UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Ashley Joseph

Assignment Date: 7/21/2016
.
Agency: LRH
 1 PATIENT INFORMATION
Patient Initials: GT Age: 51 Admission Date: 7/20/2016
Gender: female Marital Status: married Primary Medical Diagnosis acute asthma
exacerbation
Primary Language: English
Level of Education: high school graduate Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): housewife hypoxemia
Number/ages children/siblings: Son: 30 daughter: 25
3 sisters: 67, 59, 55 3 brothers: 67, 57, 53
Served/Veteran:no Code Status: unknown
If yes: Ever deployed? Yes or No
Living Arrangements: live with son and husband; husband is Advanced Directives: no
caretaker. Has only one stair from living to dining room If no, do they want to fill them out? no
Surgery Date: N/A Procedure: N/A
Culture/ Ethnicity /Nationality: White, non-Hispanic
Religion: Pentecostal but previously Catholic Type of Insurance: FL BlueCross HMO

 1 CHIEF COMPLAINT:
Shortness of breath last night but no relief with nebulization

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient is a 51 year old female who was admitted last night with asthma exacerbation and hypertension.
SOB started yesterday morning with some wheezing. No fevers but chills were noted with minimal but unproductive
Cough. She checked her blood pressure in the morning and it was elevated to the 170s. Patient states that this may be
Because she ran out of medication for about a week. Patient reports no chest pain but a history of asthma. Shortness of
Breath is worse with physical activity, and nebulizer had no effects. This has been going on since yesterday morning.

University of South Florida College of Nursing – Revision September 2014 1

  2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
1987 3 wheel accident – left arm surgery to put 2 plates in
1987 Jaw fracture surgery – pen
1987 Bleeding ulcers – controlled by Prilosec
Before 2003 Stomach ulcers – stomach ulcers – colonoscopy and Prevosid
2003 Partial hysterectomy
8 years ago Diagnosed with hypertension – atenolol and Losartan with potassium
6 months old Pneumonia
Recent Asthma (another asthma attack previously this year)
Age (in years)

2

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,
applicable
)
Father 93
Mother 87
Brother 57
Sister 59
sister 67
brother 53
sister 55
brother
65 suicide X
Comments: Include age of onset
Mom was diagnosed with cancer when patient was in high school

 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) U
Adult Tetanus (Date) Is within 10 years? (2007)
Influenza (flu) (Date) Is within 1 years? (8/2015)
Pneumococcal (pneumonia) (Date) Is within 5 years? (1/19/2015)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state “U” for the patient not knowing date received

University of South Florida College of Nursing – Revision September 2014 2

 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
NKDA No known drug allergies

Medications

Pollen,dust,dander Sneeze when exposed to pollen, dust, or dander

Other (food, tape, Bees Entire face got swollen from bee sting on nose
latex, dye, etc.) Latex Hands get very itchy
Petting animals causes rash and itch

 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)
“Asthma is a chronic inflammatory disorder of the airways… airway inflammation contributes to airway
Hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity” (NCBI). The bronchial muscles
Cause limited airflow in patients because the muscles contract too quickly, which causes the airways to become narrow.
If the inflammation that occurs becomes worse, it can lead to edema, according to NCBI. Risk factors for asthma
Exacerbation include genetics, allergens, and respiratory infections. “Tobacco smoke, air pollution, occupations, and diet
have also been associated with an increased risk for the onset of asthma, although the association has not been as clearly
established as with allergens and respiratory infections…” (NCBI). Treatment includes use of corticosteroids, inhalers, or
Nebulizers. They can be used to prevent or treat asthma attacks. Being obese has been shown to increase risk for asthma.

