UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Elecia Trowers

FUNDAMENTAL PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 06/30/2014

Agency: LRMC

Patient Initials: CS

Age: 51

Admission Date: 06/24/2014

Gender:

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code: D

Male

Primary Language: English

Iron Deficient Anemia D50.0

Level of Education: High School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): machinist

Lower GI Bleed, Hypertension

Number/ages children/siblings: 2 children, 21 and 23.

Served/Veteran: No

Code Status: Full Code

Living Arrangements: Lives with wife and kids

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

Culture/ Ethnicity /Nationality: African American

Religion: Baptist

Type of Insurance: United Health Care

1 CHIEF COMPLAINT:
Numbness in 4th and 5th left digits, Blood in feces, Dizziness
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Client states I have been having dark red blood in my feces for the past six months. I have no pain, nothing makes it
better and nothing makes it worst. The patient has been seeing his primary care Doctor on a yearly basis, and has never
been scheduled for a Colonoscopy as is required when a male turns 50 years old. The patient has a history of hemorrhoids,
Which could also be the reason for blood in the feces.

University of South Florida College of Nursing Revision August 2013

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date
06/06/2012
06/06/2010

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

stroke

Asthma

60

Arthritis

Mother

Anemia

56

Environmental
Allergies

Father

Cause
of
Death
(if
applicable
)
Cancer

Alcoholism

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Stroke
Hypertension

Brother
Sister
relationship
relationship
relationship

Comments: Include date of onset

Parents diseases started when they were in their forties (40s) both parents are dead

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (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

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)

No known Allergy
Medications

Other (food, tape,

latex, dye, etc.)

No known Allergy

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)
ANEMIA
Mechanics of Anemia : Anemia is a condition in which the body does not have enough healthy red blood cells.

Iron helps make red blood cells.

When your body does not have enough iron, it will make fewer red blood cells or red blood cells that are too
small. This is called iron deficiency anemia. (Huether & McCane. 2012)
Risk Factors: Choosing a diet that is consistently low in iron, vitamin B-12 and folate increases the risk of

anemia. Having an intestinal disorder that affects the absorption of nutrients in the small intestine such as
Crohns disease and celiac disease puts one at risk for anemia. Constant bleeding puts one at risk for anemia.
How to Diagnose: To diagnose anemia a Hematocrit, Hemoglobin, and RBC indices test may be done.
Treatment: Iron supplements (most often ferrous sulfate) are needed to build up the iron stores in body. I cases
where anemia is due to bleeding then the bleeding would need to be treated before implementing supplements
and diet. Eating foods rich in Iron will also help in replenishing the Iron stores in the body (grains , turkey, peas
and beans) (Provan & Gribben. 2010)
Prognosis: With treatment the prognosis for anemia is good; however it depends on the cause. If the anemia is
caused by an underlying problem and those problems persist then anemia will persist. Example Bleeding, under
nutrition or other GI diseases.

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

lisinopril (Zestril)
Route : Oral
Pharmaceutical class ACE inhibitor
Name

Concentration (mg/ml)

20mg

Dosage Amount (mg)

Frequency once
Home

Hospital

or

1 tablet

daily
Both

Indication
Side effects/Nursing considerations: Angioedema, hyperkalemia,

erectile dysfunction ,impaired renal function

University of South Florida College of Nursing Revision August 2013

Name: Aspirin

(Acetylsalicylic acid)

Concentration: 325

Route: Oral

mg

Dosage Amount:

Frequency :Once

Salicylates
Indication: prophylaxis of transient ischemic attack
Pharmaceutical class:

Side effects/Nursing considerations : GI

Home

Hospital

or

1 tablet

daily
Both

bleeding, dyspepsia, epigastric distress, Anemia. Give on empty stomach

Name:

pantoprazole (Protonix)
Concentration: 40 mg
Route: Oral
Frequency: once daily
Pharmaceutical class: Proton pump Inhibitor
Home
Hospital
or
Both
Indication: Erosive esophagitis associated with GERD
Side effects/Nursing considerations: Pseudomembranous

Dosage Amount: 1

tablet

colitis, hyperglycemia, abdominal pain,diarrhea.

