UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Pamela Chong

MSI & MSII PATIENT ASSESSMENT TOOL .

Agency: VA

1 PATIENT INFORMATION
Patient Initials:

TC

Gender: male

Assignment Date: Nov 4, 2014

Age: 66

Admission Date: Oct 27, 2014

Marital Status: married

Primary Medical Diagnosis: Ascites

Primary Language: English

Level of Education: High School, graduated

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Certified Aircraft welder, retired

Cellulitis

Number/ages children/siblings: Son, 34; step son, 44.

1 brother, 1 sister
Served/Veteran: Airforce
If yes: Ever deployed? Yes, Vietnam

Code Status: full code

Living Arrangements: Patient lives in a house with his wife. Home

is partially modified for wheelchair accessibility.

Advanced Directives: Yes

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

Culture/ Ethnicity /Nationality: White/American

No surgery on this admission

Religion: Baptist

Type of Insurance: Medicare

1 CHIEF COMPLAINT:
Patient stated Im having some pain and redness at the site where I get drained.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
On October 27, 2014, 66 year old male presented to the Emergency Department with increased abdominal girth and mild
abdominal pain, redness and swelling at the site of paracentesis. Patient states that he was admitted to the VA earlier in the
month (discharged 10/09/14) when he underwent paracentesis for his Non-Alcoholic Steatohepatitis Cirrhosis (NASH).
He states he undergoes this procedure about once a month for his ascites. The onset of the redness and pain was three days
prior to admission. The location is the right, upper quadrant of the abdomen, where paracentesis was performed earlier in
the month. The duration of the pain and swelling has been about four days. Characteristics include mild pain and
tenderness with redness around the area. No aggravating or relieving factors were identified and the patient has not tried
any treatment prior to coming to the hospital. Since patient appeared to have increased abdominal girth, paracentesis was
offered to the patient the night of admission, yet patient declined, stating he would rather do it in the morning. Risks and
benefits of the procedure were explained to the patient and he stated that he understood. Through physical examination, it
was determined that the patient had cellulitis of the abdominal area where paracentesis was performed. Patient is afebrile,
does not complain of fever or chills, and white blood cells were not elevated. Patient was admitted to 4N and is awaiting a
blood culture. Patient is now being treated with oral antibiotics and being monitored on telemetry for his history of Atrial
Fibrillation.

University of South Florida College of Nursing Revision September 2014

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

Father

69

Mother

75

Brother

62

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable
)
Natural
causes
Natural
causes

Environmental
Allergies

Operation or Illness
Ascites; paracentesis
Cirrhosis of the liver; Diuretics
Chronic Pain syndrome; Oxycodone
Complete rupture of rotator cuff, non traumatic
Osteoarthritis;Oxycodone
Hyperlipidemia; Simvastatin
Above the knee amputation of LLE
Peripheral vascular disease
Diabetes Type 2; Insulin/Metformin
Posterior lateral Stent placed
Coronary Artery Disease; modified diet
Atrial Fibrillation; Digoxin and Warfarin
Diverticulosis; modified diet
Anemia; no current treatment

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Date
January 2013
January 2012
May 2012
April 2010
March 2009
July 2007
December 2005
January 2001
January 2001
November 2000
May 2000
July 1998
August 1997
August 1997

Sister
Uncle, maternal

72

Lung
Cancer

Aunt, paternal
relationship

Comments:
Father was 49 when he was diagnosed with diabetes.
Mother had minimal health issues.
Maternal Uncle had lung cancer from smoking, died at age 72.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) 04/18/13
Adult Tetanus (Date) Is within 10 years? 11/07/02-DUE
Influenza (flu) (Date) Is within 1 years? 12/11/13
Pneumococcal (pneumonia) (Date) Is within 5 years? 12/11/13
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Methadone
Morphine 15mg
Heparin

Medications

Type of Reaction (describe explicitly)

Patient becomes disoriented

Patient becomes disoriented/ hallucinates
Heparin induced thrombocytopenia (HIT)

No known allergies to food, tape, latex, etc.

