UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Elecia Trowers

MSI & MSII PATIENT ASSESSMENT TOOL .

Assignment Date: 04/03/2015

Agency:

1 PATIENT INFORMATION
Patient Initials: D.P

Age: 62

Admission Date: 03/17/15

Gender:

Marital Status: Married

Primary Medical Diagnosis ICD 490-491

Female

Primary Language: English

COPD

Level of Education: High School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Disabled/cake decorator

Acute Chest Pain, Rhinovirus

Number/ages children/siblings: 2 children

Served/Veteran:
If yes: Ever deployed? Yes or No

Code Status: Full Code

Living Arrangements: Live with her husband

Advanced Directives: YES

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

Culture/ Ethnicity /Nationality: White American

Religion: Pentecostal

Type of Insurance: Medicare and Blue Cross

1 CHIEF COMPLAINT: Patient reports having pain in her chest and states, she never had pain like
that before, also reports having difficulty breathing

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient called 911 on 03/16/2015 because she was having pain in her chest and hard time breathing. Initial
assessment showed a resulted in a normal EKG and Troponin levels. Nitroglycerin was administered and the
patient had no change in the status the pain. The patient has a history of COPD and anxiety and fibromyalgia and
is suspected to be having a exacerbation of all of the above, but is admitted for further testing and treatment.

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
Date

Operation or Illness

2009
1985

Asthma and fibromyalgia

Total Hysterectomy
Removed lumps from breast

Brother

MI

Sister

Alzheimer

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Stroke

Bleeds Easily

81

Asthma

Mother

Arthritis

65

Anemia

Father

Cause
of
Death
(if
applicable
)
MI

Environmental
Allergies

HTN
Anxiety
DM

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Tonsillectomy
Appendectomy
Asthma
IDA
Fibromyalgia syndrome

relationship
relationship
relationship

Comments: Include age 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?
U
Influenza (flu) (Date) Is within 1 years?
U
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

University of South Florida College of Nursing Revision September 2014

NO

If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

Medications

NAME of
Causative Agent
Codeine
Sulfur

Type of Reaction (describe explicitly)

Rashes
Rashes

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)
Mechanics of the Disease: chronic Obstructive Pulmonary Disease (COPD) is persistent narrowing of the
airway occurring with chronic obstructive bronchitis and emphysema. Chronic Obstructive bronchitis the
occurrence of productive cough with airway obstruction for two consecutive years and emphysema is the
irreversibly destruction of the alveolar wall and the enlargement of the alveoli (cells that make up the lungs)
(Merck manual).
Risk Factors: The main risk factors include smoking, people with a familial history and smoke has a higher
risk factor. Long term exposure to lung irritants like; secondhand smoke, air pollution, and chemical fumes and
dust from the environment or workplace. The majority of people with COPD develop symptoms after age 40
(Merck manual)

How to diagnose: Chronic bronchitis is diagnosed by a history of prolonged productive cough with evidence of
airway obstruction in pulmonary function test. Emphysema is diagnosed on the basis of findings observed
during a physical examination and on pulmonary function test results. However, by the time the doctor notices
these abnormalities, emphysema is moderately severe. Findings on a chest x-ray or computed tomography (CT)
of the chest may also help in diagnosis of emphysema and sometimes chronic bronchitis. In mild COPD, the chest
x-ray is usually normal. As COPD worsens, the chest x-ray shows that the lungs contain excess air (overinflation of the lungs). Over-inflation, thinning of blood vessels or the presence of cysts in the lungs (called
bullae) suggests the presence of emphysema (Merck manual).
Treatment: The most important treatment for COPD is smoking cessation, pharmacotherapy includes;
Bronchodilators which relaxes the muscles around your airways. This helps open your airways and makes
breathing easier; the doctor might also add Inhaled Glucocorticosteroids which helps in reducing the
inflammation of the airway. COPD patients will also be encouraged to get their flu and pneumonia vaccine,
Oxygen treatment is necessary in most cases (Merck manual)
Prognosis: For people with mild COPD (stage I) the prognosis is very good and they may have a relatively
normal life expectancy but this decreases as the severity of staging increases. People with COPD who are
admitted to an ICU have an estimated death rate of about 24% and this rate can double for people over age 65.
The average life expectancy of a COPD patient who undergoes a lung transplant is about five years. People who
have COPD and continue to smoke, have a rapid decline in FEV1, who develop severe hypoxemia, develop
right-sided heart failure and/or have poor ability to do daily functions usually have a poor prognosis (Merck
manual)
University of South Florida College of Nursing Revision September 2014

