University of South Florida College of Nursing Revision April 2012 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING


2 CC: I have blood in my stools and extreme discomfort in my abdomen.



3 HPI: (OLD CART)
The patient is a 33 year old male presenting with a history of ulcerative colitis. The patient presented to the emergency
room complaining of worsening chronic ulcerative colitis discomfort that started two days ago. The patient states that the
pain he is experiencing is in his abdomen and he has blood in his stools. The patient states that the pain has not subsided
for the past few days. The patient characterizes the pain as chronic, deep, and at times sharp. The patient states that
touching his abdomen can aggravate the pain. The patient takes a number of medications to manage his ulcerative colitis
and is medically compliant.












Student: Alyssa Blumenthal
PATIENT ASSESSMENT TOOL .
Assignment Date: 04/05/2013

Agency: Saint Josephs Hospital
Patient Initials: J.C Age: 33 Admission Date: 03/17/2013
Gender: M Marital Status: S Primary Medical Diagnosis with ICD-10 code:
K51.011
Primary Language: English
Level of Education: High school Diploma Other Medical Diagnoses: Hypertension,
Asthma/Reactive airway disease
Occupation (if retired, what from?): Self Employed, Driver
Number/ages children/siblings: 3 brothers, 31, 32 and 34. 1 sister,
29.





Code Status: Full Code
Living Arrangements: Lives in a house with his current Girlfriend Advanced Directives: None

Surgery Date: N/A Procedure: N/A
Culture/ Ethnicity /Nationality: African American


Religion: Christian Baptist, no church Type of Insurance: Hillsborough County Insurance
University of South Florida College of Nursing Revision April 2012 2






University of South Florida College of Nursing Revision April 2012 3
2 PMH/PSH Hospitalizations for any medical illness or operation
Date Operation or Illness Management/Treatment













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1 IMMUNIZATION HISTORY
YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

University of South Florida College of Nursing Revision April 2012 4
1 Allergies or
Adverse Reactions
NAME of
Causative Agent
Type of Reaction (describe explicitly)
Medications






Other (food, tape,
dye, etc.)





5 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis,
prognosis or treatment)

















5 MEDICATIONS: (Include both prescription and OTC)
Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication


Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication


Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication

University of South Florida College of Nursing Revision April 2012 5
Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication


Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication


Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication


Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication


Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication


Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication


Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication


Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication


University of South Florida College of Nursing Revision April 2012 6
4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis)
Diet ordered in hospital? Analysis of home diet (Compare to food pyramid and
Consider co-morbidities and cultural considerations):
Diet pt follows at home?
Breakfast:

Lunch:

Dinner:

Snacks:





2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?

How do you generally cope with stress? or What do you do when you are upset?




Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)




+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? _______________________________________________________

Have you ever been talked down to?_______________ Have you ever been hit punched or slapped? ______________

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

Are you currently in a safe relationship?



University of South Florida College of Nursing Revision April 2012 7
5 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 Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Give the textbook definition of both parts of Ericksons developmental stage for your patients age group:



Describe the characteristics that the patient exhibits that led you to your determination:






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



+3 Cultural Assessment:
What do you think is the causes of your illness?



What does your illness mean to you?



+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?____________________________________________________________________
Do you prefer women, men or both genders? _____________________________________________________________
Are you aware of ever having a sexually transmitted infection? _______________________________________________
Have you or a partner ever had an abnormal pap smear?_____________________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___________________________________________

Are you currently sexually active? ___________________________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? __________________________________

How long have you been with your current partner?________________________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? ___________________________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?

University of South Florida College of Nursing Revision April 2012 8

+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? For how many years?
(age thru )


If applicable, when did the
patient quit?

Does anyone in the patients household smoke tobacco? If
so, what, and how much?
Has the patient ever tried to quit?


2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years?
(age thru )

If applicable, when did the patient quit?


3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
How much? For how many years?
(age thru )

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









University of South Florida College of Nursing Revision April 2012 9
10 REVIEW OF SYSTEMS
General Constitution Gastrointestinal Immunologic
Recent weight loss or gain Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: Diverticulitis Life threatening allergic reaction
Bathing routine: Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy?
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known:
Post-nasal drip Normal frequency of urination: x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth x/day Diabetes Type:
Routine dentist visits x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? Arthritis Chicken Pox
Other: Other: Other:

University of South Florida College of Nursing Revision April 2012 10
REVIEW OF SYSTEMS NARRATIVE

General Constitution
Pts perception of health:































Is there any problem that is not mentioned that your patient sought medical attention for with anyone?







Any other questions or comments that your patient would like you to know?






University of South Florida College of Nursing Revision April 2012 11

University of South Florida College of Nursing Revision April 2012 12
10 PHYSICAL EXAMINATION:
Orientation and level of Consciousness:
General Survey: Height: Weight: BMI: Pain: (include rating & location)
Pulse: Blood
Pressure:
(include location)
Temperature: (route taken?) Respirations:
SpO
2
Is the patient on Room Air or O
2
:
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 talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
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: Location: Date inserted:
no redness, edema, or discharge
Fluids infusing? no yes - what?
Peripheral IV site Type: Location: Date inserted:
no redness, edema, or discharge
Fluids infusing? no yes - what?
Central access device Type: Location: Date inserted:
Fluids infusing? no yes - what?

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
Functional vision: right eye - left eye - without corrective lenses right eye - left eye - with corrective lenses
Functional vision both eyes together: with corrective lenses or NA
PERRLA pupil size / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Weber test, heard equally both ears Rinne test, air time(s) longer than bone
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

University of South Florida College of Nursing Revision April 2012 13
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
Tactile fremitus bilaterally equal without overt vibration
CR - Crackles
Sputum production: thick thin Amount: scant small moderate large
RH Rhonchi
Color: white pale yellow yellow dark yellow green gray light tan brown red
D Diminished

S Stridor

Ab - Absent






Cardiovascular: No lifts, heaves, or thrills PMI felt at:
Heart sounds: S
1
S
2
Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: Carotid: Brachial: Radial: Femoral: Popliteal: DP: PT:
No temporal or carotid bruits Edema: [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: pitting non-pitting
Extremities warm with capillary refill less than 3 seconds





GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly Liver span cm
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: mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date / / ) Formed Semi-formed Unformed Soft Hard Liquid Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bri ght Red
Hemoccult positive / negative
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe:



University of South Florida College of Nursing Revision April 2012 14
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at _______ in UE & _______ in LE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias



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




10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):



















+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:











University of South Florida College of Nursing Revision April 2012 15

University of South Florida College of Nursing Revision April 2012 16

2 Medical Diagnoses
(as listed on the chart)
8 Nursing Diagnoses
(actual and potential - listed in order of priority)
1. 1.





2. 2.





3. 3.





4. 4.





5. 5.




University of South Florida College of Nursing Revision April 2012 17


15 for Care Plan
Nursing Diagnosis:
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal
Rationale for Interventions
Provide References
Evaluation of Interventions
on Day care is Provided
















Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
University of South Florida College of Nursing Revision April 2012 18
15 for Care Plan
Nursing Diagnosis:
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal
Rationale for Interventions
Provide References
Evaluation of Interventions
on Day care is Provided
















Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)

Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision April 2012 19

15 for Care Plan
Nursing Diagnosis:
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal
Rationale for Interventions
Provide References
Evaluation of Interventions
on Day care is Provided
















Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)

Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
University of South Florida College of Nursing Revision April 2012 20
15 for Care Plan
Nursing Diagnosis:
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal
Rationale for Interventions
Provide References
Evaluation of Interventions
on Day care is Provided
















Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)

Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care