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)
Cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue, typically caused by Staphylococcus aureus.
The infection is caused when the bacterium penetrates through a break in the skin. This may occur as an extension of a
skin wound, as an ulcer, or from furuncles or carbuncles. The area that is infected is usually warm, erythematous, swollen,
and painful. Risk factors for cellulitis include disruption to skin barrier (trauma, infection, insect bites, and injection drug
use), inflammation (Eczema or radiation therapy), or edema due to venous insufficiency and lymphatic obstruction due to
surgical procedures. The elderly, those with diabetes, hypertension, or obesity also hold increased risk for cellulitis.
Recurrent cellulitis may occur in those with compromised immune systems, diabetes, hypertension, cancer, peripheral
arterial or venous disease, chronic kidney disease, dialysis, IV or SC drug use. Cellulitis is typically diagnosed by history
and physical examination. Patients with previous trauma, surgery, human/animal bites all serve as a portal of entry for
pathogens. Patient will often complain of pain, itching and/or burning, fever, chills and general malaise. Physical findings
may include localized pain and tenderness with notable erythema, swelling, and warmth. Labs such as blood cultures,
creatine phosphokinase, C-reactive protein may also be drawn. Increased white blood cells will also indicate an infection.
Cellulitis is generally treated with antibiotics, and may be organism specific. Additional measures such as elevating limb
to reduce swelling and sterile saline dressings or cool aluminum acetate compresses for pain relief may be used. For
severe infections, debridement may be necessary. Strict glucose control is recommended for diabetics. With adequate
antibiotic therapy, the prognosis for cellulitis is good. Patient must be educated to practice good skin hygiene, especially
with minor cuts, and report any skin changes early. (Al-Qahtani, Homsi, & Nour, 2014) (Huether & McCance, 2012)

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

Concentration

Dosage Amount: 100 mg

Route: PO

Frequency: Q12hr

Pharmaceutical class: anti-inefectives/tetracyclines

Home

Hospital

or

Both

Indication: treatment of skin infection

Adverse/ Side effects: benign intracranial hypertension (higher in children), headache, PSEUDOMEMBRANOUS COLITIS, diarrhea, nausea, vomiting, esophagitis,
hepatotoxicity, pancreatitis, hypersensitivity reactions, superinfection
Nursing considerations/ Patient Teaching: Instruct patient to take medication around the clock and to finish the drug completely as directed, even if feeling better. Take
missed doses as soon as possible unless it is almost time for next dose; do not double doses. Advise patient that sharing of this medication may be dangerous. Notify
provider if rash, diarrhea, abdominal cramping, fever, or bloody stools occur. Do not treat with antidiarrheals without consulting provider.
Name: Oxycodone HCL

Concentration

Dosage Amount: 10 mg

Route: PO

Frequency: Q8hr PRN

Pharmaceutical class: Opioid agonists

Home

Hospital

or

Both

Indication: For chronic pain

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, RESPIRATORY DEPRESSION,
constipation, dry mouth, choking, GI obstruction, nausea, vomiting, physical dependence, psychological dependence, tolerance
Nursing considerations/ Patient Teaching: Medication may cause drowsiness or dizziness. Avoid concurrent use of alcohol or other CNS depressants. Advise patient
that oxycodone is a drug with known abuse potential, protect it from theft, do not give to those without Rx.
Name: Digoxin

Concentration

Dosage Amount: 0.125 mg

Route: PO

Frequency: Qdaily in a.m

Pharmaceutical class: digitalis glycosides/ antiarrhythmics

Home

Hospital

or

Both

Indication: For A.Fib

Adverse/ Side effects: fatigue, headache, weakness, blurred vision, yellow or green vision, ARRHYTHMIAS, bradycardia, ECG changes, AV block, SA block,
electrolyte imbalances with acute digoxin toxicity.
Nursing considerations/ Patient Teaching: Teach patient to take pulse and to contact health care professional before taking medication if pulse rate is <60 or >100.
Notify provider if signs of toxicity occur (green halo).
Name: Warfarin

Concentration

Dosage Amount: 6 mg

Route: PO

Frequency: Qdaily at night

Pharmaceutical class: anticoagulants

Home

Hospital

or

Both

Indication: prevention of blood clots, A. Fib.

