UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Jorge Guzman

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.
1 PATIENT INFORMATION
Patient Initials:
Gender:

BW

Male

Assignment Date: 27 OCT 2015

Agency: LRMC

Age: 28

Admission Date: 4 OCT 2015

Marital Status: Single

Primary Medical Diagnosis: Diabetic ketoacidosis

Primary Language: English

Level of Education: High School Diploma

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Unemployed, was a pest controller

Number/ages children/siblings: No kids, two siblings

Served/Veteran:
If yes: Ever deployed? Yes or No

Code Status: Full code

Living Arrangements: Lives with two roommates

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

Culture/ Ethnicity /Nationality: Caucasian

Religion: Christian

Type of Insurance: LIP

1 CHIEF COMPLAINT: Shortness of breath and extremely high blood glucose in the 700s.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient presented to the Emergency Department on Sunday 4 October 2015 for shortness of breath and elevated blood
glucose level. Patient states shortness of breath started on the Saturday prior to being rushed to the hospital. Patient was
brought to the Emergency Department when his two roommates noticed he had difficulty breathing. Patient states pain
was located in his chest and his lungs upon inhalation. Patient describes pain as a stabbing sensation. Patient states that
smoking K2 (synthetic marijuana) at home relieves the pain and shortness of breath. Patient states the pain would get
worse when he stopped smoking K2. Patient did nothing at home to help his difficulty breathing, besides calling 911.
Patient states that the severity was a 9/10. Patient has a past medical history of Type 1 diabetes mellitus, psychosis, drug
abuse including marijuana, K2 (synthetic marijuana), and methamphetamines (crystal meth). Patient has anaphylactic
allergy reactions to bee stings. Patient has a past medical history of DKA.

University of South Florida College of Nursing Revision September 2014

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

Father

52

Mother

64

Brother

39

Sister

29

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
)
Myocardi
al
infarction
abdominal
aortic
aneurysm
Does not
associate
with either

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Irritable bowel syndrome: dicyclomine (Bentyl) 20 mg 4x a day (qid)
Diabetes Type 1: insulin glargine (Lantus) 25 units 2x a day (bid)
Attention Deficit Hyperactive Disorder
Pneumonia: Vancomycin 750 mg= 150 mL IV every 8 hours (q8h)
Hypertension: Lisinopril 10 mg po daily
Intestine removal about 1 foot long due to Gangrene
Fractured neck pins and needles (Posterior neck)
Spacer in neck (Anterior neck)
Psychosis: haloperidol (Haldol) 2 mg PO 3x a day (tid)

Age (in years)

Date
6 Feb 2013

relationship
relationship
relationship

Comments: Include age of onset

Father passed away 6 months ago
Mother passed away 2 years ago

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) Is within 10 years? 5 years ago
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

NO

x
x
x
x

University of South Florida College of Nursing Revision September 2014

x
x
x

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)

No Known Drug
Allergies
Medications

Bee stings

Anaphylaxis, airway closes

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Disease: Type 1 diabetes
Mechanism of disease: The exact cause is not known but it is known that Type 1 diabetes is a result of insulin deficiency.
However, Type 1 DM can be autoimmune or non-autoimmune. It can be induced by the body killing its own pancreatic
beta cells. Hence, the pancreas does not produce sufficient insulin for the body to maintain a normal blood glucose level.
This leads to dependence of insulin via injection to keep the blood glucose level under control (Huether, 2012, pp. 458461).
Risk factors: Increased risk if type 1 diabetes runs in your family
How to diagnose: There are several ways to diagnose Type 1 diabetes. Most commonly a glycated hemoglobin (A1C) test
of 6.5% or more on two separate occasions. A random blood glucose test of 200 mg/dL or higher along with associated
symptoms of hyperglycemia such as polyuria and polydipsia. A fasting blood glucose level of 126 mg/dL or higher on two
separate occasions. A 2 hour plasma glucose of 200 mg/ dL or higher during glucose tolerance test (Huether, 2012, pp.
458-461).
How to treat: insulin therapy, exercising regularly, and proper dieting
Prognosis: There is currently no known cure for this disease however, diabetics can live a long life if they monitor and
control their blood glucose levels closely. Complications may arise inevitably but following treatment can prevent the
likelihood.
Genetic factors impacting diagnosis, prognosis, or treatment: There is a link with major histocompatibility complex, class
II, DQ alpha and beta found in Type 1 diabetics. There is also a presence of Islet cell autoantibodies and tyrosine
phosphates in most Type 1 diabetics (Huether, 2012, pp. 458-461).
A serious complication of diabetes is diabetic ketoacidosis which is a result of the body producing too many ketones. The
body produces ketones when it breaks down fat for energy instead of carbohydrates, due to the absence of insulin.
According to the American Diabetes Association the diagnostic criteria include a serum glucose level of greater than 250
mg/dL, a serum bicarbonate level of less than 18 mg/dL, a serum pH less than 7.3, an anion gap presence, and the
presence of serum ketones in the urine. Ketone accumulation causes a drop in pH which results in metabolic acidosis.
Patients with DKA may present with Kussmaul respirations, postural dizziness, central nervous depression, ketonuria,
anorexia, abdominal pain, thirst and polyuria. Treatment consists of administering fluids to correct fluid loss,
administering continuous IV insulin to correct hyperglycemia, administer potassium supplements if patient is hypokalemic
to correct electrolyte imbalance as a result of polyuria. Sodium bicarbonate may need to be administered as well to correct
acid-base imbalance (Huether, 2012, pp.465).

