UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Taylor Brown

Assignment Date: 10-18-16
.
Agency: TGH UD
1 PATIENT INFORMATION
Patient Initials: CC Age: 43 Admission Date: 10-11-16
Gender: Male Marital Status: Married Primary Medical Diagnosis: Splenomegaly
Primary Language: English
Level of Education: High School Other Medical Diagnoses: (new on this admission)
Occupation: Quest Diagnostics Customer Service Thrombocytopenia
Sickle cell/Hb-C disease w/ splenic sequestration
Number/ages children/siblings:
Children: 17 y/o female; 15 y/o male
Siblings: 1 brother; 5 sisters (pt does not know ages)
Served/Veteran: N/A Code Status: Full

Living Arrangements: Pt lives with wife and her two daughters Advanced Directives: Living Will
(ages 16 and 13)
Surgery Date: 10-18-16
Procedure: Splenectomy
Culture/ Ethnicity /Nationality: African American
Religion: N/A Type of Insurance: Blue Cross Blue Shield

1 CHIEF COMPLAINT:
Pt stated, severe pain on my left side forced presentation to the ER. Wife confirmed. The electronic medical
Record (EMR) indicated left-sided flank pain.

3 HISTORY OF PRESENT ILLNESS:

Pt presented to ER on 10-11 with left-sided flank pain. The pt describes sharp pain and overall between 8 to 10
on a pain scale of 1 to 10. Pt indicates coughing, walking for long periods of time and taking deep breaths aggravates
the pain. Pt indicates pain meds have brought the pain down to a 7 out of 10. Pt was diagnosed w/ splenomegaly
after presenting with intractable abdominal pain upon examination. Complete blood count (CBC) diagnosed
thrombocytopenia caused by sickle cell/Hb-C disease with splenic sequestration. Splenectomy surgery is scheduled
for today [10-18] at 1300.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
Since childhood, Migraines: daily dose of 10mg amitriptyline (Elavil)
pt does not know
specific date.

10/2016 Splenomegaly and Splenic Sequestration: splenectomy

Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma

of

Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
MEDICAL

Gout
Death

Mental
Heart
HISTORY (if

(angina,
applica
ble)
Pt does
Prostat
Father not
e
know.
Mother 73
Pt does
Brother (1) not
know.
Pt does
Sister (5) not
know.
relationship

relationship

relationship

Comments: Include age of onset

Pt indicates knowledge of 1 older sister with sickle cell/Hb-C w/o complications.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) 10-3-16
Adult Tetanus (Date) Is within 10 years? 10-3-16
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years? 10-17-16

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 Have you had any other vaccines given for international travel or
occupational purposes? Please List

1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Pt denies any known
medication allergies
Medications

Mayonnaise Anaphylaxis symptoms including swelling of mouth/throat, dyspnea.

Other (food, tape, Mushrooms Pt carries Epi Pen.
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)
Sickle cell-Hb-C disease is an inherited disorder of RBC that requires a defective gene (Hb-S or the sickle cell gene) from
1 parent and a second defective gene (Hb-C) from the other parent. This disease is fairly uncommon, occurring in every
1:800 births but seen almost exclusively in African Americans (Huether & McCance, pp. 540). Diagnosis is made through
hemotologic testing, looking for the defective HB-S gene and in this case the HB-C gene. Hematocrit and platelet counts
are also indicitative of the one of the possible crises of the disease splenic sequestration. As the RBC sickle in shape due
to abnormal proteins, they become increasingly viscous which slows blood flow and causes pain or possible hypoxemia
as the RBC can no longer carry an efficient amount of oxygen to body tissues (Huether & McCance, pp. 540). According
to the Huether and McCance text, the splenic sequestration crisis occurs as, [the] sickled cells become sequestered [in the
the spleen] causing blood pooling and infarction of splenic vessels because the spleen can hold as much as one fifth of
the bodys blood supply at one time, up to 50% mortality has been reported (pp. 540-541). This type of crisis is almost
exclusive to young children and is extremely rare in adults. General left-sided flank pain, splenomegaly and the symptoms
of hemolytic crisis (pallor, fatigue, jaundice and irritability) are indicators of this type of crisis. Treatment is focused on
preventing hypoxia and treating the underlying symptoms of anemia.

