/infections, nose
bleeds, post-nasal drip, oral/pharyngeal infection. Patient brushes her teeth once per day, does not regularly see
the dentist and has not had a vision screening.
Pulmonary: Patient has a dry cough that has been intermittent for the past few years. Patient denies difficulty
breathing, asthma, bronchitis, emphysema, pneumonia, tuberculosis and environmental allergies. Last CXR is
unknown.
Cardiovascular: Patient has heart murmur (unknown type and unknown date of diagnosis). Patient denies
hypertension, hyperlipidemia, chest pain/angina, myocardial infarction, CAD/PVD, CHF, thrombus, rheumatic
fever, myocarditis, and arrhythmias.
GI: Patient has been feeling nauseous since last week but has not vomited. Patient has diverticulitis, diagnosed
July 21 2014 and had appendicitis as a kid. Patient denies diarrhea, constipation, GERD, indigestion,
hemorrhoids, yellow jaundice, pancreatitis, colitis, irritable bowel, cholecystitis, gastritis/ulcers, blood in the
stool, hepatitis. Last colonoscopy unknown.
GU: Patient has nocturia of unknown duration. Patient denies dysuria, hematuria, polyuria, kidney stones, and
bladder/kidney infections. Patients normal frequency of urination is 6x/day
Women/Men Only: Patient denies any infection of the female genitalia. Patient performs self-breast exams
whenever [she] remembers. Patient does not regularly have a pap/pelvic exam. Patients last GYN exam was
in April 2014. Her menstrual cycle has been irregular (sometimes absent). Menarche: age 15; Menopause: not
yet reached. Last mammogram in April 2014 (negative). Date of DEXA bone density: unknown.
Musculoskeletal: Patient fractured her ankle in 2000, has had muscle weakness since 2010, and has chronic
back pain related to a car accident in 2010. Patient denies gout, osteomyelitis and arthritis.
Immunologic: Patient denies chills with severe shaking, night sweats, fever, HIV or AIDS, lupus, Rheumatoid
arthritis, sarcoidosis, tumor, life threatening allergic reaction and enlarged lymph nodes
Hematologic/Oncologic: Patient claims she bleeds and bruises easily and has had a blood transfusion (date
unknown). Patient denies anemia, and cancer. Patient is not aware of her blood type.
Metabolic/Endocrine: Patient has diabetes type 1 (diagnosed in 1986). Patient denies hypothyroid/hypothyroid,
intolerance to hot or cold, and osteoporosis
Central Nervous System: Patient experienced dizziness a few days ago. Patient denies CVA, severe
headaches, migraines, seizures, ticks or tremors, encephalitis and meningitis.
Mental Illness: Patient has experienced anxiety and depression since 1993. Patient denies schizophrenia and
bipolar.
Childhood Diseases: Patient denies measles, mumps, polio, scarlet fever and chicken pox.

University of South Florida College of Nursing Revision September 2014

10 REVIEW OF SYSTEMS NARRATIVE


Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No
Any other questions or comments that your patient would like you to know? No

10 PHYSICAL EXAMINATION:
General survey: Patient was awake, alert, orientated, mobile and talkative. Patient seemed to be in a good mood; was not
in pain. Patient was very mobile; was able to walk to the bathroom and shower without assistance.
Height ___170.2cm_____Weight__72.58kg____ BMI __25.1____ Pain (include rating and location)__8 (0-10 scale),
lower back__ Pulse_84___ Blood Pressure (include location)__118/83, left arm _Temperature (route taken) 98.6, oral
Respirations__16____ SpO2 __95______ Room Air or O2___________________________
Overall Appearance: Clean, hair combed, dressed appropriate for setting and temperature, maintains eye contact, no
obvious handicaps
Overall Behavior: Awake, calm, relaxed, interacts well with most (p/t has had several code greys called against her),
judgment intact
Speech: Patient is very loud and clear at times, whereas others she tends to mumble.
Mood and Affect: pleasant, cooperative (at time of interview), talkative, became tearful when discussing domestic
violence.
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 and without vermin.
IV Access: P/t did not have an IV at time of interview
HEENT: Facial features symmetric, no pain in sinus region, sclera white and conjunctiva clear/without discharge;
eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness, ears symmetric
without lesions or discharge, nose symmetric without lesions or discharge. Unable to asses TMJ, trachea, thyroid, lymph
nodes, peripheral vision, PERRLA, EOM, whisper test or lips/buccal mucosa/floor of mouth/tongue due to patients
discharge (Sylvia Greene- 11/05/2014)
Pulmonary/Thorax: respirations regular and unlabored. Unable to fully assess patient as she was discharged earlier than
expected.
Cardiovascular: No lifts, heaves, or thrills. Unable to fully assess patient has she was discharged earlier than expected.
GI: Unable to asses patient due to discharge
GU: Patient has bathroom privileges (without assistance); unable to fully assess patient due to discharge.
Musculoskeletal: Unable to assess patient due to discharge.
Neurological: Gait is smooth, regular with symmetric length of stride. Unable to fully assess patient due to discharge.

