UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Marissa Peery

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 2/27/15

Agency: VA

Patient Initials: M.Z.

Age: 59

Admission Date: 2/16/15

Gender: Male

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Cellulitis with abscess L03.1166

Primary Language: English

Level of Education: Some College

Other Medical Diagnoses: (new on this admission)

N/A

Occupation (if retired, what from?): Construction before his amputation

Number/ages children/siblings: 2 brothers and 2 sisters, no kids

Served/Veteran: Yes, Vietnam war

Code Status: Full code

Living Arrangements: Lives with his wife

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

Culture/ Ethnicity /Nationality: Caucasian

Religion: Spiritual

Type of Insurance: Uninsured

1 CHIEF COMPLAINT:
It is my left stump. I think it might be MRSA.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The patient started having the main symptoms on Monday 2/16/15. A couple weeks before being admitted, the patient
noticed a pimple like bump on his left stump, but just ignored it. It kept growing and the patient was having pain and a
fever started. The patient describes the pain as continuous and it doesnt stop. The pain is characterized as a stabbing pain.
The patient says that there are not really any factors that make the pain worse and there is nothing that really relieves the
pain. The patient tried using erythromycin cream and gauze for at home treatment, but that did not help.

University of South Florida College of Nursing Revision August 2013

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

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable
)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Left lower extremity wound washout
Left below the knee amputation
Left below the knee amputation revision, debridement, and washout

Age (in years)

Date
7/13/12
8/31/12
9/7/12

Father
Mother
Brother
Sister
relationship
relationship
relationship

Comments:

The patient cannot remember his family members ages. Patient says his sister has not had a full on stroke, but a mini stroke.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations: Pt. cant remember
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date): 5/6/13
Adult Tetanus (Date): 5/6/13
Influenza (flu) (Date) : 10/7/14
Pneumococcal (pneumonia) (Date): 3/3/11
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

University of South Florida College of Nursing Revision August 2013

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Neosporin
Viagra 50 Mg tab
Medications

Cephalexin

Other (food, tape,

latex, dye, etc.)

N/A

The patient said that he will start sneezing, become itchy, and have a
runny nose (For all of these).

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)
Cellulitis is acute bacterial infection of the skin and subcutaneous tissue most often caused by streptococci or
staphylococci (Dhar, 2013). Historically, MRSA was typically confined to patients who were exposed to the
organism in a hospital or nursing facility. MRSA infection should now be considered in patients with
community-acquired cellulitis, particularly in those with cellulitis that is recurrent or unresponsive to
monotherapy (Dhar, 2013). There are always risk factors for any disease. Patients that are immunocompromised
are always at a higher risk for infection. Risk factors include skin abnormalities, which are common in patients
with chronic venous insufficiency or lymphedema. Scars from saphenous vein removal for cardiac or vascular
surgery are common sites for recurrent cellulitis, especially if tinea pedis is present (Dhar, 2013). The doctors
usually diagnose this upon examination or they will take the patients blood or a culture. The major findings are
local erythema and tenderness, frequently with lymphangitis and regional lymphadenopathy. The skin is hot,
red, and edematous. Fever, chills, tachycardia, headache, hypotension, and delirium may precede cutaneous
findings by several hours, but many patients do not appear ill (Dhar, 2013). Treatment for cellulitis is
antibiotics.

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

Concentration 1 tab

Route: Oral

Dosage Amount 5 mg
Frequency: PO Q4H PRN

Pharmaceutical class: antipyretic

Home

Hospital

or

Both

Indication: Treatment of mild pain and fever

Side effects/Nursing considerations: Hepatotoxicity, Steven Johnsons Syndrome. Headache, and fatigue. Assess overall health before and alcohol usage before
administering.
Name: albuterol (Proventil)

Concentration: 1 puff

Route: Inhalent

Dosage Amount: 1 puff

Frequency: 1 puff PO QID

Pharmaceutical class: bronchodilator

Home

Hospital

or

Both

Indication: Used as a bronchodilator to control and prevent reversible airway obstruction caused by asthma or COPD.
Side effects/Nursing considerations: paradoxical bronchospasm, nervousness, restlessness, tremor, headache, chest pain and hypertension. Nurse should assess
lung sounds, pulse, BP before administration of medication. Observe for paradoxical bronchospasm (wheezing).