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

University of South Florida College of Nursing Revision September 2014

Name:
dicyclomine (Bentyl)
Route Oral

Concentration
20 mg/ tab

Dosage Amount 20 mg
Frequency 4x a day (qid)

Pharmaceutical class
Home
Hospital
or
Both
antispasmodic and anticholinergic
Indication:
for the treatment of patients with irritable bowel syndrome
Adverse/ Side effects
Severe constipation, bloating, stomach pain, worsening of diarrhea, feeling very thirsty or hot, being unable to urinate, heavy sweating, hot and dry skin,
Confusion, hallucinations, unusual thoughts or behavior, pounding heartbeats, fluttering in your chest.
Nursing considerations/ Patient Teaching
This medication may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert.
Drinking alcohol can increase certain side effects of dicyclomine.
Avoid becoming overheated or dehydrated during exercise and in hot weather.
Dicyclomine can decrease your sweating, which can lead to heat stroke in a hot environment.
Name: enoxaparin (Lovenox)

Concentration: 40 mg/ 0.4 mL

Route: Subcutaneous Injection

Pharmaceutical class: Anticoagulant

Dosage Amount: 40 mg

Frequency: daily
Home

Hospital

or

Both

Indication:
Prevents blood clots from forming and is used for prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE)
Adverse/ Side effects:
Bleeding gums, coughing up blood, difficulty with breathing or swallowing, dizziness, headache, increased menstrual flow or vaginal bleeding, nosebleeds,
prolonged bleeding from cuts, red or black, tarry stools, red or dark brown urine, shortness of breath
Nursing considerations/ Patient Teaching:
Stop using enoxaparin and call your doctor if you have a serious side effect such as:
unusual bleeding (nose, mouth, vagina, or rectum), bleeding from wounds or needle injections, any bleeding that will not stop, easy bruising, purple or red
pinpoint spots under your skin, pale skin, feeling light-headed or short of breath, rapid heart rate, black or bloody stools, coughing up blood or vomit that looks
like coffee grounds
Name:
Concentration:
Dosage Amount
famotidine
20 mg/ 50 mL
20 mg
Route:
Frequency:
Intravenous
200 mL/ hr for 15 minutes every 12 hours (q12h)
Pharmaceutical class:
Home
Hospital
or
Both
histamine-2 blockers that inhibits gastric secretion
Indication:
used to treat and prevent ulcers in the stomach and intestines
Adverse/ Side effects:
fever, asthenia, fatigue, anaphylaxis, angioedema, tinnitus, hallucinations, confusion, agitation, depression, anxiety, decreased libido
Nursing considerations/ Patient Teaching:
You should check with your doctor immediately if any of these side effects occur when taking famotidine:
Bleeding gums, blistering, peeling, or loosening of the skin, blood in the urine or stools, bloody, black, or tarry stools, chest pain, chills, cough, diarrhea, fever
with or without chills, general feeling of tiredness or weakness
Name
Concentration
Dosage Amount
Haloperidol (Haldol)
1 mg/ 0.2 mL
1 mg
Route
Frequency
Intravenous push
Every 6 hours
Pharmaceutical class
Home
Hospital
or
Both
Antipsychotic
Indication
Used to treat schizophrenia
Adverse/ Side effects
muscle spasms, especially of the neck and back, restlessness or need to keep moving, shuffling walk, stiffness of the arms and legs, trembling and shaking of the
fingers and hands, twisting movements of the body, weakness of the arms and legs, Difficulty with speaking or swallowing, inability to move the eyes, difficulty
breathing
Nursing considerations/ Patient Teaching
Stop using Haldol and call a doctor if you are having frequent seizures, Tardive Dyskinesia, Extrapyramidal side effects and neuroleptic malignant syndrome
as evidenced by muscle rigidity, altered mental status, tachycardia
Name
Concentration
Insulin glargine (Lantus)
25 units/ 0.25 mL
Route
Subcutaneous Injection
Pharmaceutical class
Home
long-acting type of insulin that works slowly
Indication
long-acting insulin used to treat adults with type 1 Diabetes
Adverse/ Side effects