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

replacement

Concentration

Route IV
Pharmaceutical class

Frequency

Hospital

Home

Dosage Amount

1 each

Dosage Amount

45ml/hr

PRN
or

Both

Bring electrolyte within normal range

Adverse/ Side effects: Fluid overload
Indication

Nursing considerations/ Patient Teaching

Name

nitroglycerin (Nitro-Bid)

Route

IV

Concentration

Titrate 250
Frequency

continuous infusion

Home
Hospital
or
Both
Nitrates
Indication Management of angina pectoris/ MI
Adverse/ Side effects Dizziness, headache, blurred vision, abdominal pain, nausea vomiting, hypotension, tachycardia
Nursing considerations/ Patient Teaching caution patient to change position slowly, avoid the use of alcohol, inform patient that
headache is a common side effect, advise patient to notify provider if dry mouth or blurred vision occurs.
Pharmaceutical class

Name

morphine (Astramorph PF)

Route

Concentration

2mg

IV

Dosage Amount

q4h
Hospital or

2ml

Frequency

Pharmaceutical class opioid Agonist

Home

Both

Indication: Management

of moderate to severe chronic pain.

Respiratory depression, hypotension, bradycardia, constipation, nausea, vomiting, urinary retention,
physical dependency
Nursing considerations/ Patient Teaching may cause drowsiness or dizziness, use caution when ambulation, avoid driving,
change position slowly, emphasize the importance of measure to prevent constipation
Adverse/ Side effects

Name

lorazepam (Ativan)

Route

IV

Concentration

0.5mg
Frequency

Dosage Amount

0.25 ml

PRN

Benzodiazepines
Home
Hospital
or
Both
Indication : Anxiety disorder
Adverse/ Side effects: Apnea, cardiac arrest, bradycardia, mental depression, ataxia, confusion, lethargy
Nursing considerations/ Patient Teaching Instruct patient to take medication as directed, do not stop taking the medication
abruptly, avoid drinking alcohol, use caution operating a motor vehicle, emphasize the importance of follow up
appaointment
Pharmaceutical class

Name :
Route

enoxaparin (Lovenox)

Concentration

INJ

40 mg
Frequency

Pharmaceutical class

Dosage Amount

0.4 ml

Daily

antithrombotic, low molecular

Home
Hospital or Both
weight heparin
Indication Prevention of venous thromboembolism
Adverse/ Side effects : dizziness, headache, edema, constipation, urinary retention, bleeding , anemia, osteoporosis.
Nursing considerations/ Patient Teaching : Report symptoms of unusual bleeding, dizziness, rash, fever, itching. Do not take
aspirin or ibuprofen without consulting your doctor
Name albuterol
Route

(Salbutamol)

Concentration

Dosage Amount

0.5 ml

nebulizer

Frequency q4h
adrenergics
Home
Hospital
or
Both
bronchodilator to control and prevent reversible airway obstruction caused by asthma or COPD

Pharmaceutical class
Indication

University of South Florida College of Nursing Revision September 2014

paradoxical bronchospasm, arrhythmias, hypertension, hyperglycemia, hypokalemia, tremor.

Nursing considerations/ Patient Teaching instruct patient to take albuterol as directed, contact provider if shortness of breath
develops, prime unit with 4 sprays before using, notify provider if albuterol dose is not effective.
Adverse/ Side effects

Name

budesonide (Rhinocort Aqua)

Route

Nebulizer

Concentration

0.5 mg

Dosage Amount

2ml

BID
Hospital or

Frequency

Corticosteroids
Home
Both
Indication Seasonal or perennial allergic rhinitis
Adverse/ Side effects: Nasal burning and irritation, fungal infection, dry mouth, adrenal suppression, cough.
Nursing considerations/ Patient Teaching Advise to take medication as directed, gently blow nose to clear nostrils, prime nasal
spray before first time use, warn that temporary nasal stinging may occur.
Pharmaceutical class

Name:

gabapentin (Neurotin)

Route

Oral

Pharmaceutical class Gamma-amino

Concentration

butyric acid

400mg
Home

Dosage Amount

Frequency

TID

Hospital

or

1 caplet

Both

Neuropathic pain
Suicidal thoughts, confusion, abnormal vision, rhabdomyolysis, multiply organ hypersensitivity
reaction, hypertension, weight gain, gingivitis.
Nursing considerations/ Patient Teaching Advise to take medication exactly as directed, do not take within 2hr of antacid, use
caution when operating motor vehicle, notify health care provider if experiencing thoughts of suicide.
Indication

