UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kevin Jones

PATIENT ASSESSMENT TOOL .

Assignment Date: 10/6/15

Agency: USF

1 PATIENT INFORMATION
Patient Initials: HWB

Age: 48

Admission Date: 10/5/15

Gender: male

Marital Status: single

Primary Language: English

Primary Medical Diagnosis with ICD-10 code:

K62.1
Colorectal Carcinoma

Level of Education: High School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired Military

Chronic alcoholism

Number/ages children/siblings: None

Hypertension
Bipolar disorder

Served/Veteran: Persian Gulf War

Code Status: DNR

Living Arrangements: House by himself

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: NA
Procedure:NA

Culture/ Ethnicity /Nationality: Caucasian

Religion: NA

Type of Insurance: CareMark

1 CHIEF COMPLAINT:
-

Feels like Im going through withdraw

Im shaky, and dizzy

- I feel sad all the time

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient is a 48 year old male with history of chronic alcoholism, benign essential hypertension, and bipolar disorder. He
was admitted for symptoms of withdraw and during the initial assessment he was referred to an oncologist because of
an abnormality that was observed on his rectum. The oncologist says it is a form of colorectal carcinoma. His main
problem is with the withdraw, the patient states that the discomfort is constant and are especially severe during exertion. It
is located in his whole body but mainly in his extremities. He states that it is constantly present. The characteristics of his
discomfort are tremors and dizziness. It is aggravated by exertion, and is helped by rest. He has not treated it with
anything, and his pain level was 1 on a 1-10 scale. He said its not so much pain, as much as discomfort from the tremors.

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
10/6/15
6/12/15
6/12/15
8/9/14

Father

62

Mother

70

Grandpa

60

Cancer

Grandpa

80

MI

Grandma

90

Grandma

75

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
)
Car
Accident

Alcoholism

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Colorectal Carcinoma
Chronic Alcoholism
Benign Essential Hypertension
Bipolar

Comments: Include date of onset

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 (U)
Adult Tetanus (U)
Influenza (flu)(U)
Pneumococcal (pneumonia) (U)
Have you had any other vaccines given for international travel or
occupational purposes? Please List- Unknown

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)

NKD
Medications

NKD
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)
Colorectal carcinoma is a malignancy of the colon or rectum, in this patients case it is the latter. It is the second leading
cause of cancer deaths in the United States. Contributing factors are things like family history, obesity, and those who
consume high fat, and low fiber diets. In this patients case, it is most likely related to the high fat diet that he keeps.
Symptoms of this disease are generally absent but may include things like change in bowel pattern, like in this patient he
has recently started to experience more bouts of diarrhea. Diagnosis can come from many different things such as,
digital rectal exams, anoscopy, biopsy of lesions. Once it is diagnosed, other tests must be carried out to confirm. Most
cases cant be prevented, however, they can be caught early through screening of asymptomatic men and women through
procedures like colonoscopies. Treatment depends on the location of the cancer, but the most common practice is surgical
resection of the area. (Nursing Central, 2015)

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

Concentration: 25mg

Route: PO

Dosage Amount: 50mg

Frequency: Q Daily

Pharmaceutical class: Beta Blocker

Home

Hospital

or

Both

Indication: High Blood Pressure

Side effects/Nursing considerations: Hypotension, Bradycardia
Name: folic acid (folate)

Concentration: 1mg

Route: PO

Dosage Amount: 1mg

Frequency: Q Daily

Pharmaceutical class: Water soluble vitamin

Home

Hospital

or

Both

Indication: Anemia
Side effects/Nursing considerations: Confusion, rash, fever
Name: Lorazepam (Ativan)

Concentration: 1mg

Route: PO

Dosage Amount: 1mg

Frequency: Q 6hours

Pharmaceutical class: Benzodiazepine

Home

Hospital

or

Both

Indication: Alcohol Withdraw

Side effects/Nursing considerations: Physical dependence, respiratory depression, dizziness

University of South Florida College of Nursing Revision August 2013

Name: enoxaparin (Lovenox)

Concentration: 40mg/0.4mL

Route: Subcutaneous Injection

Dosage Amount: 40mg/0.4mL

Frequency: Q Daily

Pharmaceutical class: Antithrombotic

Home

Hospital

or

Both

Indication: Prophylaxis for hospitalization

Side effects/Nursing considerations: Bleeding, anemia, erythema at injection site
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

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

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?
Normal
Analysis of home diet (Compare to My Plate and
Diet pt follows at home?
Normal
Consider co-morbidities and cultural considerations):
24 HR average home diet:
His diet was found on MyPlate to be extremely unhealthy.
Breakfast: 2 eggs scrambled, white toast
He was good in all food categories outside of dairy, which
he barely touched, and fruits which he didnt eat any. The
Lunch: Turkey Sandwich, Lays potato chips
real problem however came into play when it looked at his
empty calories which were over 2000 more than what they
Dinner: Cheeseburger, fries
have as normal which was 258. You could see the numbers
real take a bad turn when the alcohol was plugged in at the
Snacks: NA
end. His problems with his health seem to be directly
attributable to the fact that he drinks to beyond excess
Liquids (include alcohol): 1 liter of vodka, 20 oz. water
every single day. (MyPlate, 2015)
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?
Myself
How do you generally cope with stress? or What do you do when you are upset?
Drink

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

+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?
_________No_________________________________ If yes, have you sought help for this? ________NA___________
Are you currently in a safe relationship? NA, patient is currently single

University of South Florida College of Nursing Revision August 2013

 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: This stage is characterized by the need to pursue close personal relationships. Not just romantically but close
friend relationships are very important as well. If the person isnt able to cultivate these relationships it can lead them towards
isolation. (Treas, Wilkinson, 2014)
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 Isolation vs. Intimacy stage, and is more on the side of isolation. He says that he spends
most of his days at his house alone drinking. He also is a quiet and not very social person. Throughout even my
conversation with him he was very short and gave a lot of one word answers.

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

His disease process seems to be putting him further on the side of isolation, especially because he gets tired
when he does things because of his disease, it will cause him to stay home even more.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
My drinking habits
What does your illness mean to you?
It is a consequence of my lifestyle

+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?______Yes__________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ______I dont know___________________
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? _________None________________
How long have you been with your current partner?_______NA______________________________________________
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?
____ Not much ______________________________________________________________________________________
______________________________________________________________________________________________________
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)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much?

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? (give specific volume)
Vodka or Rum
1 liter daily

For how many years?

(age

thru

As long as I can remember

If applicable, when did the patient quit?
NA
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
Marijuana
How much?
For how many years?
(age 16
thru 17
NA
Is the patient currently using these drugs?
Yes No

If not, when did he/she quit?

17

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Maybe in the war

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 NA SPF:
Bathing routine: 1X per week
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
1 x/day
Routine dentist visits
NA x/year
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? NA
Other: Ive been having diarrhea

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:
Bladder or kidney infections

5 x/day

Hematologic/Oncologic

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

Pulmonary
Difficulty Breathing
Cough - dry
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 10/5/15
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
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?
Frequency of prostate exam? NA
Date of last prostate exam? NA
BPH
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
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 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: AOx3
Temperature: (route taken?)

Height: 76 in
Pulse: 82 BPM
Respirations: 18

Weight: 197.5lb BMI: 24

Pain: 1, general body
Blood
Pressure: 156/88, R. arm cuff
(include location)

SpO2: 97%
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
Slightly restless
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
mumbles
Mood and Affect:
pleasant
cooperative
cheerful
talkative
apathetic
bizarre
agitated
anxious
tearful
withdrawn
Other:
Integumentary
Skin is warm, dry, and intact- cool clammy
Skin turgor elastic
No rashes, lesions, or deformities- some bruises
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin

Peripheral IV site Type:

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

quiet
boisterous
aggressive
hostile

Location:

Date inserted:

Location:

Date inserted:

Location:

R. mid axillary Date inserted:

flat
loud

10/5/15

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 3 /3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 12 inches & left ear- 12 inches
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 August 2013

10

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:
thin
Amount: scant
CR - Crackles
Color: clear
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5 intercostal L mid. axillary
Heart sounds: S1 S2 Regular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3
Brachial: 3
Radial: 3
Femoral: 3 Popliteal: 3
DP: 3
PT: 3
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:
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
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color: amber
Previous 24 hour output:
N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance
CVA punch without rebound tenderness
Last BM: (date 10 / 6 / 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 __4_____ RUE __4_____ LUE __4_____ RLE

& __4_____ in LLE

[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: 2

Brachioradial: 2

Patellar: 2

Achilles:

Ankle clonus:

negative Babinski:

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):

Lab
Ethanol- 152 mg/dL
(normal is <10mg/dL)

Potassium- 3.1mEq/L
(normal is 3.5-5.2
mEq/L)

Glucose- 128 mg/dL

(normal is 65-110mg/dL)

Billirubin total- 1.5mg/dL

(normal is 0.2-1.3 mg/dL)

Dates
10/5/15

10/5/15

10/5/15

10/5/15

Trend
There was only one set of
labs that were on file for
this visit.

There was only one set of

labs that were on file for
this visit.

There was only one set of

labs that were on file for
this visit.
There was only one set of
labs that were on file for
this visit.

Analysis
This value is extremely
high in relation to what
the normal range is. It is
probably high due to his
drinking habits, and the
next labs should show
improvement because he
hasnt drank since coming
in.
This value is low in
relation to the normal
range. It is very close to
the range, but the doctor
was talking about starting
him on a supplement to
avoid the side effects of
hypokalemia.
This value is elevated
from the normal range,
most likely due to his diet
and the high glucose level
of certain alcohols.
This value is elevated
slightly above the normal
range, and in the case of
bilirubin it may be an
early sign of liver disease
as a result from his
drinking.

+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 currently on a normal diet. His vitals were all in normal ranges outside of his elevated blood
pressure which was 156/88. Right now he is on bed rest with bathroom privileges. He currently doesnt have any
diagnostic tests scheduled. He does have consults scheduled for the following: Psych, ADATP, Wound Care,
Palliative care, Nutrition, Occupational Therapy, and Physical Therapy.

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

1.Risk for bleeding related to impaired skin integrity.
2.Social isolation related to disease process, as evidenced by inability to engage in satisfying personal relationships.
3.Anxiety related to new diagnosis, as evidenced by a feeling of apprehension caused by anticipation of danger.
4.
5.

 15 CARE PLAN
Patient Goals/Outcomes
Monitor for signs and symptoms of
bleeding

Maintain a warm and dry

environment

Nursing Diagnosis: Risk for bleeding related to impaired skin integrity.

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Monitor orthostatic vital signs
When bleeding occurs a persons
vital signs will change
Teach patients family about signs
If the family knows what to look
of bleeding
for they can inform you of any
changes in the patient
Monitor client for any signs of
If you monitor for signs of
hemorrhage
bleeding you can know when
something goes wrong and catch it
early
Monitor coagulation studies
If you know when a persons lab
values are off, you can see when
something is going wrong
Make sure that the patient
When the patient has a good
understands the importance of a
knowledge base as to why
good healing environment
something is important they are
more likely to stick with it
Keep materials necessary at the
If the materials are within reach, it
bedside of the patient
makes keeping the environment
dry and warm much easier

Evaluation of Goal on Day care is

Provided
You can track the trends in a
patients vitals
You can have the family repeat the
teaching to be sure they understand
You will be able to document if
there is any bleeding present
throughout the day
You can check the values against
the normal values to see when
something is going wrong
Have the patient repeat the teaching
so you know they understand it
Every time you walk in the room
you can check to make sure it is
dry and warm, and that the
materials are still in the room as
well

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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Social isolation related to disease process, as evidenced by inability to engage in satisfying personal relationships.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Increased social support
Contact family to see if they would Family can be one of the strongest Ask patient how family
be willing to get more involved
bonds, and they are the building
relationship is going
with the patient
block to a healthy social life
Establish therapeutic relationship
Having daily communication with
Observe how mood is effected by
with the patient
the patient can help to reduce the
communication with the patient
feeling of isolation
Discuss causes of patients isolation If the patient can identify what
Patient will be able to explain what
triggers them to isolate, then they
causes him to isolate himself
can avoid or get rid of that trigger
Socialization enhancement
Observe barriers to social
If you are able to identify some of
Observe patient for any triggers,
interaction
the patients reason for isolation and and bring them up in an appropriate
communicate it appropriately to
way
them, then they can start to get
better at not isolating
Promote social interactions
Reassuring the patient that it is
Gauge the patients interest in
important and that they will enjoy
certain activities and see how they
more social interaction can help
respond to a variety
them to get out and participate
more
Refer client to support groups
Support groups can help bring
Have patient explain why it is
similar people together, and show
important to understand that people
the patient that they arent alone in may be struggling with some of the
the world
same problems

 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

15 CARE PLAN
Patient Goals/Outcomes

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
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

References
Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning (p. 145).
Philadelphia, PA: F.A. Davis Company.

Nursing Central from Unbound Medicine. (2015, July 1). Retrieved July 15, 2015.

ChooseMyPlate.gov. (2015, February 1). Retrieved July 15, 2015