Med Surg 2 Pat TT

UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
Student: Tiffany Tran
MSI & MSII PATIENT ASSESSMENT TOOL

1 PATIENT INFORMATION
Assignment Date: 09/06/2016

Agency: TGH SBN
Patient Initials: LG
Age: 71 year old
Admission Date: 09/04/16
Gender: Female
Marital Status: Widow
Primary Medical Diagnosis: Acute liver failure

without hepatic coma (ICD-10-CM: K72.00)
Primary Language: English

Level of Education: Bachelors of Science in business
administration
Other Medical Diagnoses: (new on this

admission) Acute cholecystitis (K81.0),
cholestasis (K83.1), coagulopathy (D68.9),
elevated liver function tests (R79.89), jaundice
(R17)
Occupation (if retired, what from?): Retired director of education of

Seminole Tribe of Florida
Number/ages children/siblings: 2 daughters40 and 44 years old
Served/Veteran: No
If yes: Ever deployed? Yes or No
Living Arrangements: Patient lives on the Seminole Indian
Reservation in Okeechobee in her own home. She lives with her
significant other of 20 years. Patient denies having stairs, area rugs,
or other obstacles that could interfere with her safely navigating her
home. Patient advises her significant other is supportive and can
care for her when she is ill. Additionally, patient states her
daughters and sons-in-law are helping her care for her cattle while
she is hospitalized.
Code Status: Full code

Advanced Directives: No
If no, do they want to fill them out?: Patient
currently declines.
Surgery Date: N/A Procedure: N/A

Culture/ Ethnicity /Nationality: Native American Seminole
Religion: Baptist
Type of Insurance: Medicare, with secondary

insurance from Seminole Tribe
1 CHIEF COMPLAINT: Patient states, I hadnt eaten well most of the summer. Id lost weightabout 10
pounds over 2-3 months. I finally went in to the doctor for all my eating problems. I thought it was gallbladder
issues, but I went to the GI doc and they said I was really sick and it was my liver. I spent Wednesday evening at
the doctor getting tests, then went to Bradenton Hospital. But, I came here because they were nervous about the
condition of my liver, so they sent me here since theyre not specialists.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital
course of stay): Patient was transferred to TGH from Bradenton Hospital on 09/04/16. She presented with jaundice,
general malaise, and diminished appetite. Patient states the onset of her symptoms was some time in June of this year. She
advises the location of her symptoms was epigastric. Regarding the duration of her symptoms, she states that her
symptoms would begin after meals and last for about 1 hour. Patient describes the character of her symptoms as heaviness
and discomfort after eating, malaise, exhaustion, and nausea. Patient denies vomiting, pain or burning. Patient advises the
only aggravator of her symptoms was eating. She advises that nothing relieved her symptoms except lying down after
eating. Patient advises she attempt to treat her symptoms by eating yogurt, but denies trying antacids or hot packs. On a
scale of 0-10 in regards to the severity of her symptoms (0 being no symptoms and 10 being very severe symptoms that
University of South Florida College of Nursing Revision September 2014
made it impossible to function), patient reports that her symptoms were generally a 4 or 5. She advises her symptoms
were tolerable and that she generally pushed through, but that she became too weak to function and, therefore, came in to
see the GI doctor this past Wednesday, August 31, 2016. Patient reports that, upon admission to Bradenton Hospital, her
liver function tests were abnormal and her liver enzymes were high (unable to access patients records from this hospital
to confirm, as TGH was in the process of acquiring these records). Patient reports that there was a biliary duct obstruction
due to a stone (of unknown origin) and that, Thursday, September 1, 2016, she had two stents placed while at Bradenton
Hospital. Patient advises an ERCP and 2 x-rays were done following this procedure (again, this report was unavailable at
this time, as TGH was in the process of acquiring these records). Patients records at TGH states that she appeared
jaundice upon admission/transfer, however, patient does not currently appear as jaundiced. Her sclera are slightly yellow,
however, her skin has returned to an appropriate color for her ethnicity. While at TGH, patient received an MRCP, the
preliminary results of which are below in the labs and procedures section. Once the results of the MRCP are final, the
hepatologist will decide if patient should receive a liver biopsy and/or be evaluated for a liver transplant. In the meantime,
patient is receiving lactulose to reduce her ammonia levels and is having labs drawn frequently (details of which are
below) in order to evaluate liver function.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Father
Unk
Mother
Unk
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
Gout
(angina,
MI, DVT
etc.)
Heart
Trouble
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Cause
of
Death
(if
applicable)
Environmental
Allergies
2
FAMILY
MEDICAL
HISTORY
Operation or Illness
Right elbow fracture (Healed on its own)
Mediport placed
Colon cancer/surgery
Hysterectomy
Appendectomy
Thyroid disease (takes Synthroid)
Hypertension (takes Tenormin)
Alcoholism
2014
12/2012
11/2012
1996
1996
Unknown
Unknown
Age (in years)
Date
Brother
Sister
Unk
relationship
relationship
relationship
Comments: Patient denies knowing ages 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) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
YES
NO
U
U
U
Pneumococcal (pneumonia) (Date) Is within 5 years?

Have you had any other vaccines given for international travel or
occupational purposes?:
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS
Medications
Other (food, tape,
latex, dye, etc.)
NAME of
Causative Agent
Darvon
(propoxyphene)
Type of Reaction (describe explicitly)

Nausea, but no vomiting
Patient denies any food, tape, latex, environmental, dye, or shellfish