Adverse/ Side effects

Name

insulin lispro (Humalog)

Concentration

75/25

Route

Dosage Amount corrective

Frequency

scale

corrective scale routine

or
Both

Pancreatics
Home
Hospital
Indication Control of hyperglycemia
Adverse/ Side effects Hypoglycemia, erythema, pruritis, swelling, anaphylaxis
Nursing considerations/ Patient Teaching : Teach proper technique for administration, advise that therapy is long term not a
cure, teach proper testing of glucose, notify provider if OTC are being taken, advise of the signs and symptoms of
hypoglycemia.
Pharmaceutical class

Name Lisinopril

(Zestril)

Concentration 5mg

Dosage Amount

1 tab

Frequency daily
ACE inhibitor
Home
Hospital
or
Both
Indication management of hypertension and heart failure
Side effects/Nursing considerations Angioedema, hyperkalemia, hypotention, chest pain, headache dizziness.
Name Lisinopril (Zestril)
Route

Oral

Pharmaceutical class

Name pantoprazole (Protonix)

Route

Concentration 40mg

IV

1 tab

once daily
Hospital or Both

Frequency

Pharmaceutical class
Indication

Dosage Amount

Proton pump inhibitor

Home

Erosive esophagitis associated with GERD, decrease the secretion of HCL acid

pseudomembranous colitis, abdominal pain, diarrhea, hypocalcemia

Nursing considerations/ Patient Teaching: Instruct to take medication as directed for full course of therapy, Advise to
avoid alcohol consumption and products that contains aspirin and NSAID. Instruct patient to notify
provider if rash, diarrhea, abdominal cramping, fever, or bloody stools occur
Adverse/ Side effects

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?
Regular
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: 1 cup plain oatmeal with 1 slice French toast
According to choose my plate the patient consume 2124
calories 258 of which were empty calorie this is 124
calorie greater than the required amount.
1 cup orange juice
Lunch: Ham lettuce cheese , tomato & mayonnaise
Dinner: Pork chops 1 cup mashed potato with gravy
Snacks: Potato chips, baby carrots
Liquids (include alcohol): 12 oz sweet tea
3 bottles water
The required grains were 6 oz. the patient had 7 oz.,
vegetable requirement was 2 cups the patient had 2
cups, fruit juice requirement was 2 cups the patient had
1 cup. Dairy was also low the patient
had 2 cups and 3 cups were required , the patient
Consumed excessive protein 9 oz. only 5 oz. was
required.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? The patient states that my husband and daughter along with a helper takes care of
me
How do you generally cope with stress? or What do you do when you are upset?
Patient states that I deal with stress badly, I get anxious when am stressed
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient states that Her recent difficulties are dealing with her anxiety which exacerbates her COPD
+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? ______________
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

University of South Florida College of Nursing Revision September 2014

 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: According to Berk, Generativity vs Self-absorption/stagnation entails the need for adults to

create or nurture things that will outlast them, often by having children or creating a positive change that benefits
other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow
involvement in the world.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is in the Generativity Vs Stagnation stage of development, the implication of this was noted
based the patient talking about her role in her great grandchildren lives, she reflects on her work as a
cake decorator and seem to find much joy in being a mother grandmother and great grandmother.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

I believe the patients illness has a great impact on her stage of development; she is no longer able to
spend quality time with her grandchildren nor is she able to relax and reflect on her accomplishments.
The patient is forced to focus on her illness and has now crossed over to a new stage of development (Ego
integrity Vs Despair).
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states I have no idea
What does your illness mean to you?
Patient states I think it just mean am sick

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?____________________YES_____________________________________________
Do you prefer women, men or both genders? ____________________MEN__________________________________
Are you aware of ever having a sexually transmitted infection? __________NO_________________________
Have you or a partner ever had an abnormal pap smear?_________________NO_____________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___________NO___________________
Are you currently sexually active? _______NO_______________ If yes, are you in a monogamous relationship?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? ________N/A___________________
How long have you been with your current partner?______________34 YEARS____________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ___YES__________
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 that religion is very important to her ______________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_Not at all_________________________________________________________________
______________________________________________________________________________________________________

+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?
How much?(specify daily amount)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

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

Has the patient ever tried to quit?