University of South Florida College of Nursing Revision August 2013

Name: atorvastatin (Lipitor)

Concentration: 1 Tab

Route: Oral

Dosage Amount: 40mg

Frequency: PO Qdaily

Pharmaceutical class: HMG COA reductase inhibitor

Home

Hospital

or

Both

Indication: adjunctive management of primary hypercholesterolemia and mixed dyslipidemia

Side effects/Nursing considerations: abdominal cramps, constipation, diarrhea, flatus, heartburn, rhabdomyolysis. The nurse should obtain a diet history,
monitor liver function, monitor for muscle cramps and if they are present, the medication should be discontinued.
Name: Lisinopril (Prinivil)
Concentration: 1 Tab
Dosage Amount: 5mg
Route: Oral

Frequency: PO Qdaily

Pharmaceutical class: ACE inhibitor

Home

Hospital

or

Both

Indication: alone or with other agents in the management of hypertension, management of HF.
Side effects/Nursing considerations: dizziness, hypotension,, angioedema, and cough. Nurse should assess for signs of angioedema,, monitor the BP and pulse.
Monitor weight and assess for fluid overload.
Name: sertraline (Zoloft)

Concentration: 1 Tab

Route: oral

Dosage Amount: 150mg

Frequency: PO QHS

Pharmaceutical class: SSRI

Home

Hospital

or

Both

Indication: major depressive disorder, OCD, PTSD

Side effects/Nursing considerations: NMS, suicidal thoughts, dizziness, drowsiness, insomnia, headache, and sexual dysfunction. Assess for suicidal tendencies,
assess for serotonin syndrome, monitor appetite and nutritional intake, monitor mood changes and behaviors.
Name: topiramate (Topamax)

Concentration: 1 tab

Route: Oral

Dosage Amount: 100mg

Frequency: PO Q8H

Pharmaceutical class: anticonvulsant, mood stabilizer

Home

Hospital

or

Both

Indication: partial-onset seizures, prevention of migraines in adults

Side effects/Nursing considerations: increase in seizures, suicidal tendencies, dizziness, drowsiness, nervousness, sedation, anxiety, impaired concentration.
Monitor for changes in behavior that would indicate suicidal tendencies or behaviors, assess seizures, assess pain, and mental status.

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? healthy diet
Analysis of home diet (Compare to My Plate and
Diet pt follows at home?-Anything I want to eat.
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: 6oz. of yogurt, 2 biscuits with sausage gravy
The patient is under most of his food groups. However, the
patient hit the target range for his grains. His intake of
grains was 6oz.
Lunch: I do not eat lunch.

It is not healthy that the patient skips over lunch. Skipping

any meal of the day will slow down the metabolism. This
was a good education point while doing my assessment.

Dinner: 1 medium grilled chicken breast with one cup of

cooked broccoli

The patient has a decent dinner, but the patient is under in

protein, dairy, and vegetables. The patients intake of protein
is 4 cups when it should be around 5 . His intake of
dairy is 2 cups when it should be 3 cups. The vegetable
intake is 1 cup when it should be 2 cups. The patient has
no intake at all of fruits.

Snacks: 5 saltine crackers

Liquids (include alcohol): water
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?-No one.
How do you generally cope with stress? or What do you do when you are upset?
I pray.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
No. I am on antidepressants and those seem to help.
+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.

University of South Florida College of Nursing Revision August 2013

Have you ever felt unsafe in a close relationship? _No___

Have you ever been talked down to? Yeah_ _ Have you ever been hit punched or slapped? __Yeah_
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_____Yes___ If yes, have you sought help for this? No__
Are you currently in a safe relationship?
Yes

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

During middle adulthood, we establish our careers, settle down within a relationship,
begin our own families and develop a sense of being a part of the bigger picture. We give back to society
through raising our children, being productive at work, and becoming involved in community activities and
organizations. By failing to achieve these objectives, we become stagnant and feel unproductive. Success in
this stage will lead to the virtue of care (McLeod, 2008).

patients age group:

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
I think that my patient could be stuck in the middle of both generativity and stagnation. My patient got married when he was older
and also does not have any kids. It seemed like he was upset that he did not have kids and got married at an older age. He could regret
not having any kids and now it is too late. At the same time, he also seemed happy with his life and how it was going.

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

Since my patient had a leg amputation, this could have caused a decrease in self-esteem and confidence, which could
have lead him to not start dating and finding someone to have a relationship with till later in life.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?- I dont know, coming to the VA? I guess I could get it anywhere
though.
What does your illness mean to you?
It makes me feel like a scumbag.

+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?- yeah.
Do you prefer women, men or both genders?-Women
Are you aware of ever having a sexually transmitted infection? No_
Have you or a partner ever had an abnormal pap smear? No
Have you or your partner received the Gardasil (HPV) vaccination? No_
Are you currently sexually active? __Yeah__When sexually active, what measures do you take to prevent acquiring a
sexually transmitted disease or an unintended pregnancy? __Use a condom___

University of South Florida College of Nursing Revision August 2013

How long have you been with your current partner?__Four 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?
__It helps me. I am a spiritual person and I pray a
lot.__________________________________________________________________________________________________
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?
Yes
No
If so, what?
How much?(specify daily amount)
For how many years? 20 years
I have cut back a lot. 5-6 cigarettes a Doesnt remember when he started
Cigarettes
smoking.
day.
If applicable, when did the
patient quit?

Pack Years: I dont know.

Does anyone in the patients household smoke tobacco? If
so, what, and how much? My sister. The same amount as
me.

Has the patient ever tried to quit? Yes.

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?-whiskey
How much? (give specific volume)
However much it took me to
passout.

For how many years? 20 years

Doesnt remember when it started.

If applicable, when did the patient quit?

5 years ago
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?- one time each for
I smoked plenty of marijuana and I only tried
For how many years? I dont
cocaine and heroin and a lot of
cocaine and heroin once.
remember.
marijuana back in the day.
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
I used to work in construction and there was a lot of asbestos around.

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 none SPF: none
Bathing routine: every other day
Other:

HEENT
Difficulty seeing-glasses
Cataracts or Glaucoma
Difficulty hearing
Ear infections-as a little kid
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth- 1 x/day
Routine dentist visits-its been a while
Vision screening-its been a while
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis-B/C
Pancreatitis-4 years ago
Colitis
Diverticulitis-mild pockets
Appendicitis
Abdominal Abscess
Last colonoscopy?-1 year ago
Other:

Chills with severe shaking

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

Genitourinary

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

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 5 x/day
Bladder or kidney infections

Hematologic/Oncologic

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

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

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?-none
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?none
Frequency of prostate exam?-1x/year
Date of last prostate exam?-last year
BPH-none
Urinary Retention-none

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar-probably, but not diagnosed
Other:

Musculoskeletal
Injuries or Fractures
Weakness-right now b/c of wound
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

10 PHYSICAL EXAMINATIONDescribe abnormal assessment below non checked boxes)

General Survey: A 59 year old Height: 69 inches
Weight: 208lbs BMI: 25
Pain: (include rating & location)
7- in my stump.
male with cellulitis to left
Pulse: 77
Blood
stump with an abscess. Pt.
Pressure: 123/74
(include location)
came in with a fever and pain
in stump.
Temperature: (route taken?)
Respirations: 18
98.9
SpO2: 95
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: HL Location: right forearm

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

talkative
withdrawn

Date inserted:

quiet
boisterous
aggressive
hostile

flat
loud

2/16/15

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- 6 inches & left ear- 6 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: N/A
Comments:

University of South Florida College of Nursing Revision August 2013

11

Pulmonary/Thorax:

Respirations regular and unlabored

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

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th ICS
Heart sounds: S1 S2 Regular Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze): Pt. was not on a tele

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 2
Carotid: 2
Brachial: 2
Radial:
2
Femoral: 2
Popliteal:
2
DP: 2
PT: 2
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: none
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
Pulses of lower extremities could only be taken on the right leg, due to left below knee amputation. Pulses were present and
+2 in right leg.

GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color:
Previous 24 hour output: N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date: (2 / 16 / 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 & LLE (not able to assess in this extremity due to amputation)
[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(unable to get up and ambulate due to needing a new prosthetic)
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: 2
Biceps: 2
Brachioradial: 2
negative Babinski: positive negative

Patellar: 2 (only in RLE)

Achilles: 2(only in RLE)

Ankle clonus: positive

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
HGB-L
Result: 12.4
Normal: 13-17

Dates
2/16/15

HCT-L
Result: 36.8
Normal: 39-49

2/16/15

Sodium- L
Result: 135
Normal: 136-145

2/16/15

Trend
The pt. is not anemic and
is not losing blood. It
could be low due to the
infection, malnutrition, or
dehydration.

Analysis
HGB shows us how much
oxygen is being carried in
our RBC. When this level
is low, it can be due to
bleeding in the body
(anemia), malnutrition, or
cancer.
HCT usually follows
HCT follows HGB in its
HGB levels. HCT is
results usually. HCT
usually low if the pt. is
reflects the amount of
anemic, but that isnt the space in the blood that
case. It could be due to
occupies RBC. This can
the infection,
be low due to anemia,
malnutrition, or
cancer, dehydration, or
dehydration.
malnutrition.
This electrolyte could be This level could be low
low because of the
due to dehydration or HR,
infection the patient has.
renal failure. A significant
He is losing fluids, so this low level in this
would cause his
electrolyte can cause a
electrolytes to decrease as decrease in mental status
well. This level is not
ant pt. could be at risk for

Calcium-L
Result: 8.6
Normal: 8.9-11

2/16/15

Neutrophil #-H
Result: 6.9
Normal: 1.73-6.7

2/16/15

MRSA nares:
Positive

2/16//15

terribly low and no

intervention is needed,
except monitoring the
levels.
This electrolyte could be
low because of the wound
and the decreasing
electrolytes that can come
with an oozing wound.
Monitoring the levels
would be the best
intervention.
The patients neutrophil
level could be high most
likely because of the
cellulitis/abscess that is
occurring.

This value is positive

because the patient has an
infection on his left
stump and most likely it
is the MRSA that came
back positive.

seizures.

A low level of this

electrolyte is usually a
problem with diet, like
not enough calcium,
Vitamin D deficiency, or
a problem with the
parathyroid.
Neutrophils are the
bodys way of fighting
things off, such as
infection. The number of
neutrophils will increase
when there is an infection
because the body is trying
to fight the foreign object
off.
This test can come back
positive if the patient has
been exposed to MRSA
and have a possible
infection.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Diet: Patient is on a normal, healthy diet.
Activity: activity is limited in the hospital at the time due to being on isolation.
Consults: The patient has a consult with prosthetics to try and size a new one.
Vitals: The patient had a fever when he came in, which could be related to the infection. The fever is down and
controlled now with acetaminophen.

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

1. Infection related to traumatized tissue.
2. At risk for falls related to impaired physical mobility

3.

4.
5.

At risk for impaired comfort related to anxiety

 15 CARE PLAN
Patient Goals/Outcomes
Remain free from symptoms of
infection yearly.

State symptoms of infection once a

day.

Demonstrate appropriate hygienic

measures every shift.

Nursing Diagnosis: Infection related to traumatized tissue.

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
To prevent further infection, the
Assess temperature of neutropenic
nurse can perform hand hygiene
clients; report a single temperature
before/after handling the patient,
of greater than 100.5 degrees F.
wearing gloves while assessing,
Fever is often the first sign of an
assure appropriate wound care and infection. The progress of infection
monitoring signs of infection such
may be more rapid, and the
as a fever.
infection may quickly become lifethreatening (Ackley and Ladwig,
2014).
The nurse should educate the
Observe and report signs of
patient on signs of infection, so the infection such as redness, warmth,
patient knows what to look out for discharge, and increased body
as well.
temperature. Change in mental
status, fever, shaking, chills, and
hypotension are indicators of sepsis
(Ackley and Ladwig, 2014).
The nurse should demonstrate what Use appropriate hand hygiene.
measures should be taken to
Meticulous infection prevention
prevent infection, such as hand
precautions are required to prevent
washing, oral care, and perineal
heal care-associated infection, with
care.
particular attention to hand hygiene
and standard precautions (Ackley
and Ladwig, 2014).

