UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Liza McGill

MSI & MSII PATIENT ASSESSMENT TOOL .

Assignment Date: 01/23/15

Agency: SMH

1 PATIENT INFORMATION
Patient Initials: P.P

Age: 71

Admission Date: 01/06/15

Gender: Female

Marital Status: Widow

Primary Medical Diagnosis

Primary Language: English

COPD

Level of Education: High School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Receptionist

Pneumothorax

Number/ages children/siblings: Two boys, age 45 & 48; one

brother, age 67
Served/Veteran: NO
If yes: Ever deployed? Yes or No

Code Status: Full Code

Living Arrangements: Patient lives by herself and take care of

herself. There is no stairs in the house. Patient is able to walk. She
does not need help taking her medications.

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: 01/06/15
Procedure:
Interventional Radiology for a lung biopsy

Culture/ Ethnicity /Nationality: Patient is Hungarian and German

Religion: Catholic

Type of Insurance: Medicare; AARP Healthcare

1 CHIEF COMPLAINT:
"For a lung biopsy"

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient is a 71 year old female with COPD for some time now has a left-sided lung mass. The lung mass has gotten
enlarged after continuous monitoring as an outpatient despite other non surgical treatments. Patient came to the hospital
on 01/06/15 for a scheduled Interventional Radiology for a biopsy. Unfortunately, patient got pneumothorax during the
procedure which requires her to get a chest tube and had to be hospitalized to resolve the issue. The patient is now on 7
CY in room 724 for continuous monitoring and treatment of chest tube placement. Patient will be placed on 2 liters of
oxygen around the clock and spiriva for shortness of breath.

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

Father

98

Mother

57

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Cause
of
Death
(if
applicable
)
Old age
Thoat
cancer

Asthma

Depression: Prozac 40mg

Arthritis

Doesn't remember

Anemia

Biopsy surgery and Pneumothorax

Environmental
Allergies

01/2015

2
FAMILY
MEDICAL
HISTORY

Operation or Illness

Alcoholism

Tubaligation
Osteoarthritis
Right shoulder arthroscopy
Hypothyrodism
Left shoulder arthroscopy
Hypercholesterolemia
COPD: Spiriva one capsule

Age (in years)

Date
Doesn't remember
Doesn't remember
05/2014
Doesn't remember
08/2014
Doesn't remember
Doesn't remember

Brother
Sister
relationship
relationship
relationship

Comments:

The disease is on the mothers' side of the family.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? Doesn't remember
Influenza (flu) (Date) Is within 1 years? 10/2014

YES

NO

X
X
X
X

University of South Florida College of Nursing Revision September 2014

Pneumococcal (pneumonia) (Date) Is within 5 years? 1/2009

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
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Patient has no know allergies to anything

Medications

Patient has no known allergies to anything

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)
The pathogenesis of Chronic Obstruction Pulmonary Disease (COPD) is based on the abnormal inflammatory
immune response of the lung to the inhalation of toxic particles and gases. COPD refers to a group of
respiratory disorders characterized by chronic and recurrent obstruction of expiratory airflow int he pulmonary
airways. COPD is the fourth leading cause of death in the United States and the sixth leading cause of death
worldwide. The risk factors for COPD include tobacco smoke, occupational dusts and chemical vapors, indoor
air pollution from biomass fuel used for cooking and heating, outdoor air pollution and any factor that affect
lung development. Genetic susceptibilities have been linked to COPD such as polymorphism of genes that code
for tumor necrosis factor, surfactant, protease and antiproteases. Also, an inherited mutation in the alphaantitrypsin gene results in the development of COPD at an early age, even if the individual do not smoke. This
gene only accounts for less than 1% of cases but it still impact prognosis and treatment. COPD is diagnosed by
several ways such as chest xray, sputum gram stain and culture, serum theophyline level, FEV1( volume of air
patient can forcibly exhale in 1 second) to FVC(forced vital capacity), white blood count, arterial blood gas and
an electrocardiogram. The treatment of COPD includes prevention of the progression of the disease, long acting
bronchodilators, oxygen therapy and smoking cessation.