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

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

Yes

No
For how many years?
(age
thru )

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?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient does not think she has ever been exposed but is currently not exposed
5. For Veterans: Have you had any kind of service related exposure?

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

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

Be sure to answer the highlighted area

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

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? 6 years ago
Other:

Chills with severe shaking

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

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 3-4 x/day
Bladder or kidney infections

Hematologic/Oncologic

Metabolic/Endocrine
2 x/day
x/year

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? 3/15/2015
Other:

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

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? 13
menopause: Hysterectomy age? 35
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision September 2014

General Constitution
Recent weight loss or gain
How many lbs? Gained 10lbs
Time frame? 2 months
Intentional? NO
How do you view your overall health? Overall health not great

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient had no other problems that she sought help for that is not already mentioned here.

Any other questions or comments that your patient would like you to know?
Patient wanted me to know that she was more than happy to help with my school project as I was so nice to her
today

University of South Florida College of Nursing Revision September 2014

10

10 PHYSICAL EXAMINATION:
General Survey: Patient
seemed a bit anxious
Temperature: (route
taken?) oral 36.6 C

Height 55
Pulse 75
Respirations 20
SpO2 100

Weight 163 lbs.

BMI 27.1
Blood Pressure: (include location)
153/83
Is the patient on Room Air or O2

Pain: (include rating and

location) Patient rates pain
as being 8 in her chest

Venturi Mask

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 Patient is anxious
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: Left AC
Date inserted: 03/16/2015
Fluids infusing?
no
yes - what? Running 0.9% and nitroglycerin
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 / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments: Patient has tremors at the TMJ
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
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 wheezing
LUL wheezing
RML wheezing
LLL wheezing
RLL wheezing

Chest expansion

CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent

University of South Florida College of Nursing Revision September 2014

11

Cardiovascular:
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)

No JVD

The reading shows sinus rhythm with a slight ST elevation

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: 3
DP: 3
PT:3
No temporal or carotid bruits
Edema: non
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of 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 03 / 15 /15 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

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

Previous 24 hour output: 1500 mLs N/A

without assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __4____ RUE __4____ LUE __4____ RLE

or

with assistance

& _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: +2

Biceps: +2

Brachioradial: +2

Patellar: +2

Achilles: +2

Ankle clonus: positive negative Babinski: positive

negative

University of South Florida College of Nursing Revision September 2014

12

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormal, 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
WBC

4.1K (L)

RBC

4.1 mil (L)

HGB

8.9 gm/dl (L)

Dates

Trend
The WBC have been
03/17/2015 trending low

Analysis
Low WBC could be due to the
patients use of steroids.

03/17/2015 The RBC have been

trending a bit low

This low RBC is indicative of this

patients anemia but for average
patient further testing would be
necessary.
Low HGB further affirms that the
patient is anemic and that the blood
cells have a low O2 carrying capacity.
Low HCT suggests that there is a low
number of RBC in a volume of blood,
which might be due to acute blood
loss, in this patients case anemia
This suggests that the patient has
normal clotting capabilities.
A normal BUN indicates that the
kidneys and liver are functioning
normally.
Normal creatinine levels indicate that
the kidneys are working and are not
diseased nor damaged
Normal sodium means that there are
normal amount of sodium in the
blood (kidney are filtrating fine)
Normal potassium means that there is
adequate amount of potassium in the
blood stream.
This indicates that further analysis is
needed; troponin needs to be retested
for peak to occur.

03/17/2015 The patients HGB have

been low

HCT

29.3%

03/17/2015 The patients HCT have

been low.

Platelets

254k/mcl

03/17/2015 The patients platelet

count have been normal
03/17/2015 The patients BUN have
ben normal

Bun

16

Creatinine

0.7

Sodium

135

03/17/2015 The patients creatinine

have been normal
03/17/2015 The patients sodium
have been normal

Potassium

3.6

03/17/2015 The patients potassium

have been normal

Troponin

0.22

03/17/2015 The patient has small

change in troponin

University of South Florida College of Nursing Revision September 2014

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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.)
The patient is on accu-check for q4h, this enables management of her diabetes. Respiratory is also on for
q2h, this is important for medication administration for the management of COPD. The patient is having
labs q2h for troponin to peak this could tell whether the patient is having MI. The patient has a
consultation with cardiology to further evaluate her chest pain. The patient is on a regular diet as all her
disease processes can accommodate it, for now the patient will remain in the hospital for further analysis.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Ineffective breathing pattern related to shortness of breath as evidence effort in taking a breath.
2. Activity intolerance related to disease process as evidence by patient being short of breath when moving.
3. Ineffective Airway clearance related to ineffective cough as evidence by cough not bringing up sputum.
4. Ineffective Individual coping related to anxiety as evidence by patient being anxious.
5. Disturbed sleeping pattern related to pain as evidence by patients pain rating.