Evaluation of Goal on Day care is

Provided
The patient was able to maintain
fever free for the shift. This was
maintained by administering
acetaminophen as needed.
Temperature was monitored every
couple of hours.

I explained to the patient what to

look for with infection. The patient
was able to describe back to me the
symptoms of infection and what he
should report to the nursing staff.
The patient was able to
demonstrate with his hands how to
use proper hand hygiene. He was
also able to describe to me how to
perform oral care and discussed the
importance of showering.

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: ensure a healthy diet and fluid intake.
PT/ OT: Pt. may need PT consult when he gets his new prosthetic.
Pastoral Care
Durable Medical Needs: Monitor for any fall risks because of injury.
F/U appts: The patient will have a prosthetic consult to get sized for a new leg prosthetic.
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
Remain free from falls every week.

Change environment to minimize

the incidence of falls every hour.

Explain methods to prevent injury

every shift.

Nursing Diagnosis: At risk for falls related to impaired physical mobility

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
The nurse should take precautions
Screen all clients for balance and
for things that can increase a risk
mobility skills. It is helpful to
for a fall. The nurse should make
determine the clients functional
sure the patient has the nurse with
abilities and then plan for ways to
them while trying to ambulate
improve problem areas to ensure
since the patient has decreased
safety (Ackley and Ladwig, 2014).
balance related to leg amputation.
The nurse should monitor the
Orient the client to environment.
patients surroundings and move
Place the call light within reach
objects around to prevent falls. The and show how to call for
bed should be at the lowest
assistance; answer call light
position, the patient should have
promptly. Use one quarter-to one
the call bell, bed alarm, ensure
half-length side rails only, and
wheels are locked, non-slip socks,
maintain bed in a low position
two side rails up and the area
(Ackley and Ladwig, 2014).
should be clear of clutter.
The nurse should explain to the
Use a high-risk fall bracelet and
patient how falls can occur and
fall risk room sign to alert staff for
how they can be prevented, so the
increased vigilance and mobility
patient knows what precautions to
assistance. Routinely assist the
take.
client with toileting on his/her own
schedule (Ackley and Ladwig).

Evaluation of Interventions on
Day care is Provided
The patient was able to avoid falls
for the day and hopefully till he
leaves the hospital. The patient had
help when ambulating which
decreased the incidence of a fall.
The patients area was free of any
clutter that could cause a fall. The
call light was always by the
patients side and we demonstrated
how to use it if needed. The bed
was at the lowest position and two
side rails were up.
The nurse and I explained to the
patient how injuries happen and we
also explained how we can prevent
them. The patient was able to
describe back to us the ways to
prevent fall and injuries.

 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: ensure a healthy diet and intake of fluids
PT/ OT: Pt. may need a PT consult when he gets his new prosthetic sized.
Pastoral Care
Durable Medical Needs: Monitor for fall risks due to injury.
F/U appts: The pt. will have a consult for a new prosthetic
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

References
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook (Vol. 10).
Dahr, D. A. (2013, November). Cellulitis. Retrieved February 27, 2015, from
http://www.merckmanuals.com/professional/dermatologic_disorders/bacterial_skin_infections/
cellulitis.html
.McLeod, S. (2008). Erik Erikson: psychosocial stages. Retrieved 2014, from
http://www.simplypsychology.org/Erik-Erikson.html
Myplate. (n.d.). Retrieved 2014, from https://www.supertracker.usda.gov/default.aspx
Nursing Central. (2013-2014). Ubound medicine (2.3 16m) [Mobile application software]. Retrieved from
httpwww.uboundmedicine.com