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Concentration
Handihaler
Dosage Amount: one capsule
Route: inhalation
Frequency: daily
Home
Hospital
or
Both X
Pharmaceutical class: Anticholinergic
Indication: COPD
Adverse/ Side effects: dry mouth, tachycardia, urinary difficulty, glaucoma, rash, angioedema
Nursing considerations/ Patient Teaching: Advise patient to notify health care provider immediately if angioedema. To
rinse mouth after using inhaler. Instruct patient of proper use of inhaler and to take as directed.
Name: Spiriva

University of South Florida College of Nursing Revision September 2014

Name: Alendronate

Concentration: 35mg

Route: By mouth

Dosage Amount: 1 Tablet

Frequency: weekly

Pharmaceutical class: Biphosphonates

Home X

Hospital

or

Both

Indication: Postmenopausal

osteoporosis, corticosteroid-induced osteoporosis

abdominal pain, blurred vision, photosensitivity, asthma exacerbation
Nursing considerations/ Patient Teaching: Instruct to take exactly as directed first thing in the morning before breakfast.
To take with plain water as juices and caffeinated beverages decreases absorption. To remain upright for
30 minutes after taking. To discontinue and notify provider if pain or difficulty swallowing.
Adverse/ Side effects: Headache,

Name: Prednisone
Route: By

Concentration: 10mg

mouth

Dosage Amount: Tapering

Frequency: 2

Pharmaceutical class: Corticosteroidal

Home

Hospital

doses

once a day

or

Both X

Indication: Inflammatory,

autoimmune disorders, allergic

adrenal suppression, increase intraocular pressure, peptic ulceration,
depression, weight gain/loss, thromboembolism, hypertension, osteoporosis
Nursing considerations/ Patient Teaching: Instruct on correct way to take medication. Advise to take as directed. To take
missed dose as soon as possible. Do not double dose. Not to stop taking abruptly as may result in adrenal
insufficiency and to notify provider as can be life threatening. Avoid alcohol and eat diet high in protein.
Adverse/ Side effects: hyperglycemia,

Name: Levothyroxine
Route: By

Concentration: 25mcg

mouth

Dosage Amount: 1

tablet

Frequency: daily

Pharmaceutical class: Thyroid

Hospital
or
Both X
preparations
Indication: Hypothyroidism, euthyroid goiters
Adverse/ Side effects: headache, arrhythmias, hyperthyroidism, weight loss, heat intolerance, insomnia
Nursing considerations/ Patient Teaching: Instruct to take at the same time every day. Explain that it does not cure
disorder but provides supplement and therapy is lifelong. Notify provide if any unusual symptoms. The
importance of follow up exams to monitor therapy.
Name: Atorvastatin
Route: By

mouth

Home

Concentration: 40mg

Dosage Amount: 1

tablet

Frequency: daily

Pharmaceutical class: Hmg

Coa reductase inhibitors Home Hospital or Both X

Indication: hypercholesterolemia, myocardial infarction, stroke,
Adverse/ Side effects: insomnia, headache, bronchitis, abdominal cramps, heartburn, hyperglycemia,
rhabdomyolysis, arthritis, rhinitis, dizziness
Nursing considerations/ Patient Teaching: Take as directed. Take missed dose as soon as possible but if more than 12
hours, omit and take the next dose at scheduled time. Avoid drinking more than a quart of grape fruit juice
per day during therapy. Notify provider of any unexplained muscle pain, tenderness or weakness
especially if accompanied by a fever.
Name: Fluoxetine
Route: By

Concentration: 20mg

mouth

Dosage Amount: 1

capsule

Frequency: daily

Pharmaceutical class: Selective

serotonin reuptake
Home
Hospital
or
Both X
inhibitor
Indication: depressive disorder, obsessive compulsive disorder, panic disorder
Adverse/ Side effects: Neuroleptic malignant syndrome, seizures, suicidal thought, anxiety, cough, increase
sweating, dry mouth, dizziness, weakness, mania
University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching: Instruct

to avoid driving as may cause dizziness, blurred vision. To look for

suicidality, panic attacks, insomnia, aggressiveness, mania and notify provider immediately. Avoid taking
other CNS depressant and alcohol. Caution when changing position as cause dizziness. To rinse mouth
frequently. Important to follow up.
Name: Xanax
Route: By

Concentration: 0.25mg

mouth

Dosage Amount: 3

Frequency: As

Pharmaceutical class: Benzodiazepine

Indication: Anxiety,

Home X

Hospital

tablets

needed

or

Both

panic disorder, anxiety associated with depression, insomnia associated with anxiety
vision, dizziness, drowsiness, constipation, rash, weight gain, nausea, paradoxical