allergies.
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 patient was diagnosed with acute liver failure without hepatic coma. Although some of her tests (magnetic
resonance cholangiopancreatography aka MRCP) were still pending, it was suspected that the patients acute liver failure
was secondary to a bile duct obstruction by a calculus. The calculus obstructing the duct was addressed by placing two
stents, however, the patients liver was already in acute failure due to the reserve of toxins that had already accumulated.
The inability to move the bodys toxins overwhelmed this patients liver, sending her into acute liver failure.
_____A patient in acute liver failure will generally present with jaundice (yellowing of the skin, sclera, and even mucous
membranes due to excess bilirubin), malnutrition, and poor clotting. Malnutrition is due to the fact that the liver is
responsible for a large portion of protein synthesis and, similarly, low platelet counts stem from the fact that the liver is
responsible for the synthesis of several clotting factors. Thereby, diagnosis of acute liver failure involves a variety of
blood tests, including tests for liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST),
bilirubin levels, albumin and prealbumin levels, and even platelet levels. If a patient is in acute liver failure, their liver
enzymes and bilirubin levels will be elevated whereas their albumin, prealbumin and platelet levels will be diminished. In
addition to utilizing blood tests, imaging such as ultrasounds, x-rays and MRCPs can be employed. Finally, patients can
receive liver biopsies to aid in the diagnosis. In this patients case, her hepatologists wanted to wait for the results of her
MRCP to finalize before deciding to move forward with a liver biopsy.
_____While diagnosis of acute liver failure is relatively simple, treatment is rather limited. Aside from a liver
transplantation, treatments seem to be merely supportive. For instance, if a patient were suffering from ascites related to
liver failure, diuretics (assuming his kidneys were functional), low-sodium diets and having a periodically scheduled
paracentesis would be used in combination to address this symptom and minimize patient discomfort. Without
transplantation, patients would be at risk for malnutrition, diminished clotting time, jaundice, and death. Even with liver
transplantation, however, patients would be facing a potential myriad of issues, such as the need for careful selfmanagement and to take immunosuppressants for the rest of their lives. Thereby, especially considering this patients age
(71), the hepatologists are carefully evaluating and considering the options before committing to a decision for the plan of
treatment.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF), home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name:alummaghydroxidesimethicone
Concentration:20020020mg/5mL
DosageAmount:30mL
(MAALOXPLUS)
suspension
Route:PO(suspension)
Frequency:Every6hoursPRNIndigestion
Pharmaceuticalclass:Antacids
HomeHospitalorBoth
Indication:Indigestion
Adverse/Sideeffects:Diarrhea,constipation,aluminumtoxicity,magnesiumtoxicity,hypophosphatemia;Seizure
Nursingconsiderations/PatientTeaching:Teachpatienttohydratewhentakingantacidandmonitorpatientsmagnesiumand
phosphatelevels.Ifpatienthasahistoryofseizures,putpatientonseizureprecautions,asthisisoneoftheadverseeffects.
Name:amLODIPine(NORVASC)
Concentration:2.5mgtablets
DosageAmount:2tablets(5mg)
Route:PO(tablets)
Frequency:Daily
Pharmaceuticalclass:Calciumchannelblockers(CCBs) HomeHospitalorBoth
Indication:Hypertension
Adverse/Sideeffects:Peripheraledema,fatigue,palpitations,dizziness,nausea,flushing;anginaexacerbation,MI,acutehypotension,
hepatitis,hypersensitivityreaction
Nursingconsiderations/PatientTeaching:Takepatientsbloodpressurepriortoadministrationaswellasonehourafter
administration.Monitorpatientontelemetry.Monitorpatientforperipheraledema.Teachpatienttocallforhelpwhengettingup,as
couldleadtoorthostatichypotension.
Name:atenolol(TENORMIN)
Concentration:25mgtablets
DosageAmount:2tablets(50mg)
Route:PO(tablets)
Frequency:Daily
Pharmaceuticalclass:Betablockers(BBs)
HomeHospitalorBoth
Adverse/Sideeffects:Bradycardia,hypotension,fatigue,dizziness,coldextremities,dyspnea,orthostatichypotension,bronchospasm,
lightheadedness,lethargy,diarrhea,nausea,vertigo,drowsiness;CHF,severebradycardia,heartblock,anginaexacerbationifabrupt
discontinuation,MIifabruptdiscontinuation,ventriculararrhythmiaduringTxandifabruptlydiscontinued,bronchospasm,
hypersensitivityreaction
Nursingconsiderations/PatientTeaching:Takepatientsbloodpressureandpulseratepriortoadministrationaswellasonehour
afteradministration.Monitorpatientontelemetry.Teachpatienttocallforhelpbeforegettingup.Teachpatientnottoabruptly
discontinuemedication,ascouldcausereboundhypertensionandtachycardia.
Name:furosemide(LASIX)
DosageAmount:20mg
Route:PO(tablets)
Frequency:Daily
Pharmaceuticalclass:Loopdiuretics
HomeHospitalorBoth
Adverse/Sideeffects:Urinaryfrequency,dizziness,nausea/vomiting,weakness,musclecramps,hypokalemia,hypomagnesemia,
orthostatichypotension,ALT/ASTelevated,blurredvision,anorexia,abdominalcramps,diarrhea,hyperuricemia,hyperglycemia,
hypocalcemia,tinnitus,paresthesia,photosensitivity,cholesterolandtriglyceridesincreased;severeelectrolyteimbalance,metabolic
alkalosis,hypovolemia/dehydration,ototoxicity,anaphylaxis,cholestaticjaundice
Nursingconsiderations/PatientTeaching:Takepatientsbloodpressurepriortoadministrationaswellasonehourafter
administration.Monitorpatientselectrolytespotassium,magnesium,ALT/ASTs(particularlyduetohercompromisedliver
function),calcium,uricacid,glucose,BUN,andcreatinine.Holdifpatientspotassiumislow.Monitorpatientforjaundice,particularly
duetohercompromisedliverfunction.Teachpatienttocallforhelpwhengettingup,ascouldleadtoorthostatichypotension.Monitor
patientsfluidintakeandoutputclosely.Besurethatpatientisnearabedsidecommodeorbathroom,asthiswilllikelycauseurinary
frequency.
Name:hydrALAZINE(APRESOLINE)
Concentration:20mg/mLinjection
DosageAmount:0.5mL(10mg)
Route:Intravenous
Frequency:Every4hoursPRNforSBP>150mmHg
Pharmaceuticalclass:Vasodilators/Nitrates
HomeHospitalorBoth
Indication:Moderatetoseverehypertension
Adverse/Sideeffects:Headache,tachycardia,angina,palpitations,nausea,vomiting,diarrhea;MI,severehypotension,neutropenia,
blooddyscrasias,hypersensitivityreaction