 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 atenolol Concentration Dosage Amount 25 mg

Route oral Frequency daily

Pharmaceutical class beta blocker Home Hospital or Both
Indication used to treat hypertension
Adverse/ Side effects decreased sex drive, fatigue, slow heartbeat, anxiety, insomnia, shortness of breath, nausea, stomach pain, dark urine, jaundice, depression
Nursing considerations/ Patient Teaching do not stop taking suddenly or without talking to doctor first, monitor heart rate and BP, avoid taking alcohol, continue using
even if you feel better, take with a glass of water and at same time everyday, you still need proper diet and exercise to increase benefits of this medicine

azithromycin (Zithromax IV) 500mg/250mL 500 mg

IV Q24hr
Antibiotic Hospital
Treat many types of infections by killing bacteria, patient is receiving because of possible respiratory infection
Tachycardia, diarrhea, stomach pain, nausea, vomiting, severe dizziness, syncope, loss of appetite, jaundice, swelling of face or tongue, headache,
allergic reaction, do not take with blood thinners such as Coumadin or warfarin
Nursing considerations/ Patient Teaching

Enoxaparin/Lovenox 40 mg/0.4mL 40 mg
SC daily
Antithrombotic, low molecular weight heparin Hospital

University of South Florida College of Nursing – Revision September 2014 3

Indication: prevent DVT or pulmonary embolism while in hospital due to decreased physical activity and increased risk of blood clots
Bleeding, edema, easily bruising, bloody stools, coughing up blood, pale skin, tachycardia, nausea, diarrhea, fever, sudden weakness, severe headache, dyspnea, atrial
fibrillation, hyperlipidemia, renal dysfunction, hematuria, pneumonia
Nursing considerations/ Patient Teaching: be careful when shaving or brushing teeth – use an electric razor to decrease risk of bleeding, avoid contact sports, keep
medication away from moisture or heat, tell any doctor or surgeon that you are taking this medication, do not inject medication in the same spot more than once

Methylprednisolone 40 mg/1 mL 40 mg
IV push Q8hr
corticosteroid Hospital
Indication: “prevents the release of substances in the body that cause inflammation” (Drugs.com) helps with patient’s asthma attack
Adverse/ Side effects: hallucinations, blurred vision, bradycardia, cardiac arrest, cataracts, glaucoma, peptic ulcer disease, dyspepsia, anorexia, nausea, vomiting,
hemorrhage, abdominal distention, hypokalemia, fluid retention, thrombocytopenia, depression, behavioral changes, erythema, bruising, thinning scalp hair
Nursing considerations/ Patient Teaching: be sure to visit an eye doctor yearly, increase intake of potassium with specific foods or supplements, avoid contact with people
who may have an infection, suddenly stopping can cause withdrawal symptoms, avoid grapefuit

Tylenol (acetaminophen) 2 tablets 325 mg

oral PRN
Pharmaceutical class: analgesic Both
Pain reliever and fever reducer, Use if patient reports headache and requests Tylenol
Adverse/ Side effects: fatigue, nausea, vomiting, hematuria, rash, hives, sore throat, ulcers in mouth, diarrhea, stomach pain, constipation, pruritis, pleural effusion,
hypoxia, tachycardia, pulmonary edema
Nursing considerations/ Patient Teaching: avoid taking this with alcohol because it can cause serious liver damage, report to HCP if you have loss of appetite, jaundice,
joint pain

Albuterol 1.25 mg/ 3 mL 1.25 mg

nebulizer PRN for coughing and wheezing
Bronchodilator Both
Indication: “relaxes muscles in the airways and increases airflow to the lungs” (drugs.com)
Adverse/ Side effects: tachycardia, palpitations, tremors, blurred vision, anaphylaxis, restlessness, irritability, anxiety, paradoxical bronchospasm, diabetic ketoacidosis,
Nursing considerations/ Patient Teaching: store at room temperature, avoid exposing medication to moisture or extreme temperature, can explode if exposed to fire

Losartan Once Dosage Amount 50 mg

oral daily
Angiotension II receptor antagonist Both
Indication: used to treat patient’s hypertension and increase blood flow
Adverse/ Side effects: upper respiratory infection, dizziness, dyspepsia, stomach pain, dry mouth, constipation, rhabdomyolysis, renal failure, vertigo, tinnitus, ataxia,
edema, orthostatic hypotension, hyperkalemia, anorexia, gout, MI, insomnia, anemia, urticaria, ecchymosis, UTI, impotence, blurred vision, nocturia
Nursing considerations/ Patient Teaching: patient is at an increased risk of falls, caution if patient has diabetes, do not take if you have kidney or liver disease, avoid if
pregnant, take with or without food, continue use even if you feel well, monitor blood pressure