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.

University of South Florida College of Nursing Revision September 2014

Lab
Urine Glucose: 2,500
(increased)
Normal: Negative

CT of Head: Negative

Blood glucose:
430 (increased)
275(increased)
Normal: 70-100
Urine ketones: 20
(increased)
Normal: Negative

WBC: 4.27 (reduced)

Dates
Date unattained- I was
unsure of where to find
the correct date as the
patient had several labs
due to her extended stay;
patient chart is now
unavailable due to
discharge
Date unattained

(9/27/2014)
(11/05/2014)
Date unattained- I was
unsure of where to find
the correct date as the
patient had several labs
due to her extended stay;
patient chart is now
unavailable due to
discharge
Date unattained

Trend
Unable to asses tread as
date was not attained.

Analysis
Increased urine glucose
indicates hyperglycemia
associated with lack of insulin
production. Glucose is
excreted in the urine in an
attempt to regulate serum
glucose.

Unable to assess; only


one CT scan performed

CT of head is necessary for


patients with DKA to asses
for cerebral edema, an
uncommon but fatal
consequence of DKA.
This may be a result of her
poor nutrition as well as her
long-time mismanagement of
her diabetes.

Patients blood glucose


was very unstable
throughout her
hospitalization.
Unable to asses tread as
date was not attained.

Unable to asses tread as


date was not attained.

Increased urine ketones


indicates diabetic
ketoacidosis. Ketone levels
are elevated to the lack of
insulin and the resulting
breakdown of fatty tissue.

Chronic hyperglycemia can


lead to immune suppressionNormal: 4.5-10
including decreased WBCs.
BUN: 16 (Normal)
Date unattained
Unable to asses tread as
Normal BUN level indicates
date was not attained.
normal liver function. This is
important to asses to ensure
patients hyperglycemia
hasnt damaged the liver.
Creatinine: 0.8 (Normal) Date unattained
Unable to asses tread as
Normal creatinine level
date was not attained.
indicates normal liver
function. This is important to
asses to ensure patients
hyperglycemia hasnt
damaged the liver.
Potassium: 4.1 (Normal)
Date unattained
Unable to asses tread as
Potassium levels are
date was not attained.
important to assess to ensure
the patient is not excreting
excess K+ in the urine, as
patients with hyperglycemia
tend to experience polyuria.
Sodium: 137 (Normal)
Date unattained
Unable to asses tread as
Sodium levels are important
date was not attained.
to assess to ensure the patient
is not excreting excess Na+ in
the urine, as patients with
hyperglycemia tend to
experience polyuria.
University of South Florida College of Nursing Revision September 2014

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


diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient is on a diabetic 2000 diet with ACHS accu checks. These treatments/procedures are important due to the
patients lack of diabetes management. The diet is important in controlling her sugar intake and could also serve
as a teaching tool for the patient to learn what types of foods she should be eating as well as the ideal portion
sizes of these foods. Accu checks are important tests to perform on diabetic patients, as they must stay within an
ideal blood glucose range. These tests must be performed regularly in order to accurately manage the patients
blood glucose by either limiting or increasing sugar intake.

