UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Danielle Giaritelli

MSI & MSII PATIENT ASSESSMENT TOOL . Assignment Date: 2/10/15

1 PATIENT INFORMATION
Patient Initials:
Gender:

CS
MALE

Agency: FHT

Age: 66

Admission Date: 2/5/15

Marital Status:SINGLE

Primary Medical Diagnosis PLEURAL

EFFUSION

Primary Language: ENGLISH

Level of Education: 10TH GRADE

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Chief Examiner in Nashville,

Tennesee
Number/ages children/siblings:
Daugher-36; Sister-65

PNEUMONIA

Served/Veteran: yes
If yes: Ever deployed? Yes

Code Status: Full Resuscitation

Living Arrangements: Patient lives in a one story mobile home by

himself.

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

Culture/ Ethnicity /Nationality: American

Religion: Spiritual and Methodist

Type of Insurance: Veterans

1 CHIEF COMPLAINT: I woke up with severe chest pain and shortness of breath.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course
of stay)

The patient is a 66-year-old male who presented to the hospital with shortness of breath and severe chest pain.
Three days prior to admission, the patient had driven from Tennessee to Tampa, where he experienced less
severe chest pain as well. The patient stated he knew he shouldnt have driven to Tampa because he was feeling
chest pain earlier, but chose to do it anyways because it was his vacation and he doesnt do it often. On
February 5, 2015, he was admitted to FHT after he woke up with sudden onset of severe and worsening chest
pain. The pain was a pressure like pain in every area of his chest. The pain was constant and just sitting there it
was getting worse. He took his nebulizer treatment and Tylenol at home to try and relieve the pain, but when it
didn't work he called 911. He rated the pain 10/10 for intensity and it stayed that way. He underwent a chest x!1
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ray, which revealed a right moderate pleural effusion. He denies any fever, sweats, blurred vision, and loss of
consciousness at any time. He has a dry cough and is a 50-year smoked who quit a few years ago after being
diagnosed with COPD.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date

Operation or Illness

N/A

COPD AND EMPYSEMA

N/A

HYPERTENSION

N/A

CHRONIC INTERSTITAL LUNG DISEASE WITH EXTENSIVE PULMONARY

EMPHYSEMA

2
FAMILY
MEDICA
L
HISTOR
Y

Ag
e
(in
ye
ars
)

Cause
of
Death
(if
applicable
)

Father

70

Empysem
a

Mother

61

Breast
Cancer

Brother

N/
A

Sister

65

Al
co
hol
is
m

Env
iron
men
tal
Alle
rgie
s

A
ne Art As
m hri th
ia tis ma

Bl
ee
ds
Ea
sil
y

Ca
nc
er

Di
ab
ete
s

Hea
rt
H
Tro
yp
Gl
G
uble
er
au
ou
(angi
te
co
t
na,
ns
ma
MI,
io
DVT
n
etc.)

Kid
ney
Pro
ble
ms

Me
nta
l
Sto
He
ma
alt Sei ch Stro Tu
zur Ul ke
h
mor
Pr es cer
obl
s
em
s

N/A

relationship
relationship

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relationship

Comments: Include age of onset

Sister is still living. Patients mother had a double mastectomy after diagnosed with breast cancer but it spread and she passed.

IMMUNIZATION HISTORY

(May state U for unknown, except for Tetanus, Flu, and Pna)

YES

NO

Routine childhood vaccinations

Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)-Patient didnt understand.
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years? Patient states he has never gotten
the flu shot.
Pneumococcal (pneumonia) 2/10/15
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES

OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

No known allergies to medications, latex, food, tape, or dye.

Medications

Other (food, tape,

latex, dye, etc.)

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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)
A pleural effusion is an accumulation of fluid in the pleural space. It can occur when homeostatic forces that
control the flow into and out of the lungs are disrupted. There is usually an underlying cause that causes the
disruption of fluid, which is how they decide to treat it. It can be a result of excess fluid production or decreased
absorption. The two major classes of pleural effusion are transudates, caused by problem with pleural fluid
formation or absorption, and exudates, commonly caused by bacterial pneumonia and pulmonary embolism.
Because pleural effusions are caused by an underlying cause or disease, it is important to diagnose it looking at
what originally caused the accumulation of fluid. Also, since it is manifestation of another illness, the risk
factors for pleural effusion are those of the underlying disease. Most commonly the treatment used is to treat
whatever is causing the pleural effusion. A thoracentesis may also be used for treatment to remove the fluid and
allow for lung expansion and better function. A chest tube may be played to also help drain and treat empyema.
Along with most of the other topics above, prognosis of a pleural effusion varies because it depends on the
underlying etiology. It is extremely important to catch it early, because it can compromise the airway and also
be malignant, which has a very low prognosis.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: metoprolol (Lopressor)