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
University of South Florida College of Nursing – Revision September 2014 4
Diet ordered in hospital? Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Frosted Mini Wheats or Special K with Naked green juice

Lunch: “whatever the kids eat at my daughter’s house” – Totino’s

Pizza; McDonald’s fish fillet sandwich with mother-in-law
Dinner: “whatever I cook” – Hamburger Helper, hot dog, Taco Bell
Fridays, or ham with beans and rice when grandma visits
Snacks: Oatmeal cake, walnuts with pecans and honey, vitamins

Liquids (include alcohol): 1 soda in Styrofoam cup, milk with cereal, water with
Lemon, V12
The patient is not consuming fruits and vegetables on a daily
basis, so she is not getting adequate nutrients that she needs. She
is eating a lot of prepared foods and fast foods, so clearly she has
a high sodium diet. The patient should decrease her sodium
intake, because it will make her hypertension worse. The only
dairy she is consuming is the milk she has with her cereal in the
mornings. She might not be getting enough grains because she
did not mention anything other than the cereal that might have
grains. She does take vitamins and drink water, but she should cut
out soda from her diet.

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
“My son and husband take care of me, and my daughter will too when she isn’t busy with her kids, work, and husband”
How do you generally cope with stress? or What do you do when you are upset?
Mother-in-law is a stressor, so patient will leave the room and try to calm herself down without saying something to MIL.
When patient is upset, she will think things through and apologize.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Seeing MIL treat husband’s grandmother makes patient extremely upset because she is close to the grandma.
Depression seems to come and go, but it returns because of MIL who lives next door and makes things worse.
Patient has difficulty making time with friends, so socialization is through social media.

+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? ____yes, ex_____

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
____yes, ex was very abusive______ If yes, have you sought help for this? __yes, friends and family were supportive__

Are you currently in a safe relationship?

Yes, very close to husband and has happy relationship

University of South Florida College of Nursing – Revision September 2014 5

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s 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 Erickson’s developmental stage for your
patient’s age group:” During middle adulthood (ages 40 to 65 yrs), we establish our careers, settle down within a relationship, begin
our own families and develop a sense of being a part of the bigger picture. We give back to society through raising our children, being productive at
work, and becoming involved in community activities and organizations. By failing to achieve these objectives, we become stagnant…”
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
Patient is empathetic towards her husband’s grandma who is very elderly. Patient has been in a happy marriage for 20 years, and she
Has 2 children who are doing well. She is happy as a housewife and enjoys taking care of her family.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
This hospitalization has prevented her from being able to care for her family and husband’s grandma. Patient is very close to the
Grandma, so her family could not tell the grandma that the patient was in the hospital because she would become upset

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“I think it is because of when I was a baby” Patient had pneumonia when she was only 6 months old and believes it may
Have scarred her. She has had a history of breathing problems ever since she could remember.

What does your illness mean to you?

“It means I have no control of my breathing, you know, it’s very scary.”

+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”
Low libido, but husband is very patient, has to reassure him that it is not because of him
Have you ever been sexually active?___yes___________________________________________________________
Do you prefer women, men or both genders? ____men___________________________________________________
Are you aware of ever having a sexually transmitted infection? ___________no_______________________________
Have you or a partner ever had an abnormal pap smear?___________no_____________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___________don’t know_______________________

Are you currently sexually active? _________no______________ If yes, are you in a monogamous relationship?
_____yes___________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _____________nothing_______________

How long have you been with your current partner?______20 years______________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? ____hysterectomy_____________

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 6

±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
__________________very important________________________________________________________________________
______________”I think about God everyday”_________________________________________________________________
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? Yes
If so, what? How much?(specify daily amount) For how many years? 11 years
Yes, cigarettes 1 pack a day, sometimes 1.5 (age 17 thru 28 )

If applicable, when did the

Pack Years: 17
patient quit?
23 years ago
Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? yes
so, what, and how much? Yes, husband smokes 2 pack/day If yes, what did they use to try to quit? Nicotine patch
Daughter smokes whenever she is stressed, both use cigarettes

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes
What? Hard liquor How much? For how many years?3
Volume: 1 bottle Started at marriage
Frequency: every week
If applicable, when did the patient quit?
Quit 3 years into marriage

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
If so, what? marijuana
How much? For how many years? “Just a couple”
“not much” (age teens thru 20 )

Is the patient currently using these drugs?