5 MEDICATIONS*: [Include both prescription and OTC; hospital, home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name Concentration Dosage Amount
amitriptyline (Elavil) 1o mg 1 tablet
Route Frequency
Oral Nightly
Pharmaceutical class
Home Hospital or Both
Tricyclic Antidepressants
Indication
Chronic pain syndromes - headache
Adverse/ Side effects
Wt gain, anticholinergic effects, orthostatic hypotension
Nursing considerations/ Patient Teaching
Monitor mental status, use sunscreen, avoid alcohol, discontinue before surgery

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Name Concentration Dosage Amount
docusate sodium (Colace) 100 mg 1 capsule
Route Frequency
Oral Twice daily
Pharmaceutical class
Home Hospital or Both
Stool Softener
Indication
Constipation
Adverse/ Side effects
Throat irritation, mild cramps, diarrhea
Nursing considerations/ Patient Teaching
Monitor BP and pulse, may cause dizziness avoid driving or operating heavy machinery until you know it affects you

Name Concentration Dosage Amount

ferrous sulfate 325 mg 1 tablet
Route Frequency
Oral Daily with breakfast
Pharmaceutical class
Home Hospital or Both
Iron supplements
Indication
Megoblastic anemia
Adverse/ Side effects
Constipation, nausea, dark stool
Nursing considerations/ Patient Teaching
Explanation of iron therapy, stool may become dark, keep out of reach of children

* (Vallerand, Sanoski, & Deglin, 2015)

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? NPO pre-op
Diet patient follows at home? Normal
24 HR average home diet:
Breakfast: Bagel w/ cream cheese
Lunch: Sandwich w/ mustard or Miracle Whip, chicken or
turkey, cheese; chips
Dinner: Varies daily; Chinese food; pizza; fried/baked
chicken; lasagna; 1 to 2 servings vary daily
Snacks: crackers and cheese, grapes, apples
Liquids (include alcohol): juice, water, Cognac
Fruit: Pt eats fruit as snack, but does not obtain the daily
recommended serving of 2 cups. Drinking whole fruit
juice would help contribute to the daily amount needed.
Vegtable: Pt lacks sufficient source of vegtables in diet,
and does not meet the 3 cups recommended daily.
Grains: Pt reports grains with breakfast and lunch. At least
half of grains are not whole grains, and falls just short of
3 oz equivalents recommended daily.
Protein: Pt receives adequate amounts of protein daily
during lunch and dinner. Pt avoids red meat and meets the
recommended 6 oz equivalents daily.
Dairy: Pt does not meet recommended daily value of 3
cups of dairy. No significant source reported in diet.
Oils: Pt meets and exceeds recommended daily allowance
of oils (6 teaspoons). Pts dinner and lunch options are high
in saturated fat and high in sodium. Pt limiting these would
decrease his risk of heart disease.

(MyPlate, 2016)

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
- Pt stated wife.
How do you generally cope with stress? or What do you do when you are upset?
- Pt stated going for walks when upset and making music relieve stress and allow release of emotions.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
- Pt denies any recent difficulties.

+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? Pt stated no

Have you ever been talked down to? Pt stated yes, by family and friends before
Have you ever been hit punched or slapped? Pt stated no
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Pt stated yes emotionally harmed
If yes, have you sought help for this? Pt stated he attended therapy
Are you currently in a safe relationship? Pt stated yes

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 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:
Erikson described intimacy as the ability to make commitments in different aspect of a persons life. This includes to
other people such as in a partnership and/or an occupational path. Isolation is the absence of intimacy (Treas & Wilkinson,
pp. 164). Pt CC is in the intimacy stage of psychosocial development. This is evidenced by marriage of a year and a half,
and their commitment to each other. Pt indicated that his wife is his main support and he previously had to care for her
after she underwent back surgery. Now, the pts wife will be taking care of the pt post op. Intimacy is also evidenced
by the pts commitment to Quest Diagnostics for over 6 years as an occupation. This hospitalization and newly
diagnosed disease process has only strengthened the intimacy between the pt and his wife.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Pt stated a gene from his mother and a gene from his father as the cause of his illness.