Concentration N/A

Route PO

Dosage Amount 25mg

Frequency BID

Pharmaceutical class: beta blocker

Home

Hospital

or

Both

Indication: hypertension, angina pectoris, prevention of myocardial infarction, management of stable heart failure, anxiety, ventricular arrhythmias,
tachycardia
Side effects/Nursing considerations: fatigue, weakness, anxiety, depression, memory loss, drowsiness, bradycardia, pulmonary edema, heart failure,
vasoconstriction, blurred vision, stuffy nose, bronchospasm, rashes, back pain, erectile dysfunction, urinary frequency

Name enoxaparin (Lovenox)

Concentration 5mg of enoxaparin sodium and

5000 IU per .01 mL of water for Injection

Route ING-subcut

Dosage Amount 40mg

Frequency daily

Pharmaceutical class anticoagulant

Home

Hospital

or

Both

Indication: prevention of ischemic complications (with aspirin) and venous thromboembolism

Side effects/Nursing considerations: dizziness, headache, edema, nausea, vomiting

Name benzonatate (Tessalon)

Concentration

Route PO

Dosage Amount 200mg

Frequency TID

Pharmaceutical class non-narcotic antitussive agent

Home

Hospital

or

Both

Indication relieve coughing; numbs throat and lungs, which makes the cough reflex less active
Adverse/ Side effects bronchospasm, headache, dizziness, constipation, nausea
Nursing considerations/ Patient Teaching Take with a full glass of water; Store it at room temperature; Make sure you swallow the pill whole because it
causes numbing of the throat and can cause choking if tried to chew

Name fluticasone-salmeterol (Advair)

Concentration

Dosage Amount 200mg

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Route 1 puff inhaled

Frequency BID

Pharmaceutical class corticosteroids

Home

Hospital

or

Both

Indication maintenance and prophylactic treatment of asthma

Adverse/ Side effects headache, dizziness, diarrhea, bronchospasm, cough, nasal stuffiness, muscle pain
Nursing considerations/ Patient Teaching Advise patients using inhalation corticosteroids to rinse mouth after use to prevent oral candidiasis; This drug
isnt to treat an acute asthma attack; Caution patients to avoid smoking, known allergens, and other respiratory irritants.

Name losartan (Cozaar)

Concentration

Route PO

Dosage Amount 25mg

Frequency daily

Pharmaceutical class angiotensin

II receptor antagonists

Home

Hospital

or

Both

Indication management of hypertension

Adverse/ Side effects dizziness, fatigue, headache, insomnia, weakness, chest pain, edema, diarrhea, nausea, myalgia, angioedema
Nursing considerations/ Patient Teaching Take missed dose as soon as remembered if it is not almost time for next dose-do not double dose; Avoid salt
substitutes containing potassium or foods containing high levels of potassium or sodium; Caution patient to avoid sudden changes in position to decrease
orthostatic hypotension; Instruct patient to notify health care professional if swelling of face, eyes, lips, or tongue or if difficulty swallowing or breathing
occur.

Name levofloxacin (Levaquin)

Concentration

Route IV

Dosage Amount 750mg

Frequency Daily-infuse over 90 minutes

Pharmaceutical class fluoroquinolones

Home

Hospital

or

Both

Indication treatment of bacterial infections, i.e. pneumonia

Adverse/ Side effects elevated intracranial pressure, hepatotoxicity, nausea, vomiting, stevens-johnson syndrome, hyper or hypo glycemia, tendinitis, tendon
rupture, anaphylaxis
Nursing considerations/ Patient Teaching Encourage patient to maintain fluid intake of at least 1500-2000 ml/day to prevent cystalluria; Advise patient to
avoid antacids within 4 hours of dose because it may decrease absorption; Do not double doses.