If not, when did he/she quit? Age 20/21 because pregnant with son
No

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Sliced finger open but got stitches

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

University of South Florida College of Nursing – Revision September 2014 7

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? “it isn’t too bad other than my asthma and hypertension. It could be worse”

Integumentary: hives or rashes during allergic reactions, use SPF 30, bathe daily
HEENT: decreased vision – wears corrective glasses, brush teeth twice daily, visits eye doctor and dentist yearly
Pulmonary: difficulty breathing due to asthma, environmental allergies, pneumonia, last CXR unknown
Cardiovascular: hypertension, last EKG last year
GI: last colonoscopy before 2003, stomach ulcers, appendicitis as teenager
GU: urinates twice daily, UTI years ago
Women/Men Only: no infection of genitalia, does monthly self-breast exam, regular menstrual cycle
Musculoskeletal: injuries and fractures from MVA, arthritis in neck, foot, and back
Immunologic: has had fevers before
Hematologic/Oncologic: does not know blood type
Metabolic/Endocrine: N/A
Central Nervous System: severe headaches
Mental Illness: depression
Childhood Diseases: pneumonia

Menarche at age 13, last gynecology exam at 3/2016, normal mammogram result 1/2015, no DEXA
scoliosis

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Bleeding ulcers, hysterectomy

Any other questions or comments that your patient would like you to know?
None

University of South Florida College of Nursing – Revision September 2014 8

±10 PHYSICAL EXAMINATION:
General survey _________patient is 51 y.o female who is obese with no visible signs of distress____________________
Height ___5’8”______Weight__95.8 kg__ BMI __32.1_____ Pain (include rating and location)___8 - headache_____
Pulse_94__ Blood Pressure (include location)__126/74 R arm_________Temperature (route taken)__36.7 C oral____
Respirations__16____ SpO2 ___96%____ Room Air or O2________O2 2L via nasal cannula______________
Overall Appearance___clean, combed hair, maintain eye contact, no obvious handicap________________________
Overall Behavior_____awake, calm, relaxed, interacts well with others, judgement intact__________________
Speech___clear, crisp diction________________________________________________________________
Mood and Affect__pleasant, cooperative, cheerful, talkative__________________________________________________
Integumentary___skin is warm, dry, intact, no tenting, no rashes, lesions, deformities, evenly distributed/clean hair______
IV Access__18 R AC inserted 7/20; no redness, discharge, edema. IV antibiotic fluids infusing________________
HEENT__symmetric face, thyroid not enlarged, no pain in sinus region, sclera white and conjunctiva clear, PERRLA, EOM intact___
Pulmonary/Thorax__respirations regular/unlabored, chest expansion symmetric, no sputum, lung sounds clear except RLL /LLL___
Cardiovascular__no heaves, lifts, thrills, S1 S2 audible, no s3 S4, no JVD, no murmurs, pulses +2 equal bilateral, no bruits
GIbowel sounds normoactive x4, no bruits, non-tender abdomen, percussion dull over liver and spleen , last BM 7/20 – formed/brown_
GU__clear urine, bathroom privileges without assistance, did not assess genitalia, patient denies problems ____
Musculoskeletal_full ROM in all extremeties w/o crepitus, strength equal bilaterally throughout 5/5, scoliosis, pulses palpable ____
Neurological: patient is awake, alert, and oriented x3, CN 2-12 grossly intact, sterognosis, graphesthesia, and proprioception intact
Active reflexes in all extremeties
Extra: peripheral vision intact, no palpable lymph nodes, no edema or tenderness, symmetric ears no discharge, mucous membranes
Pink, moist and intact, teeth are good, no clubbing, capillary refill less than 3 seconds
±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 Dates Trend Analysis