Nursingconsiderations/PatientTeaching:Takepatientsbloodpressurepriortoadministrationandagainonehourafter
administration.Monitorpatientontelemetry.Teachpatienttocallforhelpbeforegettingup.Teachpatienttomonitorforsignsand
symptomsofanaphylaxisandreport.
Name:lactulose(ENULOSE)
Concentration:20g/30mLsolution
DosageAmount:20g(30mL)
Route:PO(solution)
Frequency:2timesdaily
Pharmaceuticalclass:Osmoticlaxatives
HomeHospitalorBoth
Indication:Toaidintheeliminationofammonia(duetocompromisedliverfunction)
Adverse/Sideeffects:Flatulence,intestinalcramps,abdominaldistention,nausea,vomiting;Excessivediarrhea,electrolytedisorders,
metabolicacidosis(inexcessivedoses)
Nursingconsiderations/PatientTeaching:Teachpatienttohydrateandwarnpatientofpotentialdiarrhea.Teachpatienttocallfor
helpbeforegettingup.Besurethatpatientisnearabedsidecommodeorbathroom,asthiswilllikelycausediarrheaorfrequentbowel
movements.Monitorpatientselectrolytes.
Name:levothyroxine(SYNTHROID,
Concentration:50mcgtablets
DosageAmount:1tablet(50mcg)
LEVOTHROID)
Route:PO(tablets)
Frequency:Everymorningbeforebreakfast
Pharmaceuticalclass:SyntheticT4
HomeHospitalorBoth
Indication:Hypothyroidism
Adverse/Sideeffects:Palpitations,increasedappetite,tachycardia,nervousness,tremor,weightloss,diaphoresis,diarrhea,abdominal
cramps,insomnia,fever,headache,heatintolerance,nausea,anxiety;Arrhythmias,CHF,hypertension,angina,seizures
Nursingconsiderations/PatientTeaching:Monitorpatientsvitalsfortachycardia.Teachpatientcommonsideeffects(whichmimic
thoseofhyperthyroidism)tomonitorforandtoreportthemimmediately.Monitorpatientsheartontelemetry.
Name:ondansetronHCl(ZOFRAN)
Concentration:4mg/2mLinjection
DosageAmount:4mg(2mL)
Route:Intravenous
Frequency:Every6hoursPRNnausea,vomiting
Pharmaceuticalclass:Selective5HT3receptorantagonists
HomeHospitalorBoth
Indication:Nauseaandvomiting
Adverse/Sideeffects:Headache,constipation,fatigue,diarrhea,hypoxia,fever,urinaryretention,dizziness,agitation,pruritus;
Hypersensitivityreaction,anaphylaxis,bronchospasm,QTprolongation,torsadesdepointes,serotoninsyndrome,extrapyramidal
symptoms
Nursingconsiderations/PatientTeaching:Monitorpatientforelectrolyteimbalancesorarrhythmias.Monitorpatientfor
extrapyramidalsymptomsaswellasfatigueordecreasedrespiratorydrive.Monitorpatientsintakeandoutput,asthismaycause
urinaryretention.Teachpatienttocallforhelpbeforegettingup,asthiscouldcausefatigueanddizziness.
Name:pantoprazole(PROTONIX)
DosageAmount:1tablet(40mg)
Route:PO(tablets)
Pharmaceuticalclass:Protonpumpinhibitors(PPIs)
HomeHospitalorBoth
Indication:Prophylactictreatmentagainststomachulcers
Adverse/Sideeffects:Headache,diarrhea,abdominalpain,nausea,vomiting,dizziness,flatulence,ALT/ASTelevated;
Hypersensitivityreaction,anaphylaxis,pancreatitis,hyponatremia,hypomagnesemia(ifusedlongterm),hepaticimpairment
Nursingconsiderations/PatientTeaching:Donotcrush/cut/chew.MonitorpatientsMglevelifusingforlongtermtreatment.
MonitorpatientsALT/ASTlevels,especiallyduetoheracuteliverfailure.Teachpatienttomonitorforandreportanysideeffects.
Teachpatienttocallforhelpbeforegettingup,asthiscancausedizziness.
Name:phytonadione(vitaminK1)
Concentration:10mg/1mLinjection
DosageAmount:10mg(1mL)
Route:Subcutaneous(injection)
Frequency:Daily
Pharmaceuticalclass:SyntheticvitaminK1
HomeHospitalorBoth
Indication:Tosupplementpatientsfailingliver,asitisacofactorinthehepaticproductionofactivefactorsII,VII,IX,andX
Adverse/Sideeffects:Tastechanges,flushing,injectionsitehematomaorpain;Anticoagulantresistance,hypersensitivity,anaphylaxis
Nursingconsiderations/PatientTeaching:Teachpatientthatshemayexperiencechangeintaste.Teachpatienttomonitorforand
reportcommonsideeffectsandsignsofanaphylaxis.
Name:piperacillintazobactam(ZOSYN)
Route:IVPB(IVpiggyback)
Concentration:3.375ginNaCl0.9%50mL DosageAmount:3.375g/50mL(over
30minutes)
Frequency:Every6hours
Pharmaceuticalclass:Penicillins,extendedspectrum
HomeHospitalorBoth
Indication:Acutecholecystitis
Adverse/Sideeffects:Diarrhea,headache,constipation,nausea,insomnia,rash,vomiting,dyspepsia,pruritus,fever,agitation,
electrolyteabnormalities,LFTselevated;Anaphylaxis,hypersensitivityreaction,serumsicknesslikereaction,superinfection
Nursingconsiderations/PatientTeaching:Monitorpatientsfluidsandelectrolytes,especiallypotassium(aspatientspotassiumis
already3.5mEq/L)andLFTsduetopatientscompromisedliver.Teachpatienttomonitorforandreportcommonsideeffects.
Name:spironolactone(ALDACTONE)
DosageAmount:1tablet(25mg)
Route:PO(tablets)
Frequency:Daily
Pharmaceuticalclass:Potassiumsparingdiuretics
HomeHospitalorBoth
Adverse/Sideeffects:Nausea,vomiting,abdominalcramps/pain,musclecramps,diarrhea,headache,confusion,dizziness,
somnolence,lethargy,breastpain,fever,rash,pruritus,hyperkalemia,metabolicacidosis,hyperuricemia,GIbleeding,gastritis,gastric
ulcer;Anaphylaxis,hepatotoxicity,renalfailure,electrolyteimbalance,arrhythmias
Nursingconsiderations/PatientTeaching:Takepatientsbloodpressurepriortoadministrationandonehourafteradministration.
Monitorpatientselectrolytes,especiallyduetopatientscompromisedliver.Monitorpatientspotassium,asthiscanleadto
hyperkalemia(however,patientspotassiumisalmostlowcurrently3.5).Teachpatienttocallforhelpbeforegettingup,asthiscould
leadtohypotension.Teachpatienttomonitorforandreportcommonsideeffects.
Name:sucralfate(CARAFATE)
Concentration:1gtablets
DosageAmount:1tablet(1g)
Route:PO(tablets)
Pharmaceuticalclass:Cytoprotectants
HomeHospitalorBoth
Indication:Prophylactictreatmentforstomachulcers
Adverse/Sideeffects:Constipation;Hypersensitivityreaction,anaphylaxis,bezoarformation
Nursingconsiderations/PatientTeaching:Teachpatienttohydrateaswellastomonitorforandreportsignsofconstipationor
hypersensitivityreaction.
Name:chlorhexidinegluconate
Concentration:2%towelettes
DosageAmount:6towelettes
Route:Topical
Frequency:Daily
Pharmaceuticalclass:Antibacterials
HomeHospitalorBoth
Indication:ProphylactictreatmentagainstCLABSIsincepatienthasanaccessedMediport
Adverse/Sideeffects:Localirritation;Anaphylaxis
Nursingconsiderations/PatientTeaching:Cleansepatient,avoidingeyesandgenitals.Teachpatienttodothesame.Teachpatientto
monitorforandreportsignsandsymptomsofanaphylaxisorirritation.TeachpatientnottorinseoffwithwaterandtoallowtheCHG
todrycompletely.
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?: Low sodium diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home?: Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: 2 large scrambled eggs (milk added, cooked