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


1. Imbalanced nutrition: less than body requirements related to bodys inability to adequately metabolize and use
glucose and nutrients as evidenced by lack of insulin production seen in diabetes type 1
2. Risk for unstable blood glucose levels related to lack of diabetes management as evidenced by patients multiple
hospitalizations for DKA patients dietary recall of mostly grain-based foods.
3. Risk for infection related to hyperglycemia as evidenced by patients blood glucose level of 275.
4. Risk for deficient fluid volume related to polyuria secondary to hyperglycemia, nausea and vomiting as evidenced
by blood glucose level of 275 and patient report of feeling nauseous.
5. Adult failure to thrive related to depression as evidenced by patient statement of feeling unproductive in life an
uninvolved in the world.

University of South Florida College of Nursing Revision September 2014

15 CARE PLAN
Nursing Diagnosis: Risk for unstable blood glucose levels related to lack of diabetes management as evidenced by patients multiple hospitalizations for DKA
and dietary recall of mostly grain-based foods.

Patient Goals/Outcomes

Nursing Interventions to Achieve


Goal
Regularly monitor glucose level
and provide appropriate diet to
lower glucose levels.

Rationale for Interventions


Provide References
By regularly monitoring patients
blood glucose, the nurse can
determine what actions need to be
taken to return glucose level to
normal levels. Providing the
appropriate diet can keep/return
patient to a normal blood glucose
level.

Evaluation of Goal on Day Care


is Provided
Goal unmet: patients blood glues
was not within normal range; blood
glucose was 275.

By discharge, patient will have


adequate knowledge regarding
appropriate diet for diabetes
management *

Provide patient teaching regarding


appropriate foods and portion sizes.
Provide resources for future
reference. Consult a dietician to
further educate patient.

Based on the patients dietary


recall, the patient is not eating the
appropriate foods to best manage
her diabetes. By teaching the
patient the appropriate foods to eat
as well as the ideal portion sizes,
the patient will have a better
understanding of how to manage
her diabetes through her diet. It is
important to provide resources so
the patient can refer to them after
discharge.

On the day of care, patient did not


receive teaching regarding
appropriate diabetic diet.

By discharge, patient will


understand how to appropriately
manage blood glucose levels by
monitoring blood glucose and
appropriately administering
insulin*

Provide patient teaching regarding


how to accurately measure blood
glucose, including what times of
the day are most important as well
as teaching patient how much
insulin should be administered and
when.

Being that the patient has been


admitted for DKA several times,
one cause could be that she may
not be monitoring her blood
glucose levels appropriately or
administering her insulin correctly.
By teaching the patient proper

On the day of care, patient did not


receive teaching regarding proper
techniques for monitoring blood
glucose or administering insulin.

Patient will have blood glucose


level within normal range by the
end of eight hour shift

University of South Florida College of Nursing Revision September 2014

techniques of monitoring blood


glucose and administration of
insulin, she may have a better
chance of keeping her blood
glucose within normal range.
Include a minimum of one
Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
- Patient teaching: patient will understand how to appropriately manage blood glucose levels by monitoring blood glucose and appropriately
administering insulin
- Patient teaching: patient will have adequate knowledge regarding appropriate diet for diabetes management
- Refer client to dietician
-Patient will be discharged to another facility; make sure client is aware of what the facility is and why they are being discharged there.

University of South Florida College of Nursing Revision September 2014

References
Ackley, B., & Ladwig, G., (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to PlanningCare.
St. Louis, Missouri: Elsevier Inc.
Cherry, K. (n.d.). Erikson's Theory of Psychosocial Development. Retrieved from:
http://psychology.about.com/od/psychosocialtheories/a/psychosocial.htm
DKA (Ketoacidosis) & Ketones. (2014). Retrieved from:
http://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.html?loc=lwd-slabnav
Huether, S., & McCance, K. (2012). Understanding Pathophysiology. St. Louis, Missouri: Elsevier Inc.
MyPlate. (n.d.) Supertracker. Retrieved from: https://www.supertracker.usda.gov/foodtracker.aspx
Osborn, K. S., (2014). Medical Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson
Education, Inc.
Unbound Medicine. (2014.) Nursing Central (Version 1.24 (414)) [Mobile application software]. Retrieved
from: http://nursing.unboundmedicine.com/nursingcentral

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014