UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
FUNDAMENTAL PATIENT ASSESSMENT TOOL

Student: David A Lepin

. Assignment Date:
1 PATIENT INFORMATION

Agency: Tampa General Hospital

Patient Initials: J.G.M.

Age: 56 years old

Admission Date: 11/02/2015

Gender:

Marital Status: Married

Primary Medical Diagnosis Corneal Ulcer

Male

Primary Language: Spanish (knows some english)

Level of Education: Completed second grade

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Picks oranges at fruit farm

None (Awaiting eye culture)

Number/ages children/siblings:3 daughters aged 37, 36, 32; 2 sons

aged 34 and 30; 1 brother aged 64 and a sister aged 67
Served/Veteran: No
If yes: Ever deployed? Yes or No

Code Status: Full Code

Living Arrangements: Lives in a mobile home in Bradenton, FL

with his wife and granddaughter

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

Culture/ Ethnicity /Nationality: Latino/Mexican

Religion: Catholic

Type of Insurance: Workers Compensation

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 1 CHIEF COMPLAINT:
I got hit in the eye with a branch at work.

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

56 year old male presents to hospital with complaints of left eye pain. Patient explains that on 17 October 2015 he was
at work picking oranges, and got hit in the eye with a branch. The patient immediately experienced pain in his left eye
where he was hit, but initially did not think anything of it. Two days later on 19 October 2015, he visited Pioneer
Medical Center with complaints of worsening pain and redness around left eye. The provider prescribed natamycin
ophthalmic suspension and a referral to see ophthalmologist. On 30 October 2015 the patient visited ophthalmologist
and was prescribed moxifloxacin, timolol, and voriconazole for 10 days. The patient felt like pain and physical
appearance of his left eye was getting worse so he checked-in to ED today, 02 November 2015, with 8/10 left eye pain.
Current pain is described as 3/10 constant ache. HYDROmorphone and Percocet helped decrease pain level to 3/10, but
he does not want to take HYDROmorphone again because he vomited after administration. Pain in eye is worse with
light exposure, so he tries to leave his sunglasses on. Left eye is still red and tearing. There is white discoloration on
cornea. The patient also is currently experiencing periorbital pain with blurry vision in left eye. Denies any fever,
abdominal pain, or abnormal discharge from eye. The patient feels agitated because he as not slept due to the nurses
coming in every hour to give him his eye drops. The patients wife and granddaughter have accompanied him here
throughout his hospital stay. They are awaiting the physician in order to obtain eye culture. Timolol has been
discontinued but the patient is continuing natamycin, moxifloxacin, and voriconazole. The provider has prescribed
atropine and brimonidine. Pain is being controlled with HYDROmorphone and Percocet as needed.

Subjective information was obtained from patient and his granddaughter.

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

Operation or Illness

December 2014

Hypertension (Patient explained that he does not know what medication he was taking, but
discontinued after 5 months and never followed up.)

December 2014

Hyperlipidemia

2
FAMILY
MEDICA
L
HISTOR
Y

Ag
e
(in
ye
ars
)

Cause
of
Death
(if
applicable
)

Al
co
hol
is
m

Env
iron
men
tal
Alle
rgie
s

A
ne Art As
m hri th
ia tis ma

Bl
ee
ds
Ea
sil
y

Ca
nc
er

Di
ab
ete
s

Hea
rt
H
Tro
yp
Gl
G
uble
er
au
ou
(angi
te
co
t
na,
ns
ma
MI,
io
DVT
n
etc.)

Kid
ney
Pro
ble
ms

Me
nta
l
Sto
He
ma
alt Sei ch Stro
zur Ul ke
h
Pr es cer
obl
s
em
s

Tu
mor

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Ballistic
Trauma

Father
Mother

87

Brother

64

Sister

67

relationship
relationship
relationship

Comments: Patient denies any knowledge of any familial medical conditions.