What does your illness mean to you?

Pt stated that the illness means he is sick.

+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? Pt stated yes

Do you prefer women, men or both genders? Pt stated preference of women only________________
Are you aware of ever having a sexually transmitted infection? Pt stated no__________________________________
Have you or a partner ever had an abnormal pap smear? Pts wife stated no _______________________________
Have you or your partner received the Gardasil (HPV) vaccination? Pt and pts wife stated no _____________
Are you currently sexually active? Pt stated yes________________ If yes, are you in a monogamous relationship? Pt
stated yes_____________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? Pts wife stated she underwent sterilization sugery to avoid pregnancy________

How long have you been with your current partner?_Pts wife stated 2.5 years
Have any medical or surgical conditions changed your ability to have sexual activity? Pt stated no________________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
Pt stated an understanding of transmission of STD and did not have any further concerns

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Pt stated an absence of religion but that spirituality is present. Pt indicated a personal relationship with God that allowed him to speak
to God on his own without the aid of religion.
Do your religious beliefs influence your current condition?
Pt stated religious beliefs do not influence 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
If so, what? How much?(specify daily amount) For how many years?
(age thru )

If applicable, when did the

Pack Years:
patient quit?

Does anyone in the patients household smoke tobacco? No Has the patient ever tried to quit?
If so, what, and how much? If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Cognac How much? 2 glasses For how many years?
Volume: about 4 oz (age early 20s thru current)
Frequency: 2 times/month
If applicable, when did the patient quit?

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

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Pt stated no.

5. For Veterans: Have you had any kind of service related exposure?
N/A

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health?

Integumentary:
HEENT: Migraine headaches; Pt stated migraine HA began in childhood and are still a present day concern. Pt
indicated that the HA are rated anywhere from 3 to 7 on a pain scale of 1 to 10 and usually affect the temporal
area of the head. Pt also stated that they can last a couple of hours and are accompanied by photophobia. Pt
stated sleep and cold packs are successful home remedies.
Pulmonary:
Cardiovascular:
GI: Pt reported last BM was 10-9. Pt doesnt report any discomfortbut presence of flatulence 3-4 times daily. Pt
reported oral laxatives have been unsuccessful in relieving constipation and prescription of suppository was
ordered in the past hour.
GU:
Women/Men Only:
Musculoskeletal:
Immunologic:
Hematologic/Oncologic:
Metabolic/Endocrine:
Central Nervous System:
Mental Illness:
Childhood Diseases:

Pt denies any issues with overall health excluding current illness, history of migraines and constipation.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Pt stated no.

Any other questions or comments that your patient would like you to know?
Pt stated no.

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10 PHYSICAL EXAMINATION:

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General survey: ___Body symmetrical___
Height ___511____Weight___225 lbs__ BMI _31.4__ Pain___8-10 on left-sided abdomen___
Pulse_92__ Blood Pressure__127/76 via R arm cuff_____ Temperature __98.2 F via oral___
Respirations__17/min___ SpO2 ___99%____ Room Air or O2____via CPAP at 3L/min_____________
Overall Appearance__Pt not in distress, patent airway_________________________________________________
Overall Behavior__Pt using humor, appropriate to situation_______________________________________________
Speech ___clear, concise________________________________________________________________________
Mood and Affect___Pt using humor appropriately, smiling, positivity towards upcoming surgery, cooperative _____
Integumentary ___normal for ethnicity, mucous membranes pink and moist, no erythema _____________________
IV Access __L metacarpal___________________________________________________________
HEENT _______PERRLA, facial symmetry_____________________________________________________________
Pulmonary/Thorax ___clear, no adventitious breath sounds______________________________
Cardiovascular__S1 and S2 audible, regular rate and rhythm, no adventitious cardiac sounds _________________
GI __protuberant abdomen, tenderness and guarding on left-side, abdomen firm on palpitation, hypoactive bowel sounds_
GU __Pt urinating 6-7 times daily, no pain or increased frequency reported________________________________
Musculoskeletal _all extremities 5+ strength and full range on motion, 2+ radial and pedal pulses equal bilaterally, cap
refill < 3s ____
Neurological A&O x4