Name morphine (AVINza)

Concentration

Route PO

Dosage Amount 4mg

Frequency PRN-Q4H

Pharmaceutical class opioid agaonist

Home

Hospital

or

Both

Indication Severe pain

Adverse/ Side effects confusion, sedation, dizziness, hallucinations, headache, respiratory depression, hypotension, bradycardia, constipation, nausea,
vomiting
Nursing considerations/ Patient Teaching Instruct patient how and when to ask for pain medication; Advise patient to change positions slowly to minimize
orthostatic hypotension; Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication; Encourage patients who are
immobilized or on prolonged bed rest to turn, cough, and breathe deeply every 2 hours to prevent atelectasis.

Name

Concentration

Route

Dosage Amount
Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with
recommendations.

Diet ordered in hospital?

regular

Diet patient follows at home? Nothing specific

Analysis of home diet (Compare to My Plate and

Consider co-morbidities and cultural considerations):

24 HR average home diet:

Breakfast: 3 fried eggs with 2 slices of bacon and 1 cup of
orange juice; also 1 cup of coffee

Lunch: 4 slices of Bologna sandwich on white bread with

lettuce and mayonnaise

Dinner: Black bean and country ham soup

Snacks: 2 cinnamon rolls; peanutbutter and graham

crackers

Liquids (include alcohol): orange juice, coffee, and milk

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This patient stated he ate whatever he wanted and did not follow
any specific diet. This was made clear once he said what he ate
on a daily basis. The first thing that seemed extremely important
about this patients diet was the extreme lack of water intake. He
never drinks water. This can be a life threatening issue especially
with older patients because it can lead to dehydration. Another
alarming problem with the patients diet was lack of intake of
fruits and vegetables. The patients total calorie intake was 2,
473, with 968 of those as empty calories. Other problems with
this diet are the patient was 23g over his limit of saturated fat
and 2,884mg over his limit of sodium. This is not only
unhealthy, but can cause a decrease in his energy and another
factor in dehydration. A few substitutions in his meals could
cause a significant impact in his overall health.
Instead of having bacon for breakfast, the patient could substitute
it for a piece of fruit. Also, he could fresh spinach and onions to
his eggs, which would add vitamins and minerals, needed daily
that he was not getting elsewhere. For lunch, instead of having a
bologna sandwich, he could have lower sodium turkey. Turkey
would be a lean protein option, with a lot less fat and sodium
decreasing the overall intake. The white bread is an okay option,
but if he used wheat bread instead it would give him more fiber
and keep him full longer. Dinner was a good meal with black
beans because they are a good source of fiber. However, adding
the country ham is another huge source of sodium. He could
have a 6oz portion of baked chicken with the black beans, which
would allow for a lean protein reducing sodium and fat. Snacks
are an important part of a balanced diet, but cinnamon rolls are
not the ideal snack to be having. Explaining to the patient it is
okay in moderation is key because he can have one every once in
a while. Educating to him about high in sugar it is and he can
substitute it for a half cup of Greek frozen yogurt would still be
something sweet before bed, but a healthier option.
If the patient made these simple substitutions and additions to his
meal plan, he would feel better overall. It would help with
managing his hypertension and reducing his risk of dehydration.
Making these changes for a few weeks would result in a
significant difference in the patients overall health and wellness.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? I dont get sick very often, but when I do, my daughter helps me. She flew all the way
down from Tennessee to be here.
How do you generally cope with stress? or What do you do when you are upset? I retired so I wouldnt have a lot of
stress in my life. I do not have a lot of stress, but when I do I play games on the computer. I spend way too much time on
the computer playing golf games, but it keeps me busy.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) No.

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+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? yes_________

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_______________no____________ If yes, have you sought help for this? ______________________

Are you currently in a safe relationship? Yes. It is long distance.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust

Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority
Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for
your
patients age group: Older adults must come to view their lives as meaningful to face death without worries and regrets (Sigelman,
p. 36)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient was in the ego integrity stage. He was very cheerful and enjoyed talking to me and telling me about his past.
He loved that he was retired and was very happy that he worked all his life for that opportunity. He talked a lot about the
navy and was proud of himself and his friends for fighting in wars. The patient loves to play golf and take vacations. He
does not get stressed out because he is happy with his life. I appreciated what he had to share and liked talking to him.
He had an outgoing personality and wasnt letting the hospital upset him. He did not show any signs of regret or despair,
but exhibited emotions of happiness and joy at this point in his life.

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

This hospitalization did not impact the patients developmental stage of life. The only reason he was upset was because
it interrupted his vacation. He wasnt upset that he was in the hospital because he said it was because of his smoking that
probably caused the condition.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? I smoked way too much throughout my life and knew I would end up
having problems. There isnt any cause of my illness, except I shouldve taken better care of myself.

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What does your illness mean to you? It doesnt mean anything too me, except I missed my vacation.

+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? No
_______________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ______no___________________________

Are you currently sexually active? ________N/A___________________ If yes, are you in a monogamous
relationship? _____________N/A_______ 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?

________________________________________________________

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?
no

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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?
__It is important, but I only go to church once and a while.
Do your religious beliefs influence your current condition?
No.

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
Cigarettes

Yes

No

How much?(specify daily amount)

For how many years? 50 years

As many as I could-3 packs a day.

(age 13

thru

63

If applicable, when did the

patient quit? 3 years ago

Pack Years: 50

Does anyone in the patients household smoke tobacco? If

so, what, and how much? no

Has the patient ever tried to quit? yes

If yes, what did they use to try to quit? I quit cold
turkey.

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? Beery

Yes

No

How much? 2 bottles

For how many years?

Volume: 16 oz

(age

13 thru

45

Frequency: once a day

If applicable, when did the patient quit?
27 years ago

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?

Yes

No

If so, what?
How much?

For how many years?

(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

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University of South Florida College of Nursing Revision September 2014

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Yes. I served during agent orange and was exposed.

5. For Veterans: Have you had any kind of service related exposure? Agent orange, but nothing happened to me.

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University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS
General Constitution

Gastrointestinal

Immunologic

Recent weight loss or gain

Nausea, vomiting, or diarrhea

Chills with severe shaking

Integumentary

Constipation

Irritable Bowel

Night sweats

Changes in appearance of skin

GERD

Cholecystitis

Fever

Problems with nails

Indigestion

Gastritis / Ulcers

HIV or AIDS

Dandruff

Hemorrhoids

Blood in the stool

Lupus

Psoriasis

Yellow jaundice Hepatitis

Rheumatoid Arthritis

Hives or rashes

Pancreatitis

Sarcoidosis

Skin infections

Colitis

Tumor

Diverticulitis

Life threatening allergic reaction

Bathing routine: once in the morning

Appendicitis

Enlarged lymph nodes

Other:

Abdominal Abscess

Other:

Use of sunscreen

SPF: 30

Last colonoscopy? Two years ago.

HEENT

Other:

Hematologic/Oncologic

Difficulty seeing

Genitourinary

Anemia

Cataracts or Glaucoma

nocturia

Bleeds easily

Difficulty hearing

dysuria

Bruises easily

Ear infections

hematuria

Cancer

Sinus pain or infections

polyuria

Blood Transfusions

Nose bleeds

kidney stones

Blood type if known: Patient said AA.

Post-nasal drip

Normal frequency of urination:

Depends. 3x/day

Other:

Oral/pharyngeal infection

Bladder or kidney infections

Metabolic/Endocrine

Dental problems- cavities

Routine brushing of teeth
2 times a day

x/day-

Diabetes

Type:

Routine dentist visits once a year

Hypothyroid /Hyperthyroid

Vision screening

Intolerance to hot or cold

Other:

Osteoporosis
Other:

Pulmonary
Difficulty Breathing-

Central Nervous System

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University of South Florida College of Nursing Revision September 2014

Cough - dry

WOMEN ONLY

or productive

CVA

Asthma

Infection of the female genitalia

Dizziness

Bronchitis

Monthly self breast exam

Severe Headaches

Emphysema

Frequency of pap/pelvic exam

Migraines

Pneumonia

Date of last gyn exam?

Seizures

Tuberculosis

menstrual cycle

Environmental allergies

menarche

age?

Encephalitis

last CXR? 2015- this visit

menopause

age?

Meningitis

Other:

Date of last Mammogram &Result:

regular

irregular

Ticks or Tremors

Other:

Date of DEXA Bone Density & Result:

Cardiovascular

MEN ONLY

Mental Illness

Hypertension

Infection of male genitalia/prostate?

Depression

Hyperlipidemia

Frequency of prostate exam? Every year

Schizophrenia

Chest pain / Angina

Date of last prostate exam? 2014

Anxiety

Myocardial Infarction

BPH

Bipolar

CAD/PVD

Urinary Retention

Other:

CHF

Musculoskeletal

Murmur

Injuries or Fractures

Thrombus

Weakness- previously

Measles

Rheumatic Fever

Pain

Mumps

Myocarditis

Gout

Polio

Arrhythmias

Osteomyelitis

Scarlet Fever

Last EKG screening, when? 2015

Other:

Childhood Diseases

Chicken Pox
Other:

Other:

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

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Any other questions or comments that your patient would like you to know? No.