University of South Florida College of Nursing Revision September 2014

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 15 CARE PLAN
Nursing Diagnosis: Ineffective breathing pattern related to shortness of breath as evidence effort in taking a breath.
Patient Goals/Outcomes
Nursing Interventions to Achieve Goal
Rationale for Interventions
Evaluation of Goal
Provide References
on Day Care is
Provided
Patient maintains
*
Both
rapid,
shallow
breathing
patterns
and
Patient
remained
* Assess respirations: note quality, rate,
optimal gas exchange as pattern, depth, and breathing effort.
hypoventilation affect gas exchange. Shallow, well oxygenated
evidenced by normal
"sighless" breathing patterns postsurgery (as throughout the day
* Use pulse oximetry to monitor O2
ABGs and alert
a result of effect of anesthesia, pain, and
stating 98-100%,
saturation and pulse rate continuously.
responsive mentation or
immobility) reduce lung volume and
remained AO x4,
* Assess skin color for development of
no further reduction in
decrease ventilation.
ABGs within
cyanosis.
mental status.
normal limits
* Pulse oximetry is a useful tool to detect
* Assess patient's ability to cough
changes in oxygenation. O2 saturation should
effectively to clear secretions. Note
be maintained at 90% or greater.
quantity, color, and consistency of sputum.
* For cyanosis to be present, 5 gm of
* Assess for changes in orientation and
hemoglobin must de-saturate.
behavior.
* Retained secretions impair gas exchange.
* Change patient's position every 2 hours.

* This facilitates secretion movement and

drainage (Elsevier 2012)

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
F/U appointments ***
Med Instruction/Prescription ***
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
University of South Florida College of Nursing Revision September 2014

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Nursing Diagnosis: Activity intolerance related to disease process as evidence by patient being short of breath when moving.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal
Goal
Provide References
on Day Care is
Provided
Patient maintains activity
* Assess patient's level of mobility. * Aids in defining what patient is capable of,
Patient was able to
level within capabilities, as * Determine patient's perception
ambulate but was
which is necessary before setting realistic goals.
evidenced by normal heart of causes activity intolerance
unable to withstand
* May be temporary or permanent, physical, or
rate and blood pressure
activity, patient state
* Assess patient's
psychological. Assessment guides treatment.
during activity, as well as
cardiopulmonary status before
* Heart rate should not increase greater than 20 to she will continue to
absence of shortness of
activity using the following
30 beats above resting with routine activities. This try just a bit at a
breath, weakness, and
time. I was able to
measures:
number will change depending on the intensity of
fatigue.
complete some ROM.
* Observe and document response exercise the patient is attempting (climbing four
Patient verbalizes and uses to activity.
Vitals remained
flights of stairs versus shoveling snow).
energy-conservation
stable after
* Encourage adequate rest
* Close monitoring serves as a guide for optimal
techniques.
ambulation.
periods, especially before meals,
progression of activity.
other activities of daily living,
* To reduce cardiac workload.
exercise sessions, and ambulation. * Not all self-care and hygiene activities need to be
* Assist patient to plan activities
completed in the morning. Likewise, not all
for times when he or she has the
housecleaning needs to be completed in one day
most energy.
(Elsevier 2012)
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 **
F/U appointments **
Med Instruction/Prescription **
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
University of South Florida College of Nursing Revision September 2014

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Palliative Care

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References
Elsevier. (2012). Nursing diagnosis care plans. COPD. Retrieved April 3, 2015, from
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick04.html.
Laura E. Berk. (2010). Exploring Lifespan Development: Stages of development. (2nd Ed). Boston MA, USA. Pearson.
The Merck Manual. (2012, August 18). COPD. Retrieved April 3, 2015, from
http://www.merckmanuals.com/home/liver_and_gallbladder_disorders/manifestations_of_liver_disease/portal_hypertension.html
United States Department of Agriculture. (2013, September 30). Super Tracker: Food Tracker. Retrieved
April 3, 2015, from https://www.supertracker.usda.gov/foodtracker.aspx.

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