Adverse/ Side effects: BLEEDING, cramps, nausea, dermal necrosis, fever.
Nursing considerations/ Patient Teaching: Advise patient to report any symptoms of unusual bleeding or bruising (bleeding gums; nosebleed; black, tarry stools;
hematuria; excessive menstrual flow) and pain. Instruct patient not to drink alcohol or take other Rx, OTC, or herbal products, especially those containing aspirin or
NSAIDs, Emphasize the importance of frequent lab tests to monitor coagulation factors
Name: Metformin

Concentration

Dosage Amount:100 mg

Route: PO

Frequency BID

Pharmaceutical class: biguanides/antidiabetics

Home

Hospital

or

Both

Indication: management of type 2 diabetes

Adverse/ Side effects: abdominal bloating, diarrhea, nausea, vomiting, unpleasant metallic taste, LACTIC ACIDOSIS, decreased vitamin B12 levels
NNursing considerations/ Patient Teaching: metformin helps control hyperglycemia but does not cure diabetes. Explain to patient the risk of lactic acidosis and the
potential need for isdiscontinuation of metformin therapy if a severe infection, dehydration, or severe or continuing diarrhea occurs or if medical tests or surgery is required.
Symptoms of lactic acidosis (chills, didiarrhea, dizziness, low BP, muscle pain, sleepiness, slow heartbeat or pulse, dyspnea, or weakness) should be reported to health care
professional immediately.
Name: Insulin Aspart Human

Concentration: 100unit/mL

Route: SubQ

Dosage Amount: 5 units

Frequency: with meals

Pharmaceutical class: Rapid acting antidiabetic/hormones

Home

Hospital

or

Both

Indication: diabetes
Adverse/ Side effects: hypoglycemia, anaphylaxis
Nursing considerations/ Patient Teaching: Instruct patient on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur
Name: Insulin Glargine

Concentration: 100unit/mL

Route: SubQ

Dosage Amount: 90 units

Frequency: BID

Pharmaceutical class: Long acting antidiabetic/hormones

Home

Hospital

or

Both

Indication: diabetes
Adverse/ Side effects: hypoglycemia, anaphylaxis
Nursing considerations/ Patient Teaching: Instruct patient on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur
Name: Spironolactone

Concentration

Dosage Amount: 100mg

Route: PO

Frequency: QID

Pharmaceutical class: Potassium-sparing diuretics

Home

Hospital

or

Both

Indication: Edema associated with cirrhosis

Adverse/ Side effects: DRUG RASH WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL
NECROLYSIS, alopecia, pruritis, hyperkalemia, hyponatremia, hyperchloremic metabolic acidosis,

University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching: Advise patient to notify health care professional if rash, muscle weakness or cramps; fatigue; or severe nausea, vomiting, or
diarrhea occurs. Avoid salt substitutes and foods that contain high levels of potassium.
Name: Simvastatin

Concentration

Dosage Amount: 20mg

Route: PO

Frequency: QID

Pharmaceutical class

Home

Hospital

or

Both

Indication: For hyperlipidemia

Adverse/ Side effects: RHABDOMYOLYSIS, arthralgia, immune-mediated necrotizing myopathy, myopathy ( risk with 80 mg dose) abdominal
cramps, constipation, diarrhea, flatus, heartburn, altered taste, drug-induced hepatitis, dyspepsia, liver enzymes, nausea, pancreatitis
Nursing considerations/ Patient Teaching: Instruct patient to notify health care professional if unexplained muscle pain, tenderness, weakness occurs, especially if
accompanied by fever or malaise.

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.
Diet ordered in hospital? Diabetic diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Patient states that he only Consider co-morbidities and cultural considerations):
eats once or twice a day, yet believes he eats relatively Patients diet lacks fruits and vegetables which are a vital
healthy.
source of nutrients. Patient states he does not eat frequently,
which may lead to hypoglycemia, especially in patients
with diabetes. Patients diet appears to be high in
carbohydrates, which may have a higher glycemic index
that may cause spikes in blood sugar. A diabetic diet
recommends a diet low in carbs and sugar. Rice and beans
and pasta are high carbohydrate foods, I recommend
limiting the amount of carbs consumed and replacing them
with an extra serving of vegetables. A 2000 calories per day
is recommended to move towards a healthier weight.
24 HR average home diet:
Breakfast: patient rarely eats breakfast
My plate recommends eating 2 cups of fruit every day.
Since patient does not include much fruit in his diet, I
recommend eating either 1 cup of fresh fruit or half a cup of
dried fruit. 1 cup of 100% fruit juice also qualifies as a
serving of fruit. If eating dried fruit, try to get some with no
sugar added as this may cause hyperglycemia. Fruits make
excellent snacks.
Lunch: Rice and beans

Patients diet appears to be sufficient in protein. 5.5 oz of

protein is recommended for daily consumption. I
recommend eating protein from sources such as eggs, lean
fish or meat, nuts, or beans. Eat seafood instead of meat or
poultry twice a week.

Dinner: Spaghetti and meatballs

My plate recommends eating 2.5 cups of vegetables every

day. I recommend incorporating more vegetables into the
diet to meet this recommendation. 1 cup of raw or cooked
vegetables or 2 cups of leafy vegetables (i.e salad)

Snacks: patient says he doesnt snack much

3 cups of dairy is recommended every day. My patient

consumes only minimal dairy products. I recommend
incorporating small amounts of yogurt, milk and cheese
into the diet. I recommend non-fat or low-fat dairy
products.

Liquids (include alcohol): 2 cups of coffee, black. 1-2

glasses of water

Drinking plenty of water is good for you. Drinking 8-10

cups of water per day is the recommended amount.
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.

(choosemyplate.gov, n.d)

University of South Florida College of Nursing Revision September 2014

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
Patient states My wife helps as much as she can but she is also disabled.
How do you generally cope with stress? or What do you do when you are upset?
Patient stated I used to smoke a lot of dope. Now, I just try and let it pass and not worry about it.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
No, I havent had any difficulties recently.

+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?__Yes_____________ 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

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

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

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
Erikson believed that as we grow older and become senior citizens, we tend to slow down our productivity, and explore life as a
retired person. It is during this time that we contemplate our accomplishments and are able to develop integrity if we see ourselves as
leading a successful life. If we see our lives as unproductive, feel guilt about our pasts, or feel that we did not accomplish our life
goals, we become dissatisfied with life and develop despair, often leading to depression and hopelessness. (Eriksons Stages of
Psychosocial Development, n.d)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

For my patient, I chose Ego Integrity for the stage of psychosocial development. My patient is in the later stage of his life
where you either feel you have lived a successful life or you feel regret about many things you did or did not do. My
patient spoke highly of his wife and children which leads me to believe that he takes pride in his accomplishments. He
also enjoyed speaking about his career and seemed to take great pride in what he did. My Patient stated that he has lived a
long life thus far, and although he has many health conditions, he is still happy to be alive. This leads me to believe he is
in the Ego integrity rather than the despair stage of development.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

Having several severe and debilitating health conditions is bound to have an impact on ones developmental stage of life.
My patient does have several health conditions but seems to be in good spirits about them. It would be no surprise if
someone in his condition was in the despair stage of development. My patient does make frequent visits to the hospital
and did not seem to be severely affected by this particular visit. I do not believe that this hospitalization had any
significant impact on my patients developmental stage in life because patient remained in good spirits.

University of South Florida College of Nursing Revision September 2014

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states The doctors told me that agent orange may have something to do with many of my illnesses.

What does your illness mean to you? Patient says Theres nothing I can do about it, I just go with the flow.

+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? ____Women_______________________________________________
Are you aware of ever having a sexually transmitted infection? _No_________________________________________
Have you or a partner ever had an abnormal pap smear?__I dont think so.__________________________________
Have you or your partner received the Gardasil (HPV) vaccination? _No_____________________________________
Are you currently sexually active? _No, because of some issues down there__________________________
If yes, are you in a monogamous relationship? _I am in a monogamous relationship___________________ When
sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? _None__________________________
How long have you been with your current partner?_30 years________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _ I have had some erectile
dysfunction, unfortunately.__________________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision September 2014

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

What importance does religion or spirituality have in your life? Patient states my faith is at the very top of my priority list.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_____Not really, but I do believe my faith helps me get through some of the issues I face.
_________________________________________________________________________________________________
______________________________________________________________________________________________________

+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? Cigarettes
How much?(specify daily amount)
3-4 cigarettes/day, used to smoke a
pack per day.
Pack Years: 10
(http://smokingpackyears.com/calculate)

Yes
For how many years? 50 years
(age 13

thru

If applicable, when did the

patient quit? N/A

Does anyone in the patients household smoke tobacco? If

so, what, and how much?
Patients wife also smokes 3-4 cigarettes per day

Has the patient ever tried to quit? Patient says maybe

If yes, what did they use to try to quit? Nothing

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What?
How much? 1-2 beers
Patient states that he used to drink in the past
Volume: 12 oz.
yet only the occasional beer.
Frequency: Socially
If applicable, when did the patient quit?
Patient stated that he has not drank since cirrhosis of the liver in 2012

For how many years?

(age

21

thru

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
If so, what?
Marijuana
How much?
For how many years?
(age
17 thru present
1 joint every couple of days
Is the patient currently using these drugs?
Yes

present

55

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Yes, I was exposed to agent orange. I was also exposed to high heat/fire as a welder.
5. For Veterans: Have you had any kind of service related exposure?
Agent Orange.

University of South Florida College of Nursing Revision September 2014

 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: 30
Bathing routine: every other day
Other: Skin infection on site of
paracentesis

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

Be sure to answer the highlighted area

HEENT

Last colonoscopy? 4 years ago

Other:

Difficulty seeing; corrective lenses

Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
x/day
Routine dentist visits
x/year
Vision screening
Other: Pt has dentures

Genitourinary
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Hematologic/Oncologic

4/day

Anemia
Bleeds easily; Coumadin
Bruises easily
Cancer
Blood Transfusions
Blood type if known: O+
Other:

Metabolic/Endocrine
Diabetes
Type: 2
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? Within 1 year
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias; A. Fib
Last EKG screening, when?

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam? 1x/yr
Date of last prostate exam? March 14
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other: PTSD

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox

University of South Florida College of Nursing Revision September 2014

10

Other:

Other:

Other:

General Constitution
Recent weight loss or gain
How many lbs? 20 lbs.
Time frame? 2 days
Intentional? Yes, fluid drainage due to paracentesis.
How do you view your overall health? Fair

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.

University of South Florida College of Nursing Revision September 2014

11

10 PHYSICAL EXAMINATION:
General Survey:
Height: 66 in
Weight: 178
BMI: 28.82
Pain: (include rating and
Pt is A&O x 3,
location)
Pulse: 86
Blood Pressure: (include location)
occasionally grimaces
Pt states he has a pain rating
109/54 cuff automated, right arm
Respirations: 16
with pain. No apparent
of 9 all over his body, and is
signs of distress, no
only slightly relieved with
trouble breathing. Pt is
pain meds.
cooperative.
Temperature: (route
SpO2 : 97%
Is the patient on Room Air or O2
taken?) 98.5 (oral)
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Pt has LLE amputation but is able to transfer from bed to wheelchair with no assistance
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:
Location:
Date inserted:
Fluids infusing?
no
yes - what?
No central line, IV access in left AC
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 /2 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 5 inches & left ear- 5
inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: patient has dentures
Comments:
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: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL- WH
LUL-CL
RML- WH
LLL-CL
RLL -CL
I heard wheezes in some portion of patients lungs, most likely due to history of smoking. Patient had no complaints of

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difficulty breathing
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)
I forgot to obtain an ECG strip on the day of care.

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
3 Carotid:
3 Brachial:
3
Radial: 3
Femoral: 3
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:
no edema
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 10 / 4 / 14 )
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: Pt stated he had some diarrhea but no nausea
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe:
GU
Urine output:
Clear
Cloudy
Color:
yellow
Previous 24 hour output: 1300
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance
CVA punch without rebound tenderness

mLs

Musculoskeletal: Full ROM intact in all extremities without crepitus- YES

Strength bilaterally equal at ___5____ RUE ____5___ LUE ____5___ RLE & ____0___ in LLE (extremity absent)
[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- patient has pain
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 not tested
due to amputation; no tuning fork to test vibration.
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stridegait not tested due to fall risk/amputee
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

No reflex hammer available to test DTR

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10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab

Dates

Trend

WBC

10/27/14

7.73

Na

10/27/14
10/08/14
10/07/14

133 (L)
135 (L)
133 (L)

INR

10/27/14
10/23/14
10/08/14
10/07/14

1.45
1.33
1.59
1.46

Cl

10/27/14
10/08/14
10/07/14
10/27/14
10/07/14
10/06/14
10/27/14
10/07/14
10/06/14

93 (L)
98
99
12.9 (L)
12.2 (L)
12.5 (L)
39.7
37.6 (L)
37.9 (L)

HGB
HCT

Analysis
Patient did not have an
increase in WBC often
associated with infection.
Low sodium may be a
result of cirrhosis of the
liver or a side effect of
diuretics.
Normal INR is 0.88-1.15
yet therapeutic range for
those on Coumadin is 2-3.
Patients INR is low for
therapeutic range.
Low Chloride may also
be due to diuretics.
HGB is slightly low due
to anemia.
HCT is slightly low due
to anemia.

+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.)
Patient is on antibiotic therapy for Cellulitis, pain medication for chronic pain and arthritis, ordered 2000 calorie
diabetic diet, telemetry to monitor A. Fib., blood culture to identify source of infection, vital signs and
accuchecks Q4hrs, up with assistance.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Impaired skin integrity, related to bacterial infection, as evidence by redness and inflammation.
2. Excess fluid volume, related to compromised regulatory mechanism, as evidence by abdominal weight gain.
3. Acute Pain, related to bacterial infection, as evidence by verbal and physical cues.
4. Activity intolerance, related to physical condition and hospitalization, as evidence by AKA.

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5. Risk for injury, related to immobilization during hospital stay.

6.

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 15 CARE PLAN
Nursing Diagnosis: Impaired skin integrity, related to bacterial infection, as evidence by redness and inflammation.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will display improvement
Assess skin daily. Note color, skin
Establishes comparative baseline
Skin and wound was assessed for
in wound or lesion healing in three turgor, circulation, and sensation.
providing opportunity for timely
identification of baseline and signs
days.
Describe and measure lesions and
intervention.
of complications. Unable to
observe changes.
identify any improvement on day
of care.
Patient will demonstrate behaviors Provide and instruct in good skin
Maintaining clean, dry skin
Patient was able to identify
or techniques to prevent skin
hygienewash thoroughly, pat dry provides a barrier to infection.
techniques of proper hygiene and
breakdown and promote healing by carefully, and gently apply lotion or Patting skin dry instead of rubbing ways to prevent further skin
the end of the shift.
appropriate cream.
reduces risk of dermal trauma to
breakdown. Proper techniques were
dry, fragile skin. Massaging
performed while interacting with
increases circulation to the skin and the patient.
promotes comfort. Note: Isolation
precautions are required when
extensive or open cutaneous
lesions are present.
Patient will identify ways to
Cover open pressure ulcers with
May reduce bacterial
Patient was able to teach back ways
prevent future infection of
sterile dressings or protective
contamination and promote
to prevent future infections of
compromised tissue by the end of
barrier, such as Tegaderm or
healing.
impaired skin, including proper
the hospital stay.
DuoDerm, as indicated.
hygiene.
Patient will regain integrity of skin Obtain cultures of open skin
Identifies pathogens and
Skin integrity was not regained on
surface in one month.
lesions.
appropriate treatment choices.
day of care, follow up appointment
needed to assess this long term
goal.
Provide wound care, as indicated:
Protects ulcerated areas from
Cover ulcerated lesions with wetcontamination and promotes
to-wet dressings or Anti-biotic
healing.
ointment and nonstick dressing.
Apply topical or administer
Used in treatment of skin lesions.
systemic drugs, as indicated.
Use of agents, such as
Prederm spray, can stimulate
circulation, enhancing healing
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process. Oral or systemic

medications may be used to treat
the bacteria from within the body.
Nursing Diagnosis: Excess fluid
volume, related to compromised
regulatory mechanism, as evidence
by abdominal weight gain.
Demonstrate stabilized fluid
volume, with balanced intake and
output (I&O), stable weight, vital
signs within clients normal range,
and absence of edema by the end of
the shift

Measure I&O, noting positive

balanceintake in excess of
output. Weigh daily, and note gain
more than 0.5 kg/day.
One liter of fluid retention equals a
weight gain of 1 kilogram
(2.2 pounds).