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University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:
General Survey: Patient is sitting upright in bed with it elevated 45 degrees.
Height 177 cm Weight 88.6 kg BMI
31.5
Pain: 6 out of 10
Pulse 51
Blood Pressure: (include location)
Left Arm-130/78
Respirations 14
Temperature: (route taken?) Oral; 98.4 SpO2 95%
Is the patient on Room Air or O2
2 Liters Nasal Cannula
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: Peripheral Line
Location: Left Forearm Date inserted: 02/05/2015
Fluids infusing? no
yes - what?
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 / 2mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 12 inches & left ear- 12 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:
Pulmonary/Thorax: Respirations regular and unlabored
Transverse to AP ratio 2:1
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: Clear bilaterally
RUL crackles
LUL clear
RML crackles LLL clear
RLL crackles

Chest expansion symmetric

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 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:
PT:

University of South Florida College of Nursing Revision September 2014

!16

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.

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University of South Florida College of Nursing Revision September 2014

Lab Dates Trend Analysis

Ct of Chest
CT of Chest 02/05/2015
02/09/2015
The trend of these to tests was that the pleural effusion was improving after the first test. The first CT
of the chest revealed a small to moderate right side pleural effusion. After the second CT was performed it
showed mild improvement. The patient underwent these tests because of the pleural effusion. This is an
accumulation of fluid that can be extremely dangerous if not treated immediately and monitored closely.
These tests were done to monitor the patients progress through his hospital stay.
WBC
35.0
22.0
02/06/2015
02/10/2015 The patients white blood cell count trended downwards significantly 4 days after the first
blood draw. The patients white blood cell count is extremely higher than normal on both blood draws. The
reason it is high is because he also has pneumonia, which caused his pleural effusion. The white blood cells
indicate the presence of an infection, but because the amount of white blood cells is decreasing the infection is
improving.
Neutrophils
30.97
18.35
02/06/2015
02/10/2015 The patients neutrophil count, which is directly related to the white blood cell count, decreased
also 4 days after the first lab. Neutrophils, blood cells that are key components of fighting infection, were also
significantly higher than the normal amount in the blood. This was also because he was fighting bacterial
pneumonia and the neutrophils were fighting the infection. They are decreasing which is a positive sign
towards improvement.
ALT (SGPT)
18
71

02/06/2015
02/10/2015
On the first lab draw, the patients liver enzymes were within normal range. Four days later, it dramatically
trended upward.
The patients liver enzymes couldve increased for different reasons. Because he was not in liver failure and
did not have cirrhosis, it could have increased because of the antibiotics he was taking.
Troponin
0.01
02/06/2015 There was only one test done for troponin level.
The troponin level was drawn because the
patient was admitted with a chief complaint of chest pain. Once a heart attack was ruled out because of the
low troponin level and a pleural effusion was the diagnosis, there wasnt another reason to measure the
troponin again.
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+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.)
Vitals were performed every four hours on this patient to monitor for any changes. She has
hypertension so they wanted to keep watch on his blood pressure. Also, his heart rate because it was
below 60 since his stay.
Patient met with physical therapy too help build back up his strength. Although, he was suffering from
severe chest pain he also felt very week. Physical therapy was an additional part of his recovery that
would help him feel stronger and more comfortable ambulating.
On February 5, 2015, upon admission, the patient had a CT of his chest with contrast to look for a
pulmonary embolism. There was no pulmonary embolism found, however they saw a small to
moderate right pleural effusion.
On February 6, 2015, the patient underwent a thoracentesis with imaging. This was to help drain the
fluid and also used as a diagnostic tool. Drainage was 300cc of cloudy, yellow pleural fluid removed.
On February 7, 2015, the patient had a Chest X-ray done, which revealed worsening atelectasis in the
right lower lobe of the lung. This was done to see if the thoracentesis helped improve the pleural
effusion, but revealed the opposite.
On February 9, the patient had a CT of the chest without contrast, which showed mild improvement of
the right pleural effusion and atelectasis.
Again on February 9, 2015, there was a cardiology consult because the patient was sustaining a heart
rate of 170 for a long period of time and he felt short of breath. This was a concern, because the
patients heart rate was previously consistently under 60.

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

1. Ineffective breathing pattern r/t decrease in lung expansion (Fluid accumulation) aeb patient feeling short of breath
2. Impaired gas exchange r/t decrease in lung volume capacity aeb presence of crackles in right lung field and dyspnea
3. Ineffective airway clearance r/t weakness and poor cough effort aeb tachypnea, dyspnea, and bradycardia
4. Imbalanced nutrition-less than body requirements r/t increased metabolic needs secondary to bacterial infection aeb
decreased appetite and patient not eating
5. Risk for falls r/t severe pain and generalized weakness

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 15 CARE PLAN
Nursing Diagnosis: Ineffective breathing pattern r/t decrease in lung expansion (Fluid accumulation) aeb patient feeling
short of breath

Patient Goals/Outcomes Nursing Interventions to

Achieve Goal

Rationale for
Interventions
Provide References

Evaluation of Goal on
Day Care is Provided

Client will report ability

to breathe comfortably

Note pattern of
respiration. If client is
dyspneic, note what
seems to cause the
dyspnea.

The way in which the

client deals with the
condition and how the
dyspnea resolves or gets
worse.

The client will take deep

breaths at prescribed
intervals and demonstrate
controlled breathing.

Client will maintain a

respiratory rate and
rhythm within normal
limits

Monitor respiratory rate,

depth, and ease of
respiration

When the respiratory rate

exceeds 30 breaths/min,
along with other
physiological measures, a
study demonstrated that a
significant physiological
alteration existed.

Using touch on the

shoulder, the client will
be coached to slow their
respiratory rate,
demonstrating slower
respirations, and making
eye contact with the
client. Communication
with client will be calm
and supportive.

Client will demonstrate a Monitor vitals signs every

breathing pattern that
2 hours or as needed.
supports blood gas results
within the clients normal
parameters

A normal respiratory
pattern is regular in a
mediators, reactions, and
outcomes.

Clients activity will be

increased as tolerated, but
also using oxygen during
activity when needed.

Client will identify and

avoid specific factors that
exacerbate episodes of
ineffective breathing
patterns

A study found that when

the cause was
psychological, there was
affective dyspnea,
anxiety, and tingling in
the extremities. Whereas
the dyspnea was
physiological, there was
associated wheezing,
cough, sputum, and
palpitations.

Tell the client alternatives

to help decrease dyspnea
like leaning forward over
a bedside table or resting
their elbows on the table
if tolerated.

Attempt to determine if
clients dyspnea is
physiological or
psychological in cause.

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Client will demonstrate

Note the amount of
ability to perform pursed- anxiety associated with
lip breathing and
dyspnea.
controlled breathing.

To assess dyspnea, it is
important to consider all
of its dimensions,
including antecedents,
mediators, reactions, and
outcomes. Studies have
demonstrated that pursedlip breathing was
effective in decreasing
breathlessness and
improving respiratory
function.

Clients breathing is
improved and
demonstrates how to
perform pursed-lip
breathing effectively.
Client expresses he or she
is comfortable breathing
and has steady respiration
rate.

Long term goal per care

plan

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would
include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs maybe an incentive spirometer to help with deep breathing
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

15 CARE PLAN
Nursing Diagnosis: Impaired gas exchange r/t decrease in lung volume capacity aeb presence of crackles in right lung
field and dyspnea

Patient Goals/Outcomes Nursing Interventions to

Achieve Goal

Rationale for
Interventions
Provide References

Evaluation of Goal on
Day Care is Provided

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Client demonstrates
improved ventilation and
adequate oxygenation as
evidenced by blood gas
within normal parameters
for that client. Client will
be given supplemental
oxygen to reduce the
chances of altered level of
conscious of impaired gas
exchange.

Monitor the clients

behavior and mental
status for the onset of
restlessness, agitation,
and confusion.

Change in behavior and

mental status can be early
signs of impaired gas
exchange.

Patients oxygen
saturation is maintained
above 92% and patient
does not exhibit any signs
of respiratory distress.

Client will maintain clear

lung fields and remain
free of signs of
respiratory distress.

Auscultate breath sounds

every 1 to 2 hours. The
presence of crackles and
wheezes may alert the
nurse to airway
obstruction, which may
lead to exacerbate
existing hypoxia.