Adverse/ Side effects: blurred

excitation
Nursing considerations/ Patient Teaching: Take

miss dose within 1 hr, otherwise skip and take scheduled dose. May cause
dizziness and drowsiness so avoid driving. Teach how to reduce risk of falls. Avoid drinking grape fruit
juice. Avoid the use alcohol and other CNS depressants.
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Analysis of home diet (Compare to My Plate and
Diet ordered in hospital? Regular diet
Diet patient follows at home?
Consider co-morbidities and cultural considerations):
24 HR average home diet:
According to My Plate a healthy diet consists of fruits,
vegetables, whole grain, fat free or low fat milk, lean meat,
poultry, fish, beans, eggs, nuts, and is low in saturated fat,
cholesterol, trans fat, sodium and sugar. When I compare
my patient diet with that of the recommended, my patient

should incorporate more foods richer in fibers because

they help prevents constipation. Although peanut is
high in protein it is still not enough protein
recommended. My patient is getting the
recommended amount of fruits and vegetables. Based
on my patient health issues she could incorporate more
calcium by choosing 2% or 1% milk to her snacks or
meal. Overall, it looks as is my patient is doing her best to
incorporate a little of what recommended of the food group.
She has minimal adjustment to do.
Breakfast: 1 small bowl of rice crispy cereal or prepackage
oatmeal with 1 small apple or banana
Lunch: Meals on wheels(fruits, vegetables, protein, dairy,
grains) Patient states meal is balanced as from every food
group.
Dinner: 1 peanut butter and jelly sandwich and cereal
Snacks: chocolate pudding and whip cream
Liquids (include alcohol): 1 cup orange juice, 24 ounces of
water
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 a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? "Unfortunately my sister-in law"
How do you generally cope with stress? or What do you do when you are upset?
"I cry a lot"

University of South Florida College of Nursing Revision September 2014

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
"Last year my younger son came to live with me and got back and drugs and drinking. He cleaned out my bank account
and sold and pawn out all my valuables. I locked him for 3 years and this makes me depress and sad."

+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? Patient is not in a relationship.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. X

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:

According to the text Integrity verses Despair is when older people in adulthood must look back over their life
to see if they have accomplished what they set out to do. It states that base on that acknowledgement older
people who know they have lived a full life is not afraid to die and is in a state of integrity, but those who have
serious regrets about some choices made are terrified of death and feel a sense of despair (Belsky, 404).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is in the despair half of Integrity VS despair stage of life. My patient states she is sad about her life and that
she feels alone and homebound. She states that cries a lot as she feels depressed about some choices and some things she
allowed to happen. My patient does not outwardly shows these feelings but based on what my patient said I observed and
confirmed the findings in her behavior when I was interviewing her. She still tries to stay optimistic as she states that she
is trying to make the best of her life what's left of it.

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

I believed my patient current condition plays a big role in her stage of life. My patient had smoked for years and now its
impacting her life in a negative way.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
"My smoking"

University of South Florida College of Nursing Revision September 2014

What does your illness mean to you?

"No quality of life, I can't go or do many things, so I feel alone and home bound, sad"

+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? _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? __No____________________________
Are you currently sexually active? _No_____________________If yes, are you in a monogamous relationship?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _Not Applicable_________________________________
How long have you been with your current partner?__Not Applicable___________________________________
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?
N0

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

What importance does religion or spirituality have in your life?
___" Very little"________________________________________________
______________________________________________________________________________________________________
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? Cigarette
How much?(specify daily amount)
1 pack a day

X Yes
No
For how many years? 25 years
(age 13

thru 40

If applicable, when did the

patient quit? 30 years

Pack Years:25
Does anyone in the patients household smoke tobacco? If
so, what, and how much? NO

Has the patient ever tried to quit? YES

If yes, what did they use to try to quit? Just stop

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? N/A
How much?
Volume:
Frequency:
If applicable, when did the patient quit?

Yes

X No
For how many years?
(age

thru

University of South Florida College of Nursing Revision September 2014

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks; NO

5. For Veterans: Have you had any kind of service related exposure? NO

10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
X Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:
Other:

Be sure to answer the highlighted area

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

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
X Tumor- Left lung
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

x/day

Hematologic/Oncologic

Metabolic/Endocrine
2 x/day
2 x/year

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

Pulmonary
Difficulty Breathing
Cough - dry or productive
X Asthma
Bronchitis

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
X Monthly self breast exam

CVA
Dizziness
Severe Headaches

University of South Florida College of Nursing Revision September 2014

Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 1/23/15
Other:

Frequency of pap/pelvic exam

Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
X menopause
age? 60
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

Cardiovascular
Hypertension
X Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other:

Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
X Depression
Schizophrenia
X Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
X Weakness
X Pain
Gout
Osteomyelitis
X Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health? " Not good"

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

10 PHYSICAL EXAMINATION:
General Survey:

Height: 5ft 5in

Pulse82
Respirations: 18
SpO2: 97

Weight: 161lb
BMI
Blood Pressure: (include location):
138/72 on left arm
Is the patient on Room Air or O2: 2

Pain: (include rating and

location) 5, where chest
tubes are

Temperature: (route
liters nasal canal
taken?) 98.5, oral
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]

University of South Florida College of Nursing Revision September 2014

10

X 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]
X awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
X clear, crisp diction
Mood and Affect: X pleasant X cooperative X cheerful
talkative
X quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
X Skin is warm, dry, and intact X Skin turgor elastic X No rashes, lesions, or deformities
X Nails without clubbing X Capillary refill < 3 seconds X Hair evenly distributed, clean, without vermin

X Central access device Type: 22 Gauge

Fluids infusing? X no
yes - what?