IMMUNIZATION HISTORY

(May state U for unknown, except for Tetanus, Flu, and Pna)

YES

Routine childhood vaccinations

U (no record)

Routine adult vaccinations for military or federal service

U (no record)

Adult Diphtheria (Date)

U (no record)

Adult Tetanus (Date) Is within 10 years?

U (no record)

Influenza (flu) (Date) Is within 1 years?

Ordered, but
not given

Pneumococcal (pneumonia) (Date) Is within 5 years?

Ordered, but
not given

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

NO

If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES

OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKDA

Medications

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no known allergies
Other (food, tape,
latex, dye, etc.)

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)
The cornea is located on the sclera anterior to the pupil and lens of the eye. A corneal ulcer is a break in the epidermis of
the cornea. This can occur because of trauma, or an infection. Corneal ulcers are usually a result of a bacterial infection.
Pseudomonas, in particular, creates proteolytic enzymes like collagenase that rapidly degrade tissues; its known for
creating ulcers that lead to perforations. (Kent, 2013. p 20) Other causes of corneal ulcers include fungi and parasites.
Practicing
poor hygiene with contact lenses can increase the risk of infection or a corneal ulcer. Symptoms include pain in eye,
redness, discharge, light sensitivity, and changes in vision. The affected patient can also experience an itchy sensation
and inflammation on or around the ulcer. A person can also develop a white patch in the infected area. If left untreated,
the patient can experience loss of eyesight, or develop a scar on their cornea after treatment. Corneal ulcers are usually
treated with topical ointments or oral antibiotics and antifungals. The type of treatment is determined by the organism
causing the infection. Obtaining an eye culture will help diagnosis and treat the corneal ulcer. Gathering subjective
information, for example the events that led up to the onset of symptoms, can also help with planning treatment.
Treatment time depends on severity of the ulcer. A corneal replacement can be accomplished as a last resort.

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: atropine 1%

Concentration: 1%

Route: ophthalmic

Dosage Amount: 1 drop (gtts)

Frequency: TID

Pharmaceutical class: ophthalmic antimuscarinic, mydriatic,

anticholinergic

Home

Hospital

or

(X)Both

Indication: treatment for iritis and uveitis

Adverse/ Side effects: cycloplegia, blurred vision
Nursing considerations/ Patient Teaching : Use caution with driving or operating heavy machinery

Name moxifloxacin (VIGAMOX) 0.5%

Concentration: 0.5%

Route: ophthalmic

Dosage Amount: 1 drop (gtts)

Frequency: Q 1 hour

Pharmaceutical class: ophthalmic quinolone

Home

Hospital

or

(x)Both

Indication: bacterial conjunctivitis

Adverse/ Side effects: burning/stinging in eyes, dry eyes
Nursing considerations/ Patient Teaching: Complete the full coarse of treatment, avoid contacts because of infection, avoid direct sunlight

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Name natamycin (NATACYN) 5%

Concentration 5%

Route ophthalmic

Dosage Amount 1 drop (gtts)

Frequency Q2hours

Pharmaceutical class ophthalmic anti fungal

Home

Hospital

or

(x) Both

Indication fungal keratitis

Adverse/ Side effects corneal opacification, eye hyperemia, ocular edema, increased lacrimation
Nursing considerations/ Patient Teaching Do not take if sensitive to polyene antifungals, pregnancy category C

Name voriconazole 1%

Concentration 1%

Route ophthalmic

Dosage Amount 1 drop

Frequency Q 1 hour

Pharmaceutical class azalea anti fungal

Home

Hospital

or

(x)Both

Indication fungal keratitis

Adverse/ Side effects visual impairment
Nursing considerations/ Patient Teaching Not safe for neonates

Name HYDROmorphone (DILAUDID)

Concentration

Route IV

Dosage Amount 1-2 mg

Frequency Q4hours PRN

Pharmaceutical class opiate agonist

Home

(x)Hospital

or

Both

Indication for moderate to severe pain

Adverse/ Side effects constipation, nausea, urticaria, drowsiness
Nursing considerations/ Patient Teaching Increase water intake, and fiber consumption

Name lorazepam (ATIVAN)

Concentration 2mg/ml

Route IV

Dosage Amount 2 mg
Frequency Q4hours PRN

Pharmaceutical class benzodiazepine

Home

(x)Hospital

or

Both

Indication short-term treatment of symptoms of anxiety

Adverse/ Side effects anterograde amnesia, memory impairment, nausea, vomiting
Nursing considerations/ Patient Teaching Can cause physical dependence. Do not stop suddenly.

Name oxyCODONE-acetominophen (PERCOCET)

Concentration 5-325mg/tablet

Route oral (PO)

Dosage Amount 325mg

Frequency Q8hours PRN

Pharmaceutical class acetaminophen/opiate agonist combination

Home

Hospital

or

(x)Both

Indication moderate to severe pain

Adverse/ Side effects lightheadedness, dizziness, somnolence, insomnia
Nursing considerations/ Patient Teaching Potential for psychological dependence.

Name brimonidine (ALPHAGAN) 0.15%

Concentration (0.15%)

Route ophthalmic

Dosage Amount 1 drop (gtts)

Frequency TID

Pharmaceutical class anti glaucoma agent

Home

Hospital

or

(x)Both

Indication ocular hypertension

Adverse/ Side effects blurred vision, conjunctival blanching, vitreous detachment

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Nursing considerations/ Patient Teaching May be absorbed by contact lenses.

Name

Concentration

Route

Dosage Amount
Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with
recommendations.

Diet ordered in hospital?

Regular Diet

Analysis of home diet (Compare to My Plate and

Diet patient follows at home? Regular Diet

Consider co-morbidities and cultural considerations):

24 HR average home diet: Regular Diet

According to choosemyplate.gov, this patient consumes

Breakfast: 2 scrambled eggs, 1 cup black beans, 1 cup of

more calories in a day than what is recommended. The

shredded cheese, 2 tortillas

patient meets the daily recommended amounts of protein,

Lunch: 1 sandwich (3 slices of ham, 1 slice of cheddar

dairy, and grains;however, this patient still needs to

cheese, lettuce, 2 slices of tomato)

include more fruit and vegetables in his diet. Some fruit

Dinner: 1 cup of white rice, 1/2 cup of beans, chicken

juice can help increase his intake of fruit, and this patient

breast

may want to consider including vegetables at dinner or as

Snacks: 1-2 oranges

a snack. This patient consumes an excessive amount of

empty calories and doubles the recommended amount of

Liquids (include alcohol): 1 cup of coffee, 2-3 bottles of

water

sodium and saturated fats. Given his history of

hypertension, this diet is counter-productive. Saturated fats
will only increase his cholesterol and his chances of
having a myocardial infarction. This patient needs to cut
out saturated fats and sodium from his diet. Fish oil may
be able to help, but I would recommend following up with
a provider to control blood pressure and cholesterol. A
change in diet and engaging in physical activity daily
would also be beneficial to this patient.
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?
Wife and granddaughter.
How do you generally cope with stress? or What do you do when you are upset?
Usually talks to wife about his problems. His is also a Catholic and likes to pray, especially in times of need.

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Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The patient feels frustrated because he feels like a bother to his wife and granddaughter. Lack of sleep has also made
him agitated. The patient wants to get better so he can go back to work.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.

Have you ever felt unsafe in a close relationship? ______________No_______

Have you ever been talked down to?_______No_____ Have you ever been hit punched or slapped? ___No________

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_________________No______________________If yes, have you sought help for this? ______________________

Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust

Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority
Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation x 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: 40 - 64 years old Generativity vs self absorption/stagnation. Generativity is the process of guiding the next
generation, or improving the whole of society. Stagnation occurs when development ceases: A stagnant middle adult cannot guide
the next generation or contribute to society. (Treas, 2014 p. 190)

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

The generativity vs self absorption/stagnation stage of psychosocial development is the stage where middle adults are
transitioning to older adulthood. In this transition stage middle adults are preparing the future generations for adulthood,
or remaining stagnant and trying to find their role within society. This is the stage where many people experience
midlife crises. This patient in particular is in the stagnation stage. He does not feel like he has done enough for society,
let alone his family. He is frustrated and upset that he cannot contribute more. This patient is worried that he is not
supporting his family adequately.

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

This condition and hospitalization has only contributed to the patients developmental stage in a negative way. The
patient denies any depression but is not satisfied with the current status of his life. The patient explains that he is
anxious about his future. This condition has kept him out of work, and he feels that he has become another problem for
his granddaughter and wife. The patient is frustrated and is experiencing self-guilt.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?

The patient feels like he was being careless at work. He also feels like if he would have sought immediate
medical attention, then he would not have to be here now.

What does your illness mean to you?

The patient explains that this illness makes him feel frustrated and upset. This is just an obstacle to keep him out of
work.

+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

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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?________Does not know______________________________
Have you or your partner received the Gardasil (HPV) vaccination?
___No________________________________________

Are you currently sexually active? __Yes______________________ If yes, are you in a monogamous relationship?
_________Yes___________ When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? The patients wife can no longer have children, and they do not take
any measures to prevent acquiring a sexually transmitted disease.

How long have you been with your current partner?

_____38years__________________________________________________

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

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

What importance does religion or spirituality have in your life?

__Religion helps the patient stay positive and look for hope. He is Catholic. _
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
__The patients religious beliefs help keep him positive, especially in times like these. Prayer helps him relax and stay positive.
______________________________________________________________________________________________________

+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)

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?

If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? Beer

Yes

How much? 2-3 drinks

For how many years?

Volume: 355 mL

(age

20

thru

25

Frequency: socially
If applicable, when did the patient quit?
The patient quit when he was 25.

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?

No

If so, what?
How much?

For how many years?

(age

No

Is the patient currently using these drugs?

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
The patient reports that he works outside in the sun for 4-6 hours a day.

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5. For Veterans: Have you had any kind of service related exposure?
Not applicable

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health? Good.

Integumentary: The patient has erythema and inflammation in left periorbital region. Patient bathes daily. This
patent does not apply sunscreen but wears protective clothing. No lesions, dandruff, psoriasis, hives, or rash.
No clubbing in nails.
HEENT: The patient has erythema and inflammation in left periorbital region. he has an ulcer on right medial
cornea. Patient bathes daily. This patent does not apply sunscreen but wears protective clothing. No lesions,
dandruff, psoriasis, hives, or rash. No clubbing in nails.
Pulmonary: The patient denies any dyspnea. No cough. No environmental allergies.
Cardiovascular: This patient has a history of hypertension and hyperlipidemia. He is not taking medication for
either condition, and does not regularly follow up with a provider. No chest pain or history of myocardial
infarction. No murmurs. The patient does not remember last EKG screening.
GI: The patient denies any abdominal pain. He vomited this morning after administration of
HYDROmorphone. This patient denies any nausea, constipation or any other gastrointestinal problems.
GU: The patient denies any dysuria, oliguria, hematuria, or urinary incontinence.
Women/Men Only: The patient denies any infection of male genitalia or prostate. The patient has not had a
prostate exam.
Musculoskeletal: The patient denies any bone fractures or arthritis. no pain in joints or muscles. No weakness
in muscles.
Immunologic: The patient denies any night sweats or chills. No fever or allergies.
Hematologic/Oncologic: The patient denies any history of anemia. he has not had a blood transfusion.
Metabolic/Endocrine: The patient denies any diabetes, osteoporosis, or problems with thyroid.
Central Nervous System: The patient denies any dizziness, migraines, or severe headaches. No history of
cerebrovascular accident, transient ischemic accident, or stroke. No seizures or tremors.
Mental Illness: None
Childhood Diseases: None

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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:

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General survey
_____________________________________________________________________________________
Height ___56________Weight__152 lbs________ BMI __25_________
Pain (include rating and location)_3/10 aching pain in left eye__________________ Pulse__69_____
Blood Pressure (include location)__151/93__left arm_____________Temperature (route taken) 97.8F oral_____
Respirations____18________ SpO2 ___96%_____________ Room Air or O2____Room air___________________
Overall Appearance_Dressed appropriate for setting, maintains eye contact, appears to be in pain
Overall Behavior___Awake, responsive, opens eyes spontaneously, restless
Speech_clear and logical
Mood and Affect__apathetic, anxious, quiet
Integumentary__Skin is warm, dry, and intact. Color is appropriate for ethnicity. Skin tutor is elastic. Capillary
refill < 3 seconds. No abnormal balding. No lesions or wounds.
IV Access___22 g right median vein. No erythema, pain, or edema.
HEENT__Facial features are bilaterally symmetrical, except for eyes. Right pupil is PERRLA and 3mm.
Erythema and inflammation in left periorbital region. Blurry vision in left eye with 2mm ulcer on medial cornea.
Patient wears corrective lenses. Oral mucous is pink and moist. No abnormal lesions in oropharynx or nasal
cavity. Teeth are intact. Ears are symmetrical.
PulmonaryThorax__Lung sounds clear bilaterally from apices to bases. Unlabored respirations. No cough or
dyspnea.
Cardiovascular__Normal rate and rhythm. S1/S2 present. No chest pain. Radial pulses present bilaterally and
+2. Pedal pulses bilaterally present and +2. No heaves, lifts, or thrills. No murmurs or bruits.
GI__Last bowel movement: 11/1/2015. No pain with BM. Bowel sounds present in all four quadrants. No pain
with palpation; abdomen was tender. Percussion tympanic over abdomen and dull over liver.
GU__No hematuria or dysuria. Last time patient voided was this morning. Color was pale yellow and
consistency was clear.
Musculoskeletal__Full ROM. Strength of upper extremities was 5 bilateral. Strength of lower extremities was 5
bilateral
Neurological Patient is A&O x 4. Balance was steady.

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
Dates
1. Eye culture(Awaiting MD to obtain) 11/02/15

Trend

Analysis
I would expect to see a certain
fungal organism because of
mechanism of action of injury, or
possibly bacteria from a super
infection.

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2. WBC count (not ordered, but I would expect it to be)

I would expect to see an elevated

level of WBCs because of
infection. An elevated WBC
would mean that the patient is
reacting to an infection. Normal
range of WBCs is 5000 10000/mm^3.

+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 has an order to obtain an eye culture, and is awaiting the physician to accomplish it. A regular diet
is ordered. Vital signs are measured once a shift. There is also a an inpatient consult to Pain Management
ordered. The patient is independent and does not need any assistance ambulating.

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

1. Acute pain r/t injury agents ( biological, chemical, physical, psychological) as evidenced by self-report from patient.

2. Disturbed Sensory perception r/t altered sensory reception associated with impaired vision as evidenced by impaired
response to visual stimuli.

3. Risk for infection: Risk factor: abnormal blood profiles

4.

5.

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 15 CARE PLAN
Nursing Diagnosis: Acute pain r/t injury agents
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal

Rationale for
Interventions
Provide References

Evaluation of Goal on
Day Care is Provided

Patient will use a self1. Assess pain level in a

1. The first step in pain
1. The patient is alert and
report pain tool to
client using a valid and
assessment is to
oriented x 4, and can
identify current pain level
reliable self-report pain
determine if the client
report details of pain.
and establish a comforttool, such as 0-10
can provide a self2. Pain was assessed and
function goal.
numerical pain rating
report.
re-assessed every hour
scale.
with administration of
2. Acute pain should be
reliably assessed both
medications.
2. Assess the client for
pain presence routinely
at rest (important for
at frequent intervals,
comfort) and during
often at the same time
movement (important
as vital signs are taken,
for function and
and during activity and
decreased client risk of
rest.
cardiopulmonary and
thromboembolic
events)
Patient will report that
pain management
regimen achieves
comfort-function goal
without adverse effects.

