UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Marieta Perino

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

DL

male

Age: 76

Assignment Date: 11/04/2015

Agency: TGH SBN

Admission Date: 10/27/2015

Marital Status: married

Primary Language: English

Primary Medical Diagnosis:

AKI (acute kidