UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Nicole Bramwell

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

C.N.

Male

Assignment Date: 02/06/2015

Agency: VA

Age: 62

Admission Date: 1/06/2015

Marital Status: Single

Primary Medical Diagnosis with ICD-10 code:

Respiratory Failure

Primary Language: English

Level of Education: College Degree

Other Medical Diagnoses: No new diagnosis

Occupation (if retired, what from?): Business Owner

Number/ages children/siblings: 1 child 42
2 siblings 66, 69
Served/Veteran: Yes
If yes: Ever deployed? Yes or No
Living Arrangements: Patient lives at assisted living facility.

Code Status: Full

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

Culture/ Ethnicity /Nationality: White

Religion: Protestant

Type of Insurance: Medicare

1 CHIEF COMPLAINT: I couldnt breathe for awhile

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient stated he had experienced this before in October and was getting better, but then it happened again in January.
Patient says when he cant breathe it doesnt cause pain, but some anxiety. He doesnt know what induces his inability to
Breathe. The patient is now on a ventilator to treat the respiratory failure.

University of South Florida College of Nursing Revision August 2013

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

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

69

Glaucoma

Sister
Sister

Diabetes

66

Cancer

Brother

Bleeds Easily

Stroke

Asthma

84

Arthritis

Mother

Anemia

82

Environmental
Allergies

Father

Cause
of
Death
(if
applicable
)
Stroke

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness

Age (in years)

Date

relationship
relationship

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 (Date)
Adult Tetanus (Date) U
Influenza (flu) (Date) U
Pneumococcal (pneumonia) (Date) U
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
ALLERGIE
S OR
ADVERSE
REACTION
S

NAME of
Causative
Agent

Type of Reaction (describe explicitly)

Medications

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)

University of South Florida College of Nursing Revision August 2013

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

Concentration (mg/ml)

Route G tube

Dosage Amount (mg) 25mg

FrequencyBID

Pharmaceutical class: Beta Blocker

Home

Hospital

or

Both

Indication: Treats hypertension

Side effects/Nursing considerations: Bradycardia, HF, Pulmonary Edema. Monitor BP, HR, and pulmonary edema since patient has history of respiratory
failure.
Name: Cholecalciferol

Concentration

Dosage Amount: 400 units

Route: G tube

Frequency BID

Pharmaceutical class: Fat solube vitamins

Home

Hospital

or

Both

Indication: Promotes the intestinal absorption of dietary calcium

Side effects/Nursing considerations: Hypercalcemia. Monitor electrolytes primarily calcium and side effects of hypercalcemia like headache, irritability,
arrhythmias, hypertension, bone pain, and muscle pain.
Name: Insulin Regular Human 100units/mL Novolin

Concentration

Dosage Amount: Per sliding scale

Route: Subcutaneous

Frequency: QID

Pharmaceutical class: Pancreatics

Home

Hospital

or

Both

Indication: Control hyperglycemia in patients with diabetes

Side effects/Nursing considerations: Hypoglycemia. Monitor for signs and symptoms of hypoglycemia like clammy, cold, irritability, diaphoresis, dizziness, and
pale skin.
Name: Lansoprazole
Concentration
Dosage Amount: 30mg
Route: G tube

Frequency: QD

Pharmaceutical class: Proton Pump Inhibitor

Home

Hospital

or

Both

Indication: Treats Heartburn

Side effects/Nursing considerations: Fever, cold symptoms, gas, nausea, vomiting, diarrhea or watery stools, constipation, and increased risks for fractures.
Monitor bowel movements for diarrhea or bloody stools.
Name: Muprocin

Concentration

Dosage Amount: 2% (20mg/g)

Route: Topical to Affected Area

Frequency: BID

Pharmaceutical class:Anit-Bacterial

Home

Hospital

or

Both

Indication: Treatment for infected skin

Side effects/Nursing considerations: Burning, itching, pain, and stinging. Monitor for burning , itching, and pain when applying to skin.
Name: Prednisone

Concentration

Dosage Amount: 10mg

Route: G tube

Frequency: QD

Pharmaceutical class: Adrenal Glucocorticoid

Home

Hospital

or

Both

Indication: Treat chronic inflammatory disease

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
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?
Analysis of home diet (Compare to
My Plate and
Diet pt follows at home?
Consider co-morbidities and cultural
considerations):
24 HR average home diet:
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids (include alcohol):
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?
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)
University of South Florida College of Nursing Revision August 2013

+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?____No___________ Have you ever been
hit punched or slapped? __No____________
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? Yes
4 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
Check one box and give the textbook definition (with citation and reference) of
both parts of Ericksons developmental stage for your
patients age group:
Describe the stage your patient is in and give the characteristics that the
patient exhibits that led you to your determination:

University of South Florida College of Nursing Revision August 2013

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 cause 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?
___________________________________________
University of South Florida College of Nursing Revision August 2013

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 August 2013

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

questions)
What importance does religion or spirituality have in your life?
___________________________________________________________________
___________________________________
___________________________________________________________________
___________________________________
Do your religious beliefs influence your current condition?
___________________________________________________________________
___________________________________
___________________________________________________________________
___________________________________
+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL
EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing
tobacco?
Yes
No
How much?(specify
For how many
If so, what?
daily amount)
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
How much? (give
For how many
What?
specific volume)
years?
(age
thru
)
University of South Florida College of Nursing Revision August 2013

10

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
If not, when did
using these drugs? Yes No 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 August 2013

11

 10 REVIEW OF SYSTEMS
General Constitution
Gastrointestinal
Recent weight loss or
Nausea, vomiting, or
gain
diarrhea
Constipation
Integumentary
Irritable Bowel
Changes in
GERD
appearance of skin
Cholecystitis
Indigestion
Problems with nails
Gastritis / Ulcers
Hemorrhoids
Dandruff
Blood in the stool
Yellow jaundice
Psoriasis
Hepatitis
Hives or rashes
Pancreatitis
Skin infections
Colitis
Use of sunscreen
Diverticulitis
SPF:
Bathing routine:
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

Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:
Genitourinary

Immunologic
Chills with severe
shaking
Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening
allergic reaction
Enlarged lymph
nodes
Other:
Hematologic/Oncologic
Anemia

nocturia

Bleeds easily

dysuria
hematuria

Bruises easily
Cancer

polyuria

Blood Transfusions

kidney stones
Normal frequency of
urination:
x/day
Bladder or kidney
infections

Blood type if known:

Other:

Metabolic/Endocrine

University of South Florida College of Nursing Revision August 2013

12

Routine brushing of
teeth
x/day
Routine dentist visits
x/year

Diabetes

Hypothyroid
/Hyperthyroid
Intolerance to hot or
cold
Osteoporosis
Other:

Vision screening
Other:
Pulmonary
Difficulty Breathing
Cough - dry or
productive

Type:

Central Nervous System

WOMEN ONLY

CVA

Infection of the
Dizziness
female genitalia
Monthly self breast
Bronchitis
Severe Headaches
exam
Frequency of
Emphysema
Migraines
pap/pelvic exam
Date of last gyn
Pneumonia
Seizures
exam?
menstrual cycle
Tuberculosis
Ticks or Tremors
regular
irregular
Environmental
menarche
age?
Encephalitis
last CXR?
menopause
age?
Meningitis
Date of last
Other:
Other:
Mammogram &Result:
Date of DEXA Bone
Cardiovascular
MEN ONLY
Mental Illness
Infection of male
Hypertension
Depression
genitalia/prostate?
Frequency of prostate
Hyperlipidemia
Schizophrenia
exam?
Date of last prostate
Chest pain / Angina
Anxiety
exam?
Myocardial Infarction
BPH
Bipolar
CAD/PVD
Urinary Retention
Other:
CHF
Musculoskeletal
Asthma

University of South Florida College of Nursing Revision August 2013

13

Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening,
when?
Other:

Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

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 August 2013

14

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non

checked boxes)
General Survey:
Height:
Weight:
Pain: (include
BMI:
rating & location)
Pulse:
Blood
Pressure:
Temperature:
Respirations:
(include location)
(route taken?)
SpO2
Is the patient on Room Air or O2:
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
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

University of South Florida College of Nursing Revision August 2013

talkative

15

Peripheral IV site Type:

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

Location:

Location:

Location:

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 / mm
Peripheral vision intact
EOM intact
through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right
earinches & left earinches
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

16

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
Percussion resonant throughout all lung fields,
Clear
dull towards posterior bases
WH
Sputum production: thick thin
Wheezes Amount: scant small moderate large
CR Color: white
pale yellow yellow dark
Crackles yellow green gray light tan brown red
RH
Rhonchi
D
Diminishe
d
S
Stridor
Ab Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at:
Heart sounds: S1 S2 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: 0absent, 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
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
Bright Red
Hemoccult positive / negative (leave blank if not done)
Genitalia:
Clean, moist, without discharge, lesions or odor
Not
assessed, patient alert, oriented, denies problems
Other Describe:

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at _______ RUE _______ LUE _______ RLE &
_______ 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:
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):
Pertinent includes labs that are checked when on certain medications,
monitored for the disease process, need prior to and after surgery, and pertinent
to hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds,
X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that
is done preop) then include why you expect it to be done and what results you
expect to see.
Lab
WBC

Dates
6.9

19.8 H
Normal (4.5-11)

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

Trend
Upon admit, the
patients WBC
were in the low
normal range.
However, WBC
are trending

Analysis
Number of
infection fighting
cells. High WBC
indicates the
presence of an
infection or

upwards
indicating either
an infection or
inflammatory
process is
occurring.

inflammation.
High WBC is
often indicated in
an exacerbation of
ulcerative colitis.

This should
represent the
patients trend of
the exacerbation,
such as after
surgery, with new
meds added, or
since admission.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet,

vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also
provide rationale and frequency if applicable.)

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

1. Impaired gas exchange related to ventilation-perfusion imbalance as evidence by hypercapnia.
2. Impaired skin integrity related to immobility as evidence by wounds on lower extremities
3.
4.
5.

 15 CARE PLAN
Nursing Diagnosis: Impaired gas exchange related to ventilation-perfusion imbalance as evidence by hypercapnia.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Demonstrate improved patient gas Assess respiration, rate, depth,
Thichk, tenacious, copious
Patient was suctioned four times
exchange and adequate
pulse oximetry and suction as
secretions are a major sources of
before the end of my shift.
oxygenation as evidenced by
needed.
impaired gas exchange in small
respiration rate and pulse oximetry
airways. Deep suctioning may be
within normal range within 8
required when cough is ineffective
hours.
for expectoration of secretions
(Doenges & Moorhouse, 2010,
p.128)
During my shift I will maintain the Position the client in a
The patients head of bed
head of the patients bed between
semirecumbent position with head maintained between 30 to 45
30-45 degrees.
of the bed at 30- to 45- degreedegrees.
angle to decrease the aspiration of
gastric, oral, and nasal secretions.
Evidence shows tha mechanically
ventilated clients have a decreased
incisdence of VAP if the client is
paced in a 30- to 45- degree
semirecumbent position as opposed
to supine position (Ackley
&Ladwig, 2014, p. 375).
Monitor oxygen saturation
Pulse oximetry is useful for
Patients oxygen saturation was
continuously using pulse oximetry. tracking and /or adjusting
monitored continuously throughout
supplemental oxygen therapy for
my shift.
clients with COPD (Ackley
&Ladwig, 2014, p. 375)
Patient will be weaned of ventilator Monitor patient airway for signs
A study demonstrated that when
Patient monitored for signs of
in two weeks and able to maintain
and symptoms of respiratory
the respiratory rate exceeds 30
respiratory distress and will notify
airway patency.
distress such as respiratory rate,
breaths/min, along with
physician with any respiratory
depth, and use of accessory
physiological measures, a
changes as needed.
muscles. Keep oxygen saturation
significant cardiovascular or
greater than 92%.
respiratory alteration exists. An

oxygen saturation of less than 90%

or a partial pressure of oxygen less
than 80 mm Hg indicates
significant oxygenation problems.
(Ackley &Ladwig, 2014, p. 375)
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: Impaired skin integrity related to immobility as evidence by wounds on lower extremities.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Prevent further skin breakdown
Reposition patient every 2 hours.
The use of repositioning should be Patient was repositioned every 2
within 8 hours.
considered in all at risk individuals. hours within 8 hour shift.
Frequency of reposition will be
influenced by variables concerning
the individual and the support
surface in use. Reposition the client
with care to protect against the
adverse effects of external
mechanical forces (Ackley
&Ladwig, 2014, p.729).
Provide wound care as ordered by
Choose dressings that provide a
Provided patient with wound care
physician to maintain a moist
moist environment, keep
as ordered by provider.
wound healing environment.
periwound skin dry, and control
exudates and a eliminate dead
space (Ackley &Ladwig, 2014,
p.736).
Patient will regain integrity of skin
surface by February 28, 2015.

Inspect and monitor site of skin

Patient will have follow up
impairment at least once a day for
appointment to assess skin
color changes, redness, swelling,
integrity.
warmth, pain or other signs of
infection. Systematic inspection
can identify impending problems
early (Ackley &Ladwig, 2014,
p.729).
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

Discuss with patient and caregiver

at assisted living facility proper
wound care and signs for further
skin deterioration.

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
Doenges, M., & Moorhouse, M. (2010). Nursing care plans: Guidelines for individualizing client care
across the life span (Ed. 8. ed.). Philadelphia: F.A. Davis.