Dosage Amount
10 units
Frequency
Twice a day (bid)
Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Hypoglycemia, Hypersensitivity and allergic reactions, Renal impairment, Hepatic impairment,

Nursing considerations/ Patient Teaching
Do not administer Lantus if blood glucose levels are low. Headache, hunger, weakness, sweating, tremors, irritability, or trouble concentrating can be signs of
hypoglycemia. Avoid alcohol consumption. Follow recommended diet, medication, and exercise routines to avoid hyper/hypoglycemia.
Name
Concentration
Dosage Amount
Insulin lispro (Humalog corrective)
5 units
Route
Frequency
Subcutaneous Injection
Routine
Pharmaceutical class
Home
Hospital
or
Both
rapid-acting human insulin analog
Indication
used to lower blood glucose
Adverse/ Side effects
Itching skin rash over the entire body, wheezing, trouble breathing, fast heart rate, sweating, or feeling like you might pass out
Nursing considerations/ Patient Teaching
Do not use this medication when you have low blood sugar (hypoglycemia). Tell your doctor if you have kidney disease and/or liver disease. Limit alcohol intake.
Check your blood glucose levels at least once a day.
Name
Concentration
Dosage Amount
lisinopril
10 mg/ 1 tab
10 mg
Route
Frequency
Oral
daily
Pharmaceutical class
Home
Hospital
or
Both
angiotensin converting enzyme (ACE) inhibitor
Indication
Used to treat high blood pressure (hypertension) or congestive heart failure
Adverse/ Side effects
A light-headed feeling, like you might pass out; little or no urinating; nausea, slow or unusual heart rate, weakness, loss of movement; painful or difficult
urination, swelling in your feet or ankles, feeling tired or short of breath; upper stomach pain, itching, tired feeling, loss of appetite, dark urine, clay-colored
stools, jaundice (yellowing of the skin or eyes)
Nursing considerations/ Patient Teaching
Do not use lisinopril if you are pregnant.
Drink plenty of water
Skip the missed dose if it is almost time for your next scheduled dose.
Avoid drinking alcohol
Do not use salt substitutes or potassium supplements
Name
Concentration
Dosage Amount
Piperacillin-tazobactam (Zosyn)
3375 mg/ 50 mL
3375 mg
Route
Frequency
Intravenous
Every 6 hours at 100 mL/ hr for 30 minutes
Pharmaceutical class
Home
Hospital
or
Both
Penicillin class antibacterial combined with a beta lactamase inhibitor
Indication
Reduces the development of drug-resistant bacteria
Adverse/ Side effects
Diarrhea, Constipation, Nausea, Vomiting, Headache, Insomnia, Oral candidiasis, Rash, Pruritus, hemolytic anemia, agranulocytosis, interstitial nephritis,
Stevens-Johnson syndrome,
Nursing considerations/ Patient Teaching
Call your doctor if you have a serious side effect such as:
diarrhea that is watery or bloody, pale or yellowed skin, dark colored urine, fever, confusion or weakness, feeling light-headed or short of breath, rapid heart
rate, trouble concentrating, easy bruising, unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your skin, dry mouth,
increased thirst, confusion, increased urination, muscle pain or weakness, fast heart rate, feeling light-headed, fainting, fever, chills, body aches, flu symptoms
Name
Concentration
Dosage Amount
Vancomycin
750 mg/ 150 mL
750 mg
Route
Frequency
Intravenous
Every 8 hours (q8h)
Pharmaceutical class
Home
Hospital
or
Both
Antibiotic
Indication
used to treat serious bacterial infections such as MRSA, pseudomembranous colitis caused by clostridium difficile
Adverse/ Side effects
Red Man Syndrome, tinnitus, change in the amount of urine, easy bleeding/bruising, fever, persistent sore throat, persistent diarrhea, oral thrush or a new
vaginal yeast infection, hepatotoxicity
Nursing considerations/ Patient Teaching
Administer medication slowly to avoid any toxic effects
Check patients allergies
Drink plenty of water to avoid nephrotoxicity
Tell your doctor promptly if you have symptoms such as flushing of the upper body, dizziness, low blood pressure, or muscle pain/spasms of the chest and back.
Watch for signs of superinfections

University of South Florida College of Nursing Revision September 2014

Monitor BP for hypotension

Monitor renal function
Check peak and trough levels

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Carbs 75
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Poor
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Hash browns (1 cup), 2 sausage patties,
Grains 0 oz.
scrambled eggs (quick eggs), with ketchup on the side, 1
Vegetables 1 cup(s)
diet Pepsi 12 oz. can
Fruits 0 cup(s)
Dairy cup(s)
Protein Foods 4 oz.
Oils 3 tsp
Lunch: Mashed potatoes with butter, gravy, French fries,
ketchup on the side, 2 slices of meat loaf, 1 diet Pepsi 12
oz. can, 1 6 oz. light strawberry yogurt

Grains 2 oz.
Vegetables 1 cup(s)
Fruits cup(s)
Dairy cup(s)
Protein Foods 5 oz.
Oils 3 tsp.

Dinner: two slices of pepperoni pizza, 1 diet pepsi 12 oz.

can

Grains 3 oz.
Vegetables cup(s)
Fruits 0 cup(s)
Dairy cup(s)
Protein Foods 0 oz.
Oils 2 tsp.

Snacks: mixed fruit cup

Fruits cup

Liquids (include alcohol): A diet Pepsi at every meal and

water in between. Pt denies alcohol consumption

According to choose my plate my patient consumed too

many calories. He had a pretty good consumption of grains
at 5.5 oz., vegetables were over consumed by cup, fruits
were under consumed by 1 cup, dairy was under
consumed by 1 cup, protein was overconsumed by 4.5 oz.,
and oils were overconsumed by 2 tsp. My patient ate too
many empty calories, had too much saturated fat and almost
tripled the recommended sodium.

My recommendations would be to have my patient eat

smaller portions overall, which is easier said than done.
Considering my patient is a type 1 diabetic I would try to
limit sweets and carbohydrates. My patient does well by
drinking diet Pepsi instead of regular Pepsi. However, I
would encourage him to drink less soda and drink more
water instead. I would let my patient know the importance
of consuming fruits and the vitamins that certain fruits
have. I would educate my patient on eating less meat and
increasing dairy intake. I would coach my patient to eat less
salt by choosing the lower sodium items and by not adding
salt to any foods. Another component to this that was not
part of the questionnaire was how often they exercise. My
patient stated that he does not exercise at all, however he
stated he has never been overweight. I suggested to my
patient that exercise is very important and that he should try
it sometime. I would empathize with my patient by letting
them know that these lifestyle changes are not easy but if
he cares about his own health he is going to have to make
these changes.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Both roommates help me when Im sick.

University of South Florida College of Nursing Revision September 2014

How do you generally cope with stress? or What do you do when you are upset?
Smoke a joint. Go fishing
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Both of my parents dying has been kind of hard for me. I just stay at home and play XBOX One with my roommates.

+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 by
police______
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? Im not in a relationship.

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.x 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:28 year old male
Intimacy vs. Isolation (ages 21-40) According to Traes and Wilkinson, intimacy is defined as the capacity to commit himself to
concrete affiliations and partnerships and to develop the ethical strength to abide by such commitments. Avoiding intimacy is
isolation (Treas, 2014, p. 164). The moral of the story is to establish an intimate relationship with a significant other, feel loved, and
stay committed to work. Companion is key for this stage.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is indeed in the intimacy vs. isolation stage. He is exhibiting signs of loneliness and isolation. This can be a
result of both his parents dying and not having a bond with his family. Patient states that he is not in a committed
relationship. It seems like he has a poor sense of self which can lead to depression.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

Patient seems isolated and has not cared enough to change his lifestyle for the better. Patient stated he is hospitalized
every month. It may be because since he does not take care of himself like he knows he should he and ends up being
admitted. He may find a sense of companion and care in the hospital that he is missing at home because of all the
attentiveness he receives while in the hospital. Maybe if he finds a significant other to motivate him to better himself he
will change his lifestyle.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Poor diet, lack of insulin, lack of exercise, drugs, lack of sleep.
What does your illness mean to you?
I think its a joke, Im in the hospital every month.

University of South Florida College of Nursing Revision September 2014

+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? __Male patient does not apply______________________
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?
__No____________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease
or an unintended pregnancy? __I strap up._________
How long have you been with your current partner? 1 or 2 years with my main____________
Have any medical or surgical conditions changed your ability to have sexual activity? _Diabetes, not erected all the
time__
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision September 2014

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

What importance does religion or spirituality have in your life?
__Very important, I go to church on Sundays.
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
Yes, I have faith that God will watch over me.
______________________________________________________________________________________________________

+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)
Cigarettes, Marlboro Reds
1 pack a day

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

thru

28

If applicable, when did the

patient quit? 6 months ago

Pack Years: 12
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? Yes

If yes, what did they use to try to quit? Cold turkey and
patches sometimes

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? Beer
How much? 12 Pack
Volume:
Frequency: Socially
If applicable, when did the patient quit? 7
years ago
Patient states he stopped drinking alcohol when he was 21

Yes

No
For how many years? 5 years
(age

16

thru

21

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much? 1 joint/ day, Meth
Marijuana, Crystal Meth, Xanax, Cocaine
For how many years? 5 years
every other day
Patient states he started using Meth because of
(age 23 thru
28
)
a girl.
Is the patient currently using these drugs?
Yes No

If not, when did he/she quit?

Since Saturday

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Currently on leave of absence.
5. For Veterans: Have you had any kind of service related exposure?
N/A

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10

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health? Poor, I dont take care of it like I should.

Integumentary: No fever, no chills, no rash, no itching, no redness, no edema, no lesions, no ulcers

HEENT: No deformities, no masses, no lesions, no headache, no blurred vision, no sore throat, no earache, no
difficulty hearing, no congestion, no neck pain,
Pulmonary: persistent cough, sputum production yellow in color, no hemoptysis, denies any current shortness of
breath, respirations are normal, unlabored
Cardiovascular: denies any current chest pain, no bruits noted, no thrills noted,
GI: No nausea, no vomiting, diarrhea, no constipation
GU: No dysuria, urinates frequently, no hematuria
Women/Men Only: Denies burning sensation while urinating
Musculoskeletal: no joint pain, no edema, no muscle aches, no rigidity
Immunologic: No swelling, no pruritus
Hematologic/Oncologic: No anemia, no bleeding, no bruising
Metabolic/Endocrine: polyuria, polydipsia
Central Nervous System: denies seizures, no weakness, no numbness,
Mental Illness: no anxiety, depression, denies any current hearing of voices
Childhood Diseases: Attention Deficit Hyperactive Disorder (ADHD), Type 1 diabetes

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Pneumonia, constantly coughing.