Ferrous Sulfate (FE-50)

Concentration: 324 mg
Dosage Amount: 1 tablet
Route: Oral
Frequency: Once daily
Pharmaceutical class: iron supplements
Home
Hospital
or
Both
Indication: Treatment and prevention of iron deficiency
Name:

Side effects/Nursing considerations:

Name

dizziness, headache syncope, GI bleeding, dark stools. Give with food.

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

University of South Florida College of Nursing Revision August 2013

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
NPO
Analysis of home diet (Compare to My Plate and
Diet patient follows at home?
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Does not eat breakfast
Lunch: Turkey sandwich, with cheese lettuce and tomato
Dinner: Potatoes meat and greens and corn
Snacks: Meat cutlets
Liquids (include alcohol): Beer x6
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.

According to use my plate analysis the target for

grains eaten by for the client is 6 oz. but only 3 oz.
was consumed, the target for vegetable is 2 cup only
1 was eaten, the target for fruit is 2 cups and zero
was consumed, the target for dairy is 3 cups and only
cup was consumed and the target for protein is 5
cups and 8 was consumed. The clients diet is 16
calories over the recommended 735 of which are
empty calories.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? The patients wife assist him when he is ill
How do you generally cope with stress? or What do you do when you are upset? Patient claims he does not get stressed
nothing really bothers me he stated, he also said he does not get upset.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient stated that not having a job is his most recent difficult situation, drinking and smoking helps to keep him
relaxed.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? ____________No__________
Have you ever been talked down to? __Yes________Have you ever been hit punched or slapped? ____Yes__________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?

University of South Florida College of Nursing Revision August 2013

_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:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: middle adulthood 40-65
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is in the ego Integrity vs Despair. The patient reflected on his life and although he feels his drinking
and lifestyle habits contributes to his illness he was very satisfied with his life and still is, as he continues
drink, smoke and not care about his nutritional needs.

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

The diseases seem to have no impact on my patients developmental stage of life. He has changed nothing about his
lifestyle, since he found out about his illness.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states he has no idea, but it is probably his drinking
What does your illness mean to you?
I dont know

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?___________________________Yes____________________________________
Do you prefer women, men or both genders? ___________Women________________________________________
Are you aware of ever having a sexually transmitted infection? __NO_________________________________________
Have you or a partner ever had an abnormal pap smear?_ ______No___ __________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ______No________________________________
Are you currently sexually active? _____Yes______________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? ___NON______________________
How long have you been with your current partner?_____23 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?
_______Religion is very is very important to me it kept my marriage together_____________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
__________________________________________________No_______________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)
11 per day

Yes
No
For how many years? 36 years
(age 15

thru 51

If applicable, when did the

patient quit?

Pack Years: 200.75

Does anyone in the patients household smoke tobacco? If
so, what, and how much? Everyone
Patient tried to quit it lasted for two weeks

Has the patient ever tried to quit? Yes

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Beer during the week
How much? (give specific volume)
Rum on weekends
6 12oz. bottle per day
Patient drinks 24oz. rum on weekends
If applicable, when did the patient quit?

For how many years?

(age 17

thru 51

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 28
thru 30
)
Marijuana
1lb total
Cocaine
4 oz. total
Is the patient currently using these drugs?
If not, when did he/she quit?
Yes No
Patient quit 21 years ago
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Yes cigarette smoking.

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
Pts perception of health:

Integumentary: Black itchy patch on right leg, denies any other skin conditions
HEENT: patient lost peripheral vision denies all other HEENT abnormality
Pulmonary: patient has dry cough and crackle but denies any respiratory problems
Cardiovascular: Patient has hypertension
GI: Patient has Lower GI bleed
GU: Patient denies any GU problems
Women/Men Only: denies any male only problems
Musculoskeletal: Patient has numbness in fingers denies other problems
Immunologic: patient denies any immunologic problems
Hematologic/Oncologic: Patient has Anemia denies any cancer or other disorders
Metabolic/Endocrine: Patient Denies any metabolic or endocrine problems
Central Nervous System: Patient denies any central nervous system disorders
Mental Illness: Patient denies any mental illness
Childhood Diseases: Patient denies any childhood disease.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Yes Patient sought medical attention with his primary care physician for hemorrhoids.