1. Ask the patient to

1. The relationship
1. The patient reported
identify a comfortbetween pain level and
comfort pain level and
function goal, a pain
function goals should
was able to perform
level, on a self-report
be a major focus of the
desired activities.
tool, that will allow the
development of
2. Pain was managed
client to perform
individualized pain
using multimodal
necessary or desired
management plans.
approach. No adverse
activities easily.
effects noted.
2. The advantage of this
approach is that the
2. Manage acute pain
using multimodal
lowest effective dose
approach.
of each drug can be
administered, resulting
in fewer or less severe
adverse effects such as
over sedation and
respiratory depression.

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Patient will describe non 1. Avoid giving pain

1. IM injections are
1. The patient did not
pharmacological methods
medications
painful, result in
receive and pain
that can be used to help
intramuscularly.
unreliable absorption,
medications IM. Pain
achieve more comfortand lead to variable
medication was given
2. Explain to the client
function goal.
the pain management
blood levels of the
orally.
approach, including
administered
2. Pharmacological and
pharmacological and
medication.
non pharmacological
non pharmacological
pain management
2. One of the most
interventions, the
important steps toward
methods were
assessment and
improved control of
explained to patient.
reassessment process,
pain is a better client
The patient verbalized
potential adverse
understanding of the
understanding.
effects, and the
nature of pin, its
importance of prompt
treatment, and the role
reporting of unrelieved
of proved control of
pain.
pain is a better client
understanding of the
nature of pain, its
treatment, and the role
the client needs to play
in pain control.
Patient will state ability to 1. Ask the client to
obtain sufficient amounts
describe appetite,
of rest and sleep.
bowel elimination, and
ability to rest and
sleep. Administer
medications and
treatments to improve
these functions.
2. Administer
supplemental opioid
doses as ordered to
keep the clients pain
level at or below the
comfort-function goal,
or desired outcome if
the client is unable to
provide a self-report
based on clinical
judgement or
behaviors.

1. Opioid-induced
1. Opioids helped
constipation is a
decrease pain level and
common and
patient was able to rest.
significant problem in 2. Patient was allowed
pain management.
time to rest before
administration of
2. Prevention and early
detection are much
medications.
easier than
management of opioidinduced constipation.
3. 2. An order for prn
supplementary opioid
doses between regular
doses is an essential
backup.

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Patient will describe how

unrelieved pain will be
managed.

1. In addition to
1. Cognitive-behavioral
1. Patient explained how
administering
strategies can restore
keeping the light off
analgesics, support the
the clients sense of
avoided making pain
clients use of non
self-control, personal
worse.
pharmacological
efficacy, and active
2. Patient explained how
methods to help control
participation in his or
Percocet helped
pain, such as
her own care.
manage pain.
distraction, imagery,
2. Obtaining an
relaxation, and
individualized pain
application of heat and
history helps to
cold.
identify potential
factors that may
2. Ask the client to
describe prior
influence the clients
experiences with pain,
willingness to report
effectiveness of pain
pain, as well as, factors
management
that may influence pain
interventions,
intensity, the clients
responses to analgesic
response to pain,
medications including
anxiety, and
occurrence of adverse
pharmacokinetics of
effects, and concerns
analgesics.
about pain and its
treatment and
informational needs.

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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
(X)Pastoral Care
Durable Medical Needs
*(X)F/U appointments
*(X)Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? (X)Yes No
Rehab/ HH
Palliative Care

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References
(n.d.). Retrieved November 11, 2015, from http://www.clinicalpharmacology-ip.com.ezproxy.hsc.usf.edu/
default.aspx

Ackley, B. (2010). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). Maryland
Heights, Mo.: Mosby.

Kent, C. (2013). Review of ophthalmology. Winning the Battle against Corneal Ulcers, 20.

SuperTracker: My Foods. My Fitness. My Health. (n.d.). Retrieved November 11, 2015, from https://
supertracker.usda.gov/

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

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