Any other questions or comments that your patient would like you to know? No

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11

10 PHYSICAL EXAMINATION:
General survey __No signs of distress_______
Height ___68____Weight___110 lbs_______ BMI ___16.7________
Pain (include rating and location)____0_____ Pulse___115____ Blood Pressure (include location)_130/85 Leftarm_
Temperature (route taken)____oral 99.6 F___
Respirations_____16_____ SpO2 ______98%_________ Room Air or O2___________________________
Overall Appearance ___Alert and oriented x 3, skin color is consistent for ethnicity , no signs of distress, good overall
appearance
Overall Behavior ___Alert and oriented x 3, compliant, cooperative___________________________
Speech ____clear, not slurred, pt has no teeth _________________________________________________
Mood and Affect ___Seemed relaxed and comfortable like nothing was bothering him
Integumentary___ Warm, dry, skin color is consistent for ethnicity
IV Access___18 gauge in the right anetcubital____________________________________________________
HEENT ___No masses, no lesions, symmetrical, no earache, no difficulty hearing, no blurred vision, no redness in
the sclera, sclera is white, eyes are PERRLA pupils equal round reactive to light and accommodation, no nasal
deformities, no swelling of the nose, nostrils a pink and moist, oral mucosa is pink and moist no deformities, tongue
is not swollen, no pain in the head or neck , no jugular vein distention noted, persistent cough with yellow sputum
Pulmonary/Thorax __light crackles upon inspiration in both lower lobes, no pain, no difficulty breathing ,breaths
are unlabored, no use of accessory muscles, no wheezing
Cardiovascular ___Heart sounds are normal, elevated rate and regular rhythm, carotid, radial, and pedal pulses are
palpable bilaterally elevated rate and regular rhythm, s1 and s2 heard equally, no thrills, bruits noted, equal chest
rise and fall, pt denies any pain in chest
GI___ Abdomen non tender, no guarding, no facial grimace upon palpation, pt has constant bowel movements, pt
states having diarrhea, bowel sounds are hyperactive, pt states last bowel movement was 30 minutes ago_
GU ____Pt states last void was 15 minutes ago and that he notes he has the urge to go more frequently than usual. Pt
states urine is clear
Musculoskeletal _no tenderness noted, no edema in extremities, pt able to ambulate without assistance and perform
ADLs independently, denies coordination problems
Neurological Strength is equal in all extremities, spine is intact, no tenderness noted

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.
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13

Lab
Dates
WBC

Trend
6.9

19.8 H
Normal (4.5-11)

Serum glucose level

290 mg/dL
818 mg/dL= critically
high
DKA >250 mg/dL
Hemoglobin
11.6 gm/dL= low
9.8 gm/dL= low
13.7 gm/dL= low
Normal (13.5-18 g/dL)
WBC
11.9 k/mcL = high
41.1 k/mcL= high
Normal (5000-10,000/
mm^3)
POC Glucose Strip
411 mg/dL= critically
high
>600 mg/dL= critically
high
Normal (65-99 mg/ dL)
Potassium level
3.3 mEq/L= low
Normal (3.5-5.0 mEq/L)

(03/18/2013)
(03/22/2013)

10/6/2015
10/4/2015

10/6/2015
10/5/2015
10/4/2015

10/6/2015
10/4/2015

10/6/2015 @ 1100
10/4/2015 @ 1028

10/6/2015

Serum Bicarbonate= CO2

on Cerner
21= normal
10/6/2015
10 mEq/L= critically low 10/4/2015

Analysis
Upon admit, the patients
WBC were in the low
normal range. However,
WBC are trending
upwards indicating either
an infection or
inflammatory process is
occurring.
After several forms of
insulin therapy, patients
serum glucose level is
still high

Number of infection
fighting cells. High WBC
indicates the presence of
an infection or
inflammation. High WBC
is often indicated in an
exacerbation of ulcerative
colitis.
A serum glucose level
greater than 250 mg/dL is
an indicator of diabetic
ketoacidosis

Patients Hgb is low

which can indicate that
tissues are perfusing
inadequately

Low Hgb count may

indicate anemia and may
be a result of blood loss
or hemolysis

Patients WBC are still

relatively high which
indicates an active
infection is still present

Elevated WBC count

indicates the presence of
an infection.

Patients blood glucose

level is elevated and
rising. May need higher
dose of insulin

Elevated blood glucose is

normal in a diabetic
patient but can be
dangerous if not treated
rapidly. Diabetic
ketoacidosis may occur.
Low potassium levels
may occur in patients
with diabetes due to
polyuria.

Patients potassium levels

are lower than normal.
This can be a direct side
effect from the use of
insulin.
Upon admit patients
Serum pH was critically
low. With administration
of Bicarbonate Serum pH
was corrected back to
normal
Indicators of diabetic
ketoacidosis. All VBG
are critically low.

Body was trying to

compensate metabolically
for acidosis.