In severe exacerbations of
chronic obstructive
pulmonary disease, lung
sounds may be
diminished or distant with
air trapping.

Clients lung sounds will

improve and will be
auscultated every 2 hours
to assess for improvement
or worsening of crackles.

Client will verbalize

understanding of oxygen
supplementation and
other therapeutic
interventions.

Administer humidified
oxygen through an
appropriate device (nasal
cannula or venturi mask
per the physicians order;
aim for an oxygen (O2)
saturation level of 90% or
above. Watch for onset of
hypoventilation.

There is a fine line

between ideal or
excessive oxygen
therapy; increasing
somnolence is caused by
retention of carbon
dioxide leading to carbon
dioxide narcosis.

Client will understand

why they are getting
supplemental oxygen and
the evidence behind it.

Client will verbalize

understanding the
importance of positioning
to maximize airway
effectiveness and lung
expansion.

Position the client to

optimize respiration (e.g.,
head of bed elevated
30-45 degrees and
repositioned at least every
2 hours).

An upright position
allows for maximal lung
expansion; lying flat
causes abdominal organs
to shift toward the chest,
which crows the lungs
and makes it more
difficult to breathe.

Client was repositioned

every 2 hours and always
with the head of the bed
elevated. This made it
easier for the client to
breathe deeply and
effectively.

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University of South Florida College of Nursing Revision September 2014

Include a minimum of
one
Long term goal per care
plan

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would
include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs - maybe an incentive spirometer to help with deep breathing
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

15 CARE PLAN
Nursing Diagnosis: Risk for falls r/t severe pain and generalized weakness
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal

Rationale for
Interventions
Provide References

Evaluation of
Interventions on Day
care is Provided

Client will remain free of

falls

Use a high-risk fall

These steps alert the
armband/bracelet and Fall nursing staff of the
Risk room sign to alert
increased risk of falls.
staff for increased
vigilance and mobility
assistance.

Client and family will be

aware about the fall
reduction measures that
are being used and can be
used at home to prevent
falls.

Environment will be
changed to minimize the
incidence of falls

Thoroughly orient the

client to environment.
Place the call light within
reach and show how to
call for assistance; answer
call light promptly.

The client will understand

what he or she can do to
change the environment
at home to reduce the
risks of falls.

The client will better

know his or her
surroundings and
knowing how to use the
call light will reassure the
client will call when help
is needed.

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University of South Florida College of Nursing Revision September 2014

Explain methods to
prevent injury

Use one quarter- to one

half- length side rails
only, and maintain bed in
a low position, Ensure
that wheels are locked on
bed and commode. Keep
dim light in room at
night.

Use of full side rails can

result in the client
climbing over the rails,
leading with the head, and
sustaining a head injury.
Side rails with widely
spaced vertical bars and
side rails not situated
flushes with the mattress
have been associated with
asphyxiation deaths
because of rail and in bed
entrapment and should
not be used.

The client will be taught

how to safely ambulate at
home, including safety
measures such as
handrails in bathroom,
and need to avoid
carrying things or
performing other tasks
while walking.

Patient will call for

assistance when getting
up or needing help and
wont be afraid to ask for
assistance.

Routinely assist the client

with toileting on his or
her own schedule. Always
take the client to
bathroom on awakening
and before bedtime.

Keep the path to the

bathroom clear, label the
bathroom, and leave the
door open.

Patient will call for

assistance when needing
to get up or use the
bathroom. Patient will
safely make it to and from
where he or she needs to
go.

DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include
for discharge teaching)
Consider the following needs:
SS Consult *
Dietary Consult *
PT/ OT *
Pastoral Care
Durable Medical Needs
F/U appts *
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
(pp. 61, 491-495). United States: Mosby, an imprint of Elsevier Inc.
Rubins, J. (2014). Pleural Effusion . Retrieved February 12, 2015, from
http://emedicine.medscape.com/article/299959-overview
Sigelman, C. K., & Rider, E. A. (2009). Life-span human development (pp. 36, 332-334). Australia:
Wadsworth Cengage Learning.
SuperTracker - MyPlate. Retrieved January 14, 2014, from http://www.choosemyplate.gov/supertrackertools/supertracker.html
Vallerand, A. H., & Sanoski, C. A. (2014). 2014 drug information update for Davis's drug guide for nurses,
thirteenth edition and Nurses med deck, thirteenth edition. Philadelphia: F.A. Davis Company.

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