with butter), 1 cup corn grits (regular, cooked with salt and
margarine), 1 6 oz container strawberry yogurt (low-fat), 8
oz coffee (flavored)
Lunch: 1 grilled ham and cheese sandwich (made with
margarine), 1 single serving bag of ruffled potato chips (1
oz), 8 fl oz iced tea (brewed, sweetened with low calorie
sweetener)
Dinner: 1 cup spaghetti sauce with ground beef
(homemade), 1 medium slice garlic bread, 1 cup mixed
vegetables (canned, cooked without fat), 8 fl oz iced tea
(brewed, sweetened with low calorie sweetener)
Snacks: 1 6 oz container strawberry yogurt (low-fat), 1
medium banana, 1 plum, 1 cup avocado
Liquids (include alcohol): 20 oz water
The patient advised that, lately, her appetite has decreased

to the point that she rarely ate more than a yogurt per day.
In order to complete the 24-hour average home diet
analysis, the patient decided to recount a typical meal that
she used to eat prior to her current symptoms. As evidenced
by the graphs above, prior to her current symptoms, the
patient met and exceeded her daily total calorie limit
(2213/2000 calories). She consumed 90% of the grain (all
refined), 142% of the vegetable, 66% of the fruit, 77% of
the dairy, and 181% of the protein requirements. The
patient consumed 44/50 g of the daily sugar limit, 29/22 g
of the daily saturated fat limit, and 4719/2300 mg of the
daily sodium limit. The patient consumed a variety of
foods, but her consumption of protein far exceeded that of
dairy and whole fruits. Furthermore, the patient chose
refined grains rather than whole grains. At this point, due to
her diminished appetite, it is paramount, now more than
ever, that the patient chooses high calorie foods/snacks that
will help her balance her nutrition as much as possible. Due
to her low albumin, high protein snacks would be advisable
as well. The dietitian was consulted and agreed to help
patient build a meal-plan prior to her discharge.
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?: Patient states her partner of 20 years lives with her in her home on the Seminole
Indian Reservation in Okeechobee and he takes care of her when she is ill. Additionally, she asserts that her sons-in-law
and her daughters have been helping her feed and care for her cattle since she became weaker during the summer.
How do you generally cope with stress? or What do you do when you are upset?: Patient states that when she is upset
or stressed, she generally lies down. She states she has been more upset lately because she was a very active person who
was always outside, in the woods, feeding and checking her cattle, and the like. Patient states that this summer, when she
began getting weaker, she began coping with her stress and sadness by lying down.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life): Patient
states she is slightly overwhelmed by her recent diagnosis and confused as to what will happen to her if they cannot get
her liver issues addressed and managed. She states that the idea of a transplant is scary for her and that she has been
hoping that she does not need a liver transplant.
+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? ____N/A_______________
Are you currently in a safe relationship?:
Yes. Patient states she is in a very trusting and safe relationship.
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair
Identity vs.
Role Confusion/Diffusion
Trust vs. Mistrust

Intimacy vs. Isolation
Autonomy vs. Doubt & Shame

Initiative vs. Guilt
Industry
Generativity vs. Self absorption/Stagnation
Ego Integrity vs.
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage
for your patients age group: The patient is 71 years old and, thus, is in the late adulthood (also known as maturity) developmental
stage of her life. In this stage of life, a person will be in the psychosocial crisis of ego integrity versus despair. If a person is achieving
ego integrity, she will be accepting responsibility for herself, her decisions, and how they have affected her life. If a person is stalled in
despair, however, she will be unable to be accept responsibility for herself and her life, rendering her unable to grow as a person and
find peace. The patient will be stagnant in despair.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
This patient appears to be achieving success in this developmental stage of her life. She exhibits signs of ego integrity, as evidenced by
her report that she is happy with her life and her health. She reports that she is at peace with her life and that her religion has a positive
influence on her outlook, even in the face of her new diagnosis. Patient appears accepting of her diagnosis and the fact that she is in
the third act of her life. She expresses happiness with her life partner and her decisions to be with him after she became a widow.
Finally, patient expresses comfort in the fact that she lives in a house that is sandwiched between her daughters houses.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: It appears
that this diagnosis has had little impact on the patients ego integrity. As mentioned above, the patient seems accepting of her diagnosis
and has a positive, but realistic outlook on this stage of her life.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?: Patient denies having any true beliefs about the cause of her illness.
She states that her culture does believe that when a family member worries about health issues (in the way a
hypochondriac would), it brings health issues to another family member. In her case, the patient laughed and joked that
perhaps it was her hypochondriac cousin who was killing her with her worries.
What does your illness mean to you?: Patient states that her illness does not mean anything significant to her and that
she is just waiting for her doctors to formulate a plan of action.
+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? ____Yes to the monogamous relationship, no to sexually active_______
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an
unintended pregnancy?: ___N/A_____________________________________________________________________
How long have you been with your current partner?:_____20 years_________________________________________
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?:
Patient denies having concerns about sexual health or how to prevent sexually transmitted diseases.____
1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?: Patient states that spirituality and religion play a very important
role in her life. She states that she attends church every Sunday and Wednesday and encourages her family to do the same. She says
that religion has an extremely positive influence on her life.____________________________________________________________
____________________________________________________________________________________________________________
Do your religious beliefs influence your current condition?: Patient states that her religious beliefs calm her in regards to her
current condition. She states that being able to pray to God makes her feel less anxious. Patient states she is looking forward to her
preacher coming to visit her from the Seminole Indian Reservation in Okeechobee. _________________________________________
+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?: N/A
How much?(specify daily amount):
N/A
Yes
No____________
For how many years?: N/A
(age: N/A
thru: N/A
If applicable, when did the

patient quit?: N/A
Pack Years: N/A

Does anyone in the patients household smoke tobacco? If
so, what, and how much?: No
Has the patient ever tried to quit?: N/A

If yes, what did they use to try to quit?: N/A
2. Does the patient drink alcohol or has he/she ever drank alcohol?:
What?: N/A
How much?: N/A
Volume: N/A
Frequency: N/A
If applicable, when did the patient quit?:
N/A
Yes
No
(age: N/A
thru: N/A
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?: N/A
How much?: N/A
(age: N/A
Is the patient currently using these

drugs? Yes No
thru: N/A
If not, when did he/she quit?:

N/A
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks?: Patient denies
any known exposure to occupational or environmental hazards/risks.
5. For Veterans: Have you had any kind of service related exposure?: N/A (Patient has never been in the service.
10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF: 0
Bathing routine: Daily shower at home
with shower chair (Daily CHG bath at
hospital)
Other: Patients skin was jaundiced upon
Admission, but it is no longer jaundiced.
Patient denies use of sunscreen.
Immunologic
Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Appendicitis
Enlarged lymph nodes
Abdominal Abscess
Other: Patient denies problems with
Last colonoscopy?: 2014
immunologic system.
Other: Patient was jaundiced upon

admission, but is no longer jaundiced.
Patient is experiencing loose stools due to
her lactulose.
HEENT
Difficulty seeing
Wears glasses
Cataracts or Glaucoma: Had cataract
surgery
Difficulty hearing
Ear infections
Genitourinary
Anemia
nocturia (2-3 times a night)

dysuria
hematuria
Sinus pain or infections

Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems: Receding gums
Routine brushing of teeth
2x/day
Routine dentist visits
Hematologic/Oncologic
polyuria
kidney stones
Normal frequency of urination: 3-6x/day
Bladder or kidney infections
Bleeds easily
Bruises easily
Cancer (Colon In remission since
2012)
Blood Transfusions
Blood type if known: Unknown
Other:
Metabolic/Endocrine
Diabetes
Type:
Hypothyroid /Hyperthyroid: Patient

takes Synthroid (since 2006)
Intolerance to hot or cold: Patient
believes that this is a side effect of
chemotherapy.
Osteoporosis
Other:
4x/year
Vision screening
1x/year
Other:
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?: 2 weeks ago in Okeechobee
when she went to the doctor for
constipation
Other: Patient denies having any
pulmonary problems.
Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam: 1/year
Date of last gyn exam?: Unknown
menstrual cycle
regular
irregular
menarche
13 age?
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
menopause
Meningitis
~51
age?: After her
hysterectomy (around 1996)
Date of last Mammogram &Result: 2015

(Per patients, result was normal.)
Other: Patient denies problems with CNS
Date of DEXA Bone Density & Result:

2006 (Per patients, results were normal.)
MEN ONLY
Cardiovascular
Hypertension: Takes medication (see
above)
Hyperlipidemia: Takes medication (see
above)
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Infection of male genitalia/prostate?
Depression
Frequency of prostate exam?
Schizophrenia
Date of last prostate exam?