VBG
All VBGs came back
Serum pH
positive for diabetic
6.87= critically low
10/4/2015
ketoacidosis
(acidosis)
Bicarbonate(HCO3)
2.9= critically low
10/4/2015
CO2
16= critically low
University of South Florida College of Nursing Revision September 2014
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I would expect to see a serum bicarbonate level, a serum pH, anion gap presence, and ketone urinalysis in order
to confirm diabetic ketoacidosis. I would expect to see a serum bicarbonate level of less than 18 mg/dL, a serum
pH less than 7.3, an anion gap presence, and the presence of serum ketones in the urine upon admission.
Patient had Echocardiogram. Results of echo find an ejection fraction of 65-70% which rules out Congestive
Heart Failure.
Hemoglobin: The abundance of ketones and associated pH reduction impair oxygen release from red blood cell
hemoglobin. Less oxygen is available for cellular aerobic respiration. The result is tissue hypoxia, a shift toward
anaerobic cellular respiration, and metabolic acidosis ("EMS Recap: Diabetic Ketoacidosis | EMSWorld.com")
.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient needs to go on a sugar free diet. Limited carbohydrates. Patient should start an exercise regimen and try to
get into a rehab program to prevent illicit drug relapse. Patient should have his A1C monitored. Patient should be
checking his blood glucose three times a day.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Infections related to PULMONARY INFILTRATES as evidenced by elevated white blood cell count and pneumonia.
2. At risk for amphetamine and psychostimulant intoxication related to recreational drug use as evidenced by Crystal
Meth , K2 (synthetic marijuana), cocaine abuse.
3. Electrolyte imbalance related to frequent and loose stools as evidenced by diarrhea/ low potassium levels.
4. At risk for falls related to medication regimen, i.e. Haldol and lisinopril.
At risk for fluid volume deficit related to diarrhea and polyuria
5 Knowledge Deficit related to disease process, treatment and individual care needs as evidenced by unfamiliarity with
information, patient asking questions, further education needed.
Noncompliance of diabetic regimen related to lack of knowledge of diabetes management as evidenced by hyperglycemia
Risk for unstable blood glucose level related to ineffective coping with chronic disease.
Unstable glucose level related to lack of adherence to diabetes management, inadequate blood glucose monitoring,
medication noncompliance, physical activity level, and drug abuse evidenced by hyperglycemia

University of South Florida College of Nursing Revision September 2014

15

 15 CARE PLAN
Nursing Diagnosis: Infections related to secondary causes such as complications from diabetes as evidenced by elevated white blood cell count and
pneumonia.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Achieve timely resolution of
Monitor vital signs closesly,
During this period of time,
Some goals for this patient were
current infection without
especially during initiation of
potentially fatal complications
achieved. The patient remained
complications.
therapy.
(hypotension, shock) may develop
free of infection and breathing
(Treas, 2014)
difficulty and oxygen saturation
stayed in normal levels.
Interventions should be continued
so infection is not spread
throughout body or to others.
The long term goal for this patient
to participate in prevention of
further complications, which
include illicit drug cessation and
proper hygiene, should be
emphasized often.
State symptoms of infection of
which to be aware

Educate patient of symptoms

associated with infection

Maintain white blood cell count

within normal limits

Monitor lab values closely and

frequently

Providing knowledge such as

pamphlets or quick lessons will
promote and raise awareness to the
patient.
(Treas, 2014)
Note and report lab values
(Treas, 2014)

Encourage patient to eat nutritious

meals
Demonstrate appropriate hygienic
measures such as handwashing

Wash hands before and after

patient contact

Educate patient on aseptic technique

to prevent infection from spreading
(Treas, 2014)

Teach patient proper hand hygiene

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Outline steps to enhance general

Increase natural defense, limit
health and well being, balance rest
exposure to pathogens.
and activity, well-rounded diet,
avoidance of crowds during cold/ flu
season and persons with URIs
Review importance of cessation of Smoking destroys tracheobronchial
illicit drug use and smoking
ciliary action, irritates bronchial
mucosa, and inhibits alveolar
macrophages, compromising bodys
natural defense against infection.
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 X No
*Rehab/ HH
Palliative Care

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References
Ackley, B. (2010). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). Maryland Heights, Mo.: Mosby.
EMS Recap: Diabetic Ketoacidosis | EMSWorld.com. (n.d.). Retrieved October 28, 2015.
Huether, S. (2012). Alterations of Hormonal Regulation. In Understanding pathophysiology (5th ed., pp. 458-461). St. Louis, Mo: Elsevier.
Kee, J., & Hayes, E. (n.d.). Pharmacology: A patient-centered nursing process approach (8th ed.).
SuperTracker: My Foods. My Fitness. My Health. (n.d.). Retrieved October 23, 2015.
Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning (p. 164). Philadelphia, PA: F.A. Davis Company.

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