Assess circulating volume status,

developing or resolution of fluid
shifts, and response to therapeutic
regimen. Positive balance/weight
gain often reflects continuing fluid
retention. Note: Decreased
circulating volume (fluid shifts)
may directly affect renal
function and urine output, resulting
in hepatorenal syndrome.

Patient remained free of edema,

balanced I&O, stable vital signs,
and no significant weight gain
throughout the shift.

Patient will be able to describe

symptoms that indicate need to
consult health care provider by the
end of the hospitalization.

Monitor vital signs as well as CVP,

if available.

Patient understands that if any

difficulty breathing occurs he must
seek medical attention
immediately.

Patient will maintain clear lung

sounds, with no evidence of
dyspnea or orthopnea.

Auscultate lung and heart sounds.

Patient will be able to demonstrate

behaviors to monitor fluid status
and prevent or limit recurrence.

Administer diuretics: loop diuretic

such as furosemide (Lasix),
thiazide diuretic such as

Tachycardia and hypertension are

common manifestations.
Tachypnea usually present with or
without dyspnea. Elevated
CVP may be noted before dyspnea
and adventitious breath
sounds occur. Hypertension may be
a primary disorder or
occur secondary to other associated
conditions such as HF.
Adventitious sounds (crackles) and
extra heart sounds (S3) are
indicative of fluid excess, possibly
resulting in rapid development of
pulmonary edema.
To achieve excretion of excess
fluid, either a single thiazide
diuretic or a combination of agents

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Patients lung sounds remained

clear throughout the entire shift.

Patient recognizes the need for

fluid restriction to reduce the
reoccurrence of ascites. Patient is
17

hydrochlorothiazide (Esidrix), or
potassium-sparing diuretic such as
spironolactone (Aldactone).

Assess for presence and location of

edema formation.

Note presence of neck and

peripheral vein distention, along
with pitting edema, and dyspnea.
Maintain semi-Fowlers position if
dyspnea or ascites is present.
Implement fluid restriction as
ordered, especially when serum
sodium is low.

may be selected, such

as thiazide and spironolactone. The
combination can be
particularly helpful when two
drugs have different sites of
action, allowing more effective
control of fluid excess.
Edema can be either a cause or a
result of various pathological
conditions reflecting four
competing forces: blood
hydrostatic and osmotic pressures
and interstitial fluid
hydrostatic and osmotic pressures.
The dynamic interaction
of these four forces allows fluid to
shift from one body
compartment to another. Edema
may be generalized or
localized in dependent areas.
Elderly clients may develop
dependent edema with relatively
little excess fluid.
Signs of cardiac decompensation
and HF.

able to recognize when he needs to

come in to release the excess fluid.

Gravity improves lung expansion

by lowering diaphragm and
shifting fluid to lower abdominal
cavity.
Fluid restriction may decrease
intravascular volume and
myocardial workload.

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:
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SS Consult
Dietary Consult *
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments *
Med Instruction/Prescription *
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
Patient will be discharged home with home healthcare to do his abdominal dressing changes. Dietary consult may be needed to discuss dietary
limitations due to diabetes as well as possible fluid and sodium restrictions. Follow up appointment needed to inspect progress of wound healing, as
well as fluid status. Patient will be instructed to take all medications as prescribed, paying particular attention to his antibiotics. Patient must be
instructed to take the whole prescription, regardless if he is feeling better.

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References
Ackley, B.J. & Ladwig, G.B. (2014). Nursing diagnosis handbook (10th ed.). Maryland Heights, MO.: Mosby
Al-Qahtani, J., Homsi, A., & Nour, B. (2014). 5-minute clinical consult (23rd ed.). Unbound Medicine, Inc.
Philadelphia, PA: FA Davis Company [Software].
Eriksons Stages of Psychosocial Development. Retrieved from
http://allpsych.com/psychology101/social_development.html [Website]
Huether, S. E., McCance, K. L. (2012). Unerstanding Pathophysiology (5th ed.). St. Louis, MO: Elsevier
United States Department of Agriculture. My plate. Retrieved from http://www.choosemyplate.gov/index.html
[Website]
Valerand, A. H., Sanoski, C. A., & Deglin, J.H. (2013). Daviss drug guide for nurses (13th ed.). Unbound
Medicine, Inc. Philadelphia, PA: FA Davis Company. [Software]

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