BPH
Urinary Retention
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?: 09/04/16
Other: Patients rhythm is sinus rhythm.
Anxiety
Bipolar
Other: Patient denies mental illness.
Musculoskeletal
Injuries/Fx: Right elbow Fx in 2014
(Per patient, healed on its own.)
Weakness: Secondary to acute liver
failure
Murmur
Mental Illness
Pain
Gout
Osteomyelitis
Arthritis: Slight arthritis in her fingers.
Patient denies taking medication to treat it
Other:
Childhood Diseases
Measles: Patient denies memory of the
disease, but knows that she had it.
Mumps: Patient denies memory of the
disease, but knows she had it.
Polio
Scarlet Fever
Chicken Pox
Other:
General Constitution
Recent weight loss or gain
How many lbs?: Lost 20 pounds
Time frame?: About 3 months (From June to now)
Intentional?: Unintentional
How do you view your overall health?: Patient states she feels pretty healthy, save her liver condition. She states that her
physicians also say she is perfectly healthy except her liver.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?: Patient
denies any further problems that she did not mention.
Any other questions or comments that your patient would like you to know?: Patient denies having any other
questions or comments.
10 PHYSICAL EXAMINATION:
General Survey: Patient Height: 64 in
Weight: 69.3 kg
BMI: 26.2
Pain: Patient denies pain or
appears groomed,
Pulse: 70 (monitor)
Blood Pressure: 122/62 (79) taken discomfort at present.
appropriate and is not in Respirations: 25
automatically on left arm
distress.
Temperature: 98.2 F
SpO2: 99%
Is the patient on Room Air or O2:
Room air
oral
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
talkative
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
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: Mediport
Location: Right chest
Date inserted: Accessed 09/05/16
Fluids infusing?
no
yes - what? NaCl 0.9% at 5mL/hr (KVO)
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / 3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 24 inches & left ear- 24 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Unremarkable dentition. Teeth are straight and none are missing.
Comments: Patients sclera are still slightly jaundiced.
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
Chest expansion symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: clear white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: Lung sounds are clear in all lobes, but diminished (difficult to auscultate). Patient denies dyspnea or history
pulmonary issues.
RUL: D, C
LUL: D, C
RML: D, C
LLL: D, C
RLL: D, C
CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent
Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze):
HR: 70 bpm PR: 0.20 QRS: 0.08 QT: 0.36 Rhythm: Sinus rhythm
No JVD
Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 2+ Carotid: 2+ Brachial: 2+
Radial: 2+ Femoral: 2+
Popliteal: 2+
DP: 2+
PT: 2+
No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: N/A
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
GI
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
Last BM: (date 09/05/2016)
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: Patient denies nausea or emesis currently.
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe: Patient reports hemorrhoids, but denies pain.
GU
Urine output:
Clear
Cloudy
Color: Yellow, concentrated
Previous 24 hour output:
1700 mL
Foley Catheter
Urinal or Bedpan
Bathroom Privileges/Bedside commode without assistance or with assistance
CVA punch without rebound tenderness
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at ____5___ RUE ___5____ LUE ___4____ RLE & ___4____ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
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
Patient deferred the Romberg test (as she has weakness moving about, especially with her active bowels due to the lactulose. Patient
deferred testing of deep tendon reflexes as she felt uncomfortable with the idea. Patients gait is regular, but she shuffles because she is
weak. She ambulated with physical therapy and a gait belt.
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/Diagnostic Test
Loaded X-ray of Endo
Biliary Duct:
This X-ray was performed at
the Bradenton Hospital and the
exact results were still being
loaded into TGHs computer
system. The patient reports
that the X-ray was what
determined that she had a
blockage of her ducts and
deemed it necessary for her to
have 2 stents placed the week
prior to her transfer to TGH.
Magnetic resonance
cholangiopancreatography
(MRCP): The results of this
procedure were still
preliminary, as they had not
been approved, but this was
the information available.
1. Distended gallbladder with
thickened walls and
cholelithiasis. Evidence of
inflammatory changes of the
intra and extra hepatic bile
ducts. These findings may
represent cholecystitis with
concomitant cholangitis as can
occur in the setting of a
recently passed stone. A
secondary possibility of
underlying neoplastic
infiltration cannot be entirely
excluded and warrants further
evaluation by ERCP when
clinically appropriate.
Dates
(Loaded on
09/05/16, 0651)
(09/05/16, 1210)
Trend
Analysis
As stated, while at
Bradenton Hospital, this
X-ray was taken and,
according to the patient,
deemed it necessary for
her to receive 2 stents.
The results of the X-ray

were unavailable for
viewing on the day care
was provided, however,
the patients account
indicates that, perhaps,
this was part of the strain
that put her into acute
liver failure.
Patients preliminary
MRCP results
demonstrated issues with
her liver, gallbladder, and
free fluid in her stomach.
Patients preliminary
results are congruent with
her diagnoses of acute
liver failure and
cholecystitis. Depending
on what the finalized
results report, the patient
will be evaluated for the
necessity of a liver
biopsy.
2. Irregular liver contour

compatible with cirrhotic
changes.
3. Mild-to-moderate free fluid
in the abdomen.
Aspartate transaminase
[AST (SGOT)]:
1. 190 units/L
(09/05/2016, 1102)
2. 187 units/L
(09/06/2016, 0653)
Normal (10 40 mEq/L)
Alanine transaminase [ALT

(SGPT)]:
1. 136 units/L
(09/05/2016, 1102)
2. 131 units/L
(09/06/2016, 0653)
Normal (7 56 units/L)
Total & Conjugated

Bilirubin:
1. 9.8 mg/dL & 7.5 mg/dL
(09/05/2016, 1102)
2. 9.6 mg/dL & 7.3 mg/dL
(09/06/2016, 0653)
Normal total bilirubin (0.3