Location: Right hand

flat
loud

Date inserted: 01/21/15

HEENT: X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ
Trachea midline
X Thyroid not enlarged
X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge
X 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
X Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
X Nose without lesions or discharge X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:
Pulmonary/Thorax: X Respirations regular and unlabored
Transverse to AP ratio 2:1 X Chest expansion
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL
LUL
RML
LLL-dimished sounds
RLL
CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent

University of South Florida College of Nursing Revision September 2014

11

Cardiovascular: X No lifts, heaves, or thrills

Heart sounds: X S1 S2 audible X Regular
Irregular
No murmurs, clicks, or adventitious heart sounds X No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

X Calf pain bilaterally negative X Pulses bilaterally equal [rating scale: 0-absent, 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: legs- mild
pitting
X non-pitting
X Extremities warm with capillary refill less than 3 seconds
GI
X Bowel sounds active x 4 quadrants; no bruits auscultated
X No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
X Abdomen non-tender to palpation
Last BM: (date 01 / 23 / 15
)
X Formed Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

X Not assessed, patient alert, oriented, denies problems

GU
Urine output: X Clear
Cloudy
Color: yellow
Foley Catheter
Urinal or Bedpan X Bathroom Privileges
CVA punch without rebound tenderness

Previous 24 hour output:

without assistance

mLs N/A

or X with assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

X 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]

X vertebral column without kyphosis or scoliosis

X Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Neurological: X Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
X CN 2-12 grossly intact
X 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):

Lab
Potassium
Glucose

Dates

Trend
4.1
109

Analysis
Need to be monitor as
patient on meds that may
decrease it level
Patient on medications
that can increase its level

University of South Florida College of Nursing Revision September 2014

12

Hematocrit

32.1

Chest Xray

Normal

Sodium

136

It is necessary to monitor
HGB when taking certain
medication that affects
blood.
Series ordered as for
chest tube
Patient takes medication
that will affect serum
level

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,

multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
Diet: Regular
Vitals: Temp: 98.5, SPO2: 99 on 2L O2, B/P: 138/72, Pulse: 82, RR: 20
Activity: Bathroom privileges with assistance
Diagnostic test: Chest Xray (portable)
Consult: Case Manager, Pulmonary consult
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Risk for infection related to invasive procedure (NANDA 480)
2. Risk for ineffective airway clearance (NANDA 129)
3. Risk for ineffective coping (NANDA 262)
4. Anxiety (NANDA 138)
5.

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 15 CARE PLAN
Patient Goals/Outcomes
Patient will remain free from
symptoms of infection

Nursing Diagnosis: Nursing Diagnosis goes here

Nursing Interventions to
Rationale for Interventions
Achieve Goal
Provide References
Observe and report signs of
Fever is often the first sign of
infection such as increased
an infection. (NANDA 481)
body temperature

Evaluation of Goal on Day

Care is Provided
No sign of infection as temp
was 98.5F

Patient will demonstrate how to

cough effectively (short term
goal)

Encourage patient to use

Incentive Spirometer

A study showed that using

Patient showed to used I.S
respiratory bundle that includes effectively and breathing was
a I.S. decrease the risk of
clear.
patient been transfer to a critical
care for respiratory issues
(NANDA 130)

Patient will use effective coping

strategies ( Long term goal)

Explore with patient previous

as to handle stress

A psychoeducation that
includes client ways of coping
strategies used before showed
significant improvement of
depression (NANDA 262)

Patient showed signs of

improvement with smiles but
states she is still depress. Will
continue to work with patient
until discharge.

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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:
X SS Consult - for discharge planning in 2 days
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
X F/U appointments
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? X Yes No
X Rehab/ HH
Palliative Care

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References
Belsky, J. (2010). Experiencing the lifespan (2nd ed.). New York: Worth Publishers
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: an evidence-based guide to planning care (Tenth ed.). Maryland
Heights, Missouri: Mosby Elsevier

"MyPlate.gov" Super Tracker. United States Department of Agriculture, n.d. Web. 4 July 2014.
<https://www.supertracker.usda.gov/foodtracker.aspx
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software].
Daviss Laboratory and Diagnostic Tests (Complete Blood Count; Potassium, Blood). Nursing Central.
Retrieved from http://www.unboundmedicine.com/products/nursing_central

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