Potassium levels: 3.4
Normal is 3.5-5
Creatinine is 2.9
(normal is about 1)
7/20/2016 Potassium was low when
patient was admitted, but
patient mentioned taking
one of her meds with K
so this may happen due to
hypertension medication
7/20/2016 Creatinine was low when
patient was admitted,
monitor this
Some hypertension
medications can cause
lowered potassium levels
because it is excreted
more along with sodium
and water
High creatinine levels can
mean possible kidney
disease. It could mean
kidneys are not properly
filtering out waste

University of South Florida College of Nursing – Revision September 2014 9

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled
diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Vitals every 8 hours because that is the normal requirement in this hospital. Patient is on a cardiac diet due to
Her hypertension. An echo is scheduled for today to check on her heart and see if it is functioning properly with
Such an elevated blood pressure. She will have a consult with the respiratory therapist to improve her beathing.
No accuchecks are needed.

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

1. Ineffective breathing pattern related to bronchospasm as evidenced by shortness of breath, patient states
Difficulty breathing, and diagnosis of acute asthma exacerbation

2. Anxiety related to change in health status as evidenced by patient states feeling no control over breathing

3. Imbalanced nutrition, more than body requirements related to BMI of 32.1 as evidenced by patient’s narrative of
Diet in a normal 24 hour day including many unhealthy foods

4. Activity intolerance related to asthma exacerbation as evidenced by shortness of breath, and patient refusing to get
out of bed due to difficulty breathing, fatigue

5. Risk for constipation related to increased fluid output as evidenced by side effects of medications, low fiber in diet

University of South Florida College of Nursing – Revision September 2014 10

± 15 CARE PLAN
Nursing Diagnosis: ineffective breathing pattern related to bronchospasm as evidenced by SOB, patient states difficulty breathing, asthma
exacerbation
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will experience decreased Administer albuterol and O2 Improve relaxation of respiratory Patient is not experiencing asthma
bronchospasms Therapy via nasal cannula Muscles and increase O2 Exacerbation anymore

Patient will decrease blood Nurse will administer losartan and Medications will treat hypertension Patient has a lower blood pressure
Pressure to normal range (120/80) Atenolol; put patient on cardiac Cardiac diet will improve effects That is in a normal range (126/74)
diet Of the medication

Patient will have normal Nurse will monitor respiratory A normal respiratory rate without Patient has rate that is within the
Respiratory rate and no pain Rate and identify use of accessory Use of accessory muscles indicates Normal limits and does not use
Muscles for breathing Patient is breathing normally Accessory muscles or report pain
Position patient in semi-fowler This position increases air flow

Patient will not report shortness of Nurse will administer O2 therapy Improve the amount of 02 the Patient does not have SOB
Breath or difficulty breathing Through nasal cannula 2 Liters Patient has so that they can breathe
Include a minimum of one
Long term goal per care plan
±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
X Dietary Consult (learn how to eat a proper diet to help with improving patient’s blood pressure)
□PT/ OT
□Pastoral Care
□Durable Medical Needs
□F/U appointments
X Med Instruction/Prescription (renew hypertension medication and get better nebulizer)
 □ are any of the patient’s medications available at a discount pharmacy? X Yes □ No
□Rehab/ HH
□Palliative Care

University of South Florida College of Nursing – Revision September 2014 11

University of South Florida College of Nursing – Revision September 2014 12
 References

McLeod, S. (2013). Erik Erikson. Retrieved July 23, 2016, from http://www.simplypsychology.org/Erik-

Erikson.html

(n.d.). Retrieved July 23, 2016, from https://www.drugs.com/

National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of

Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD):

National Heart, Lung, and Blood Institute (US); 2007 Aug. Section 2, Definition, Pathophysiology and

Pathogenesis of Asthma, and Natural History of Asthma. Available from:

http://www.ncbi.nlm.nih.gov/books/NBK7223/

University of South Florida College of Nursing – Revision September 2014 13

University of South Florida College of Nursing – Revision September 2014 14