1.9 mg/dL) & Normal
conjugated bilirubin (0 0.3
mg/dL)
Although extremely
elevated, patients AST
liver enzymes are
trending down when
comparing her lab results
from the morning care
was provided to her lab
results from the afternoon
that she was transferred
to TGH from Bradenton
Hospital.
This downward trend of

the patients liver
enzymes is expected, as
patient had two stents
placed to address her duct
obstruction. The
hepatologists were
pleased with this trend
and advised they would
continue to monitor the
patients liver enzymes.
Although extremely
elevated, patients ALT
liver enzymes are
trending down when
comparing her lab results
from the morning care
was provided to her lab
results from the afternoon
that she was transferred
to TGH from Bradenton
Hospital.
This downward trend of

the patients liver
enzymes is expected, as
patient had two stents
placed to address her duct
obstruction. The
hepatologists were
pleased with this trend
and advised they would
continue to monitor the
patients liver enzymes.
While extremely
elevated, patients total
and conjugated bilirubin
levels were trending
down from the time of
her initial transfer to TGH
to the day care was
provided. Along with the
downward trend of these
results, the patients
jaundice was greatly
decreased (according to
reports of her initial
jaundice) to just a slight
yellow tinge in her sclera.
As patients liver function

was slowly improving
following the placement
of her two stents, it is
expected that her total
and conjugated bilirubin
levels would be trending
down. Her providers and
the hepatologists
consulted were pleased
with this downward trend,
accompanied by an
immense decrease of her
jaundice, and
recommended continued
monitoring of her labs.
Albumin:
1. 1.4 g/dL
(09/05/2016, 1102)
2. 1.5 g/dL
(09/06/2016, 0653)
Normal (3.5 5.5 g/dL)
Although below the

normal range, the
patients albumin was
trending slowly upward
from her initial transfer to
TGH.
Due to the patients

compromised liver
function, her below
normal albumin levels are
expected. Hopefully, as
her liver function
improves, her liver should
be able to synthesize
more albumin and the
trend will continue to be
positive.
Patients magnesium
levels are slightly below
the normal range, but are
slowly trending upward
as her liver is slowly
improving.
As liver disease and liver

failure will generally be
accompanied by
hypomagnesemia, it is not
surprising that the
patients magnesium
levels are slightly below
normal.
Patients platelet counts

are a significant amount
below normal levels, but
they are trending upward
as her liver slowly
recuperates.
Due to the fact that the

liver mediates platelet
production with
thrombopoietin, it is
expected that the patients
platelet counts would be
lower than normal due to
her compromised liver
function.
N/A
Due to the patients

compromised liver and
the potential for hepatic
encephalopathy, it would
be expected that her
ammonia levels would be
tested and monitored as
well. When her provider
was contacted, however,
he advised that it was not
necessary to monitor her
ammonia levels and that
he was not concerned
with them, as they were
Magnesium:
1. 1.3 mEq/L
(09/05/2016, 1102)
2. 1.4 mEq/L
(09/06/2016, 0653)
Normal (1.8 3.0 mEq/L)
Platelet count:
1. 100 thousand cells/mcL
(09/05/2016, 1102)
2. 103 thousand cells/mcL
(09/06/2016, 0653)
Normal(150450thousand
cells/mcL)
Other/Expected Labs:
Ammonia
(Not ordered)
being addressed with the

lactulose.
+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: Low sodium
Vitals: Patient on telemetry monitor as well as continuous pulse oximetry (on room air). Vitals documented
Q4hours
Activity: Activity with standby assistance. Patient has bathroom privileges, but uses the bedside commode for
her safety due to her loose and unpredictable stools (secondary to consumption of lactulose).
Consults: Hepatology (for her acute liver failure, and as part of her potential evaluation for liver transplant),
dietitian (for her inadequate nutrition and diminished appetite), social services (to aid in coordination of her
care with the Seminole Indian Reservations healthcare team), physical therapy (to evaluate and treat patient for
her weakness and impaired mobility during her hospital stay).
Procedures/Scheduled diagnostic tests:
o Daily labs: To continue monitoring patients liver function.__________________________________
o Liver biopsy: Potential liver biopsy, depending on the finalized results of patients MRCP._________
Chlorhexidine gluconate 2% towelettes: Patient has an accessed Mediport on her right chest that requires a
daily CHG bath in order to prevent CLABSI.
15 CARE PLAN
1st Priority Nursing Diagnosis: Imbalanced nutrition, less than body requirements related to decreased appetite with liver disorder as evidenced by
patients decreased albumin level (1.5 g/dL), patient report of uncomfortable, heavy postprandial feeling, patient report of diminished appetite, and
patient report of unintentional weight loss (of 20 pounds in the last 3 months)
Patient Goals/Outcomes
Nursing Interventions to Achieve Goal
Rationale for
Evaluation of Goal on
Interventions
Day Care is Provided
Provide References
By the end of the 10-hour
1. Recognize that patients with acute disease related
1. When a patient is dealing By the end of the 10-hour
shift, the patient will
malnutrition are using more calories and need increased
with an acute disease, he
shift, the patient met the
recognize factors
calories to maintain their nutritional status.
will need more calories in
goal and was able to
contributing to
2. Note laboratory test results as available: serum albumin, order to maintain his
identify her acute liver
underweight.
prealbumin, serum total protein, and electrolytes.
nutritional status.
failure and inadequate
3. Help the patient/family identify the area to change that
2. A serum albumin level of nutrition as contributing
will make the greatest contribution to improved nutrition.
less than 3.5 is considered
factors to her being
4. Build on the strengths in the patients/familys food
an indicator of risk of poor
underweight.
habits. Adapt change to their current practices.
nutritional status.
5. Avoid interruptions during mealtimes; meals should be
3. By identifying patients
eaten in a calm and peaceful environment. Interruptions
area of greatest need, nurse
have a negative effect on patients nutrition.
will be able to help
empower patient to make
the greatest improvement in
the most efficient way.
4. By meeting patient in his
comfort zone and adapting
nutritional teaching to his
needs with his current
habits in mind, the nurse is
more likely to motivate him
to make positive changes to
his diet.
5. Some hospitals have
started a protected
mealtime effort to ensure
that patients are not
disturbed during mealtime.
1. Select appropriate teaching aids for the
1. By considering the
shift, patient will identify

nutritional requirements.
patients/familys background.
2. For the patient who is malnourished and can eat, offer
small quantities of energy-dense and protein-enriched
food, served in an appetizing fashion, at frequent intervals.
3. Suggest community resources as suitable (food sources,
counseling, Meals on Wheels, senior centers).
4. Implement instructional follow-up to answer the
patients/familys questions.
patients/familys
background prior to
choosing teaching aids, the
nurse is more likely to have
a successful interaction with
the patient.
2. Fortified foods, such as
those with increase protein,
were acceptable to patients
if they tasted the same as
regular foods.
3. These community
resources assist patients
who cannot prepare their
own meals in getting the
adequate amount of
nutrition.
4. Following up on the
patients/familys questions
is vital to the process of
evaluating how much the
patient/family learned about
his nutritional requirements.
shift, this goal was met, as

the patient was able to
identify her nutritional
requirements, recognizing
that she needs to eat small
quantities of energy-dense
and protein-enriched food.
By discharge, patient will

consume adequate
nourishment.
1. Monitor food intake; record percentages of served food

that is eaten (25%, 50%, 75%, 100%). Keep a 3-day food
diary to determine actual intake; consult with dietitian for
actual calorie count if needed.
2. Evaluate the intake of the patient using the United States
Department of Agricultures My Tracker online software,
available at
https://www.choosemyplate.gov/SuperTracker/default.aspx
(U.S. Department of Agriculture, 2010).
3. Note laboratory test results as available: serum albumin,
prealbumin, serum total protein, and electrolytes.
4. Weigh the patient daily in acute care, weekly to monthly
in extended care at the same time (usually before
1. Use of a food diary is

helpful for both the patient
and the nurse, to examine
usual foods eaten, patterns
of eating, and presence of
deficiencies in the diet.
2. Evaluating the patients
intake is essential to
determining what his diet is
missing.
3. A serum albumin level of
less than 3.5 is considered
an indicator of risk of poor
As this is a long-term
goal, it was not evaluated
by the end of the 10-hour
shift. The patient will
continue with the plan of
care and this goal will be
evaluated closer to
patients discharge.
breakfast), with same amount of clothing.