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 Dates Trend Analysis
Hemoglobin (Hgb) Since admit, the pts Hgb Protein in RBC that
11.2 (L) 10-14-16 has been lower than the carries oxygen. Low Hgb
9.9 (L) 10-18-16 normal range indicating indicates anemia. In this
Normal range (men): anemia. Hgb continues to case, the splenic
13.5-17.5 trend downward as the sequestration has
RBC protein can carry decreased the Hgb count
less oxygen to the body as RBC pool in and
tissues. around the spleen.
Hematocrit (Hct) Since admit, the pts Hct The percentage of RBC
32.4% (L) 10-14-16 has been decreasing present in the blood. Low
28.2% (L) 10-18-16 rapidly at about 1% daily. Hct indicates in the case
Normal range (men): Thus indicating a destruction of RBC b/c of
45% decrease in the total the new diagnosis of
number of RBC present sickle cell/Hb-C disease
in the blood. and an enlarged spleen.
Platelet Count (PC) Upon admit, PC was low PC is indicative of a pts
113 (L) 10-14-16 but increased to normal ability to clot properly. A
127 (L) 10-15-16 range on 10-18. Pt was low PC in this case is
143 (L) 10-16-16 diagnosed with caused by the splenic
197 10-18-16 thrombocytopenia. sequestration, or the
Normal range: pooling of platelets inside
150-450 bil/L of the spleen causing it to
enlarge and dec the PC.

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

University of South Florida College of Nursing Revision September 2014 10
diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)

Diet: NPO pre-op, no snacks

Vitals: to be taken every 6 hours
Activity: up ad lib, independently
Consult: pastoral care
Surgery: splenectomy scheduled 10-18 at 1300

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

1. Constipation related to decrease in gastrointestinal motility as evidenced by change in bowel pattern, hypoactive bowel
sounds and inability to defecate.

2. Fatigue related to new physiological condition as evidenced by impaired ability to maintain usual routines and impaired
ability to maintain usual physical activity.

3.

4.

5.

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 15 CARE PLAN
Patient Goals/Outcomes
Pt goal of having a bowel
movement prior to having surgery.
Nursing Diagnosis: Nursing Diagnosis goes here
Nursing Interventions to Achieve Rationale for Interventions
Goal Provide References
Possible interventions to stimulate Laxatives are used to move feces
a BM includes laxatives and an through the GI tract by stimulating
enema, as the pt does not have peristalsis.
limited mobility and is constantly An enema is instilled into the
receiving liquids through IV. rectum to soften feces, distend the
colon, and stimulate peristalsis and
evacuation of feces (Treas &
Wilkinson, pp. 979).
Evaluation of Goal on Day Care
is Provided
The goal of having a bowel
movement prior to surgery was
unsuccessful. An enema would be
the next course of action to help the
pt reach his goal.

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 post op diet, proper diet to stimulate a BM, proper diet for new diagnosis of sickle cell/Hb-C disease
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

Pt discharge planning would include making sure the patient understands the new disease process and management of it. The pt would need to be
aware of how living without a spleen may affect his life, such as an increase risk of infection and/or a weakened immune system.

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 References

Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook: an evidence-based guide to

planning care (11th ed.). St. Louis, MO: Elsevier.

Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology, 5e (Huether, understanding

Pathophysiology) (5th ed.). Philadelphia, PA, United States: Elsevier Health Sciences.

MyPlate | Choose MyPlate (2016, January 7). Retrieved October 20, 2016, from

https://www.choosemyplate.gov/MyPlate

Traes, L. S., Wilkinson, J. M. (2014). Basic Nursing Concepts, Skills, and Reasoning. Philadelphia, PA: F.A.

Davis Company.

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2015). Daviss Drug Guide for Nurses (Fifteenth ed.).

Philadelphia: F. A. Davis Company.

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