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

University of South Florida College of Nursing Revision August 2013

10 PHYSICAL EXAMINATION:
General survey _____________________________________________________________________________________
Height __6 feet____Weight_185lbs_ BMI ___25.1____ Pain (include rating and location)___NON___________
Pulse_______ Blood Pressure (include location)_____________________Temperature (route taken)____________
Respirations____________ S_99__________ Room Air or O2______room air_____________________
Overall Appearance____Calm Relaxed____________________________________
Overall Behavior________________Normal_ No apprehention______________________________
Speech___________Clear and Concise_______________________________________________________
Mood and Affect_________________Good mood pleasant__________________________________________
Integumentary__Black patch on right foot other areas of skin clean and intact_______________________
IV Access_________Patient has IV access on right wrist____________________________________________
HEENT____________lack of peripheral vision_______Normal finding in other areas____________
Pulmonary/Thorax______Dry cough and crackles_______________________________________________
Cardiovascular____________Hypertensive_______________________________________________
GI_________________Lower GI bleed_____________________________________________________
GU_____________Normal finding________________________________________________________________
Musculoskeletal____________________Numbness in 4th and 5th right digits__________________________
Neurological: Normal findings

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):
The patient has no currents labs that were done however he is scheduled for a colonoscopy, and a MRI. These
labs can pinpoint the portion of the GI where the bleeding originates.
Lab
HGB

Dates
C 7.8 gm/dl
L 25.1%

06/24/2014

Trend
Upon admit, the patients
HGB were below the
normal values. The
decrease in HGB indicate
a decrease in RBC
oxygen carrying capacity
which indicates anemia

Analysis
A low number of oxygen
carrying cells, indicates
that the RBC oxygen
carrying capacity is way
below normal, which is
shown in the low HBG.
This is indicative of
Anemia.

University of South Florida College of Nursing Revision August 2013

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
The patient is current NPO (Eating with GI bleed can irritate the GI and exacerbate the bleeding) and his
vitals are normal at BP 133/86 , pulse 69, Spo2 99 and temperature ( vital are checked every 4 hours)
36.6. The patient is mobile and is required mobilize at least twice per day (This will help in preventing bed
ulcers and clot formation). The patient is scheduled for
A MRI and also a colonoscopy are scheduled (These test will find the portion of the GI where the bleeding
is coming from). He is also scheduled for consult with neurology (mental status and function is important
since the patient has been bleeding for six months without seeking medical attention).
No accu check monitoring is on file.

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

1. Ineffective tissue perfusion, due to excessive bleeding.
2. Activity intolerance related to imbalance between oxygen supply and demand.
3. Imbalanced nutrition less than body requirement related to anemia.
4. At risk for injury related to alteration in peripheral and sensory perception
5. Education deficit pertaining to Anemia.

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 15 CARE PLAN
Nursing Diagnosis: (Which nursing diagnosis you are doing your care plan on goes here.)
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult *
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments *
Med Instruction/Prescription *
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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References

Provan, D. & Gribbens, J. (2010). Molecular Hematology: Anemia of Chronic diseases (3rd Ed). West Sussex ,
UK. Wiley, Blackwell.
Huether, E.S. & McCance, L.K. (2012) Understanding Pathophysiology: Alterations of Hematologic Function
(5th Ed). St Louis Missouri, USA. Loren S. Wilson.
United States Department Of Agriculture. ( 2013, September 30). Super Tracker: Food Tracker. Retrieved
June 28, 2014, from https://www.supertracker.usda.gov/foodtracker.aspx

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