5. Monitor for signs of malnutrition, including brittle hair
that is easily plucked, bruises, dry skin, pale skin and
conjunctiva, muscle wasting, marked decrease in body fat,
smooth red tongue, cheilosis, and a flaky paint rash over
lower extremities.
nutritional status.
4. Weighing the patient
daily in acute care enables
the healthcare team to
follow the trend of his
weight, ensuring that any
sudden weight loss or
weight gain is detected.
5. Monitoring for the listed
signs and symptoms will
alert the healthcare team to
patients nutrition status.
2nd Priority Nursing Diagnosis: Activity intolerance related to weakness or fatigue caused by impaired liver function as evidenced by patients slow
and unsteady gait, patient report of weakness and fatigue, and patients report of decreased ability to perform her activities of daily living at home
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
By the end of the 10-hour shift,
1. Refer the patient to physical
1. Physical therapy can suggest
By the end of the 10-hour shift, this
patient will be able to verbalize an therapy to help increase activity
strength training and possible
goal was met, as the patient was
understanding of the need to
levels and strength.
weight training, to regain strength, able to verbalize the need to
gradually increase activity based
2. Slow the pace of care. Allow the increase endurance, and improve
gradually increase her activity.
on testing, tolerance, and
patient extra time to carry out
balance.
symptoms.
physical activities.
2. Slow gait in the elderly may be
3. Allow for periods of rest before
related to fear of falling, decreased
and after planned exertion periods
strength in muscles, reduced
such as meals, baths, treatments,
balance or visual acuity, knee
and physical activity.
flexion contractures, and foot pain.
4. Teach the patient/family the
3. Both physical and emotional rest
importance of and methods for
help lower arterial pressure and
setting priorities for activities,
reduce the workload of the
especially those having a high
myocardium.
energy demand (e.g. home/family
4. With patients weakness, it is
events). Instruct in realistic
important to plan ahead in order to
expectations.
avoid exertional breathlessness and
falls.
By the end of the 10-hour shift,
1. Instruct the patient to stop the
1. These are common symptoms of By the end of the 10-hour shift, the
patient will maintain normal skin
activity immediately and report to
angina and are caused by a
patient goal was met, as the patient
color, and skin is warm and dry

with activity.
the physician if the patient is

experiencing the following
symptoms: new or worsened
intensity or increased frequency of
discomfort; tightness or pressure in
chest, back, neck, jaw, shoulders,
and/or arms; palpitations;
dizziness; weakness; unusual and
extreme fatigue; excessive air
hunger.
2. Obtain any necessary assistive
devices or equipment needed
before ambulating the patient (e.g.
walkers, canes, crutches, portable
oxygen).
3. Use a gait walking belt when
ambulating the patient.
4. When getting a patient up,
observe for symptoms of
intolerance such as nausea, pallor,
dizziness, visual dimming, and
impaired consciousness, as well as
changes in vital signs; manual
blood pressure monitoring is best.
5. Monitor and record the patients
ability to tolerate activity: note
pulse rate, blood pressure, monitor
pattern, dyspnea, use of accessory
muscles, and skin color before,
during, and after the activity. If the
following signs and symptoms of
cardiac decompensation develop,
activity should be stopped
immediately: onset of chest
discomfort or pain; dyspnea;
palpitations; excessive fatigue;
lightheadedness, confusion, ataxia,
temporary insufficiency of
coronary blood supply. Symptoms
typically last for minutes as
opposed to momentary twinges. If
symptoms last longer than 5 to 10
minutes, the patient should be
evaluated by a physician. Pulse rate
and arterial blood oxygenation
indicate cardiac/exercise tolerance;
pulse oximetry identifies hypoxia.
2. Assistive devices can help
increase mobility.
3. Gait belts improve the
caregivers grasp, reducing the
incidence of injuries of patients and
nurses.
4. When an adult rises to the
standing position, blood pools in
the lower extremities; symptoms of
central nervous system
hypoperfusion may occur,
including feelings of weakness,
nausea, headache, lightheadedness,
dizziness, blurred vision, fatigue,
tremulousness, palpitations, and
impaired cognition. Automatic
devices cannot reliably detect or
rule out orthostatic hypotension,
indicating that nurses need to use
manual devices to take accurate
postural blood pressures for
optimal patient care.
5. The above are symptoms of
intolerance to activity and
continuation of activity may result
in patient harm.
was able to ambulate and maintain

normal skin color. Patient reported
weakness, but skin remained warm
and dry.

participate in prescribed physical
activity with appropriate changes
in heart rate, blood pressure, and
breathing rate; maintain monitor
patterns (rhythm and ST segment)
within normal limits.
pallor, cyanosis, nausea, or any

peripheral circulatory
insufficiency; dysrhythmia;
exercise hypotension; excessive
rise in blood pressure;
inappropriate bradycardia; or
increased heart rate.
1. When getting a patient up,
observe for symptoms of
intolerance such as nausea, pallor,
dizziness, visual dimming, and
impaired consciousness, as well as
changes in vital signs; manual
blood pressure monitoring is best.
2. Monitor and record the patients
ability to tolerate activity: note
pulse rate, blood pressure, monitor
pattern, dyspnea, use of accessory
muscles, and skin color before,
during, and after the activity. If the
following signs and symptoms of
cardiac decompensation develop,
activity should be stopped
immediately: onset of chest
discomfort or pain; dyspnea;
palpitations; excessive fatigue;
lightheadedness, confusion, ataxia,
pallor, cyanosis, nausea, or any
peripheral circulatory
insufficiency; dysrhythmia;
exercise hypotension; excessive
rise in blood pressure;
inappropriate bradycardia; or
increased heart rate.
3. Instruct the patient to stop the
activity immediately and report to
the physician if the patient is
1. When an adult rises to the

standing position, blood pools in
the lower extremities; symptoms of
central nervous system
hypoperfusion may occur,
including feelings of weakness,
nausea, headache, lightheadedness,
dizziness, blurred vision, fatigue,
tremulousness, palpitations, and
impaired cognition. Automatic
devices cannot reliably detect or
rule out orthostatic hypotension,
indicating that nurses need to use
manual devices to take accurate
postural blood pressures for
optimal patient care.
2. The above are symptoms of
intolerance to activity and
continuation of activity may result
in patient harm.
3. These are common symptoms of
angina and are caused by a
temporary insufficiency of
coronary blood supply. Symptoms
typically last for minutes as
opposed to momentary twinges. If
symptoms last longer than 5 to 10
minutes, the patient should be
evaluated by a physician. Pulse rate
and arterial blood oxygenation
As this is a long-term goal, it was

not evaluated by the end of the 10hour shift. The patient will
continue with the plan of care and
the goal will be evaluated closer to
the patients discharge.

demonstrate increased tolerance to
activity.
experiencing the following

symptoms: new or worsened
intensity or increased frequency of
discomfort; tightness or pressure in
chest, back, neck, jaw, shoulders,
and/or arms; palpitations;
dizziness; weakness; unusual and
extreme fatigue; excessive air
hunger.
indicate cardiac/exercise tolerance;

pulse oximetry identifies hypoxia.
1. Recognize that malnutrition

causes significant morbidity due to
the loss of lean body mass.
2. Evaluate the patients nutritional
status. Consider a dietitian referral
to assess nutritional needs related
to activity intolerance; provide
nutritional supplements to increase
nutritional level if needed.
3. Provide emotional support and
encouragement to the patient to
gradually increase activity. Work
with the patient to set mutual goals
that increase activity levels. Fear of
breathlessness, pain, or falling may
decrease willingness to increase
activity.
4. Assess the home environment
for factors that contribute to
decreased activity tolerance such as
stairs or distance to the bathroom.
Refer to occupational therapy, if
needed, to assist the patient in
restructuring the home and ADL
patterns.
1. Providing nutrition early helps

maintain muscle and immune
system function, and reduce
hospital length of stay.
2. Improved nutrition may help
increase inspiratory muscle
function and decrease dyspnea.
3. In patients with Parkinsons
disease motivations for exercising
included hope that exercise would
slow the disease or prevent a
decline in function, feeling better
with exercise, belief that exercise is
beneficial, and encouragement
from family members. This could
apply to patients with other
disorders.
4. During hospitalization, patients
and families often estimate energy
requirements at home inaccurately
because the hospitals availability
of staff support distorts the level of
care that will be needed.
As this is a long-term goal, it was

not evaluated by the end of the 10hour shift. The patient will
continue with the plan of care and
the goal will be evaluated closer to
the patients discharge.
3rd Priority Nursing Diagnosis: Fatigue related to malnutrition as evidenced by patients slow and unsteady gait as well as by patient report of
fatigue and diminished ability to perform her normal activities of daily living at home.
4th Priority Nursing Diagnosis: Risk for bleeding related to impaired liver function, vitamin K deficiency, and altered clotting mechanisms
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: Patient is awaiting results of MRCP in order to decide whether or not she will require a liver biopsy. Following this potential test,
patient may need to be evaluated by the transplant committee for a liver transplant. Social services is involved in helping coordinate her care at TGH
with her healthcare provider back at home on the Seminole Indian Reservation. The social worker is also helping arrange patients ride home to
Okeechobee after discharge.
* Dietary Consult: Patient is waiting on a dietary consult to address her inadequate nutrition/diminished appetite secondary to her acute liver
failure and cholecystitis.
PT/ OT: The physical therapists at TGH were consulted and evaluated the patient the day after she was admitted. Patient walked with physical
therapy daily in order to avoid deconditioning while she was hospitalized.
RT: Not applicable
Pastoral Care: Patient denies need for pastoral care. Patient had a pastoral care representative from the local Seminole tribe hospital visit her
while she was hospitalized. Patient declines the offer to complete an advance directive at this time.
Durable Medical Needs
* Transplant Team: Patient may need to schedule procedures for transplant evaluation and a meeting with the transplant board/team if her MRCP
results and, subsequently, her liver biopsy results qualify her thusly.
F/U appointments: Patient may need an outpatient liver biopsy appointment and follow-ups with the transplant team. Patient will need to follow
up with her primary care physician on the reservation for maintenance of her health, in any case.
* Med Instruction/Prescription: Patient may need instruction on the importance of her new medications, like lactulose and vitamin K, in regards to
her liver condition.
Are any of the patients medications available at a discount pharmacy? Yes
No
Rehab/HH
* Palliative Care: Patient may request palliative care to aid her in reestablishing her norm, depending on the results of her procedures.
References
Ackley,B.J.,&Ladwig,G.B.(2014).Nursingdiagnosishandbook:Anevidencebasedguidetoplanningcare(10thed.).MarylandHeights,MO:
MosbyElsevier.
Barrett,K.E.(2014).Functionalanatomyoftheliverandbiliarysystem.InK.Barrett(Eds.),Gastrointestinalphysiology,2ndedition.Retrieved
September17,2016http://accessmedicine.mhmedical.com.ezproxy.hsc.usf.edu/content.aspx?bookid=691&Sectionid=45431411
Epocrates,Inc.(2016).Epocrates(Version16.6)[Mobileapplicationsoftware].Retrievedfromhttp://itunes.apple.com
Halter,M.J.(2014).Relevanttheoriesandtherapiesfornursingpractice.Varcarolisfoundationsofpsychiatricmentalhealthnursing(pp.2224).
SaintLouis:Elsevier.
Huether,S.E.,&McCance,K.L.(2012).UnderstandingPathophysiology(5thEditioned.).St.Louis,MO:ElsevierMosby.
UnitedStatesDepartmentofAgriculture.(2016,Jan7).Choosemyplate.Retrievedfromhttp://www.choosemyplate.gov/MyPlate

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UNIVERSITY OF SOUTH FLORIDA

MSI & MSII PATIENT ASSESSMENT TOOL

Assignment Date: 09/06/2016

Age: 71 year old

Admission Date: 09/04/16

Marital Status: Widow

Primary Medical Diagnosis: Acute liver failure

Primary Language: English

Other Medical Diagnoses: (new on this

Occupation (if retired, what from?): Retired director of education of

Code Status: Full code

Surgery Date: N/A Procedure: N/A

Type of Insurance: Medicare, with secondary

University of South Florida College of Nursing Revision September 2014

Age (in years)

Comments: Patient denies knowing ages of onset.

University of South Florida College of Nursing Revision September 2014

Pneumococcal (pneumonia) (Date) Is within 5 years?

Type of Reaction (describe explicitly)

Patient denies any food, tape, latex, environmental, dye, or shellfish

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014

24 HR average home diet:

Breakfast: 2 large scrambled eggs (milk added, cooked

The patient advised that, lately, her appetite has decreased

University of South Florida College of Nursing Revision September 2014

+2 DOMESTIC VIOLENCE ASSESSMENT

Yes. Patient states she is in a very trusting and safe relationship.

Trust vs. Mistrust

Autonomy vs. Doubt & Shame

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014

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

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

If applicable, when did the

Pack Years: N/A

Has the patient ever tried to quit?: N/A

Is the patient currently using these

If not, when did he/she quit?:

University of South Florida College of Nursing Revision September 2014

10 REVIEW OF SYSTEMS NARRATIVE

Nausea, vomiting, or diarrhea

Chills with severe shaking

Enlarged lymph nodes

Other: Patient denies problems with

Last colonoscopy?: 2014

Other: Patient was jaundiced upon

nocturia (2-3 times a night)

Sinus pain or infections

Hypothyroid /Hyperthyroid: Patient

Central Nervous System

age?: After her

hysterectomy (around 1996)

Date of last Mammogram &Result: 2015

Other: Patient denies problems with CNS

University of South Florida College of Nursing Revision September 2014

Date of DEXA Bone Density & Result:

Infection of male genitalia/prostate?

Frequency of prostate exam?

Date of last prostate exam?

University of South Florida College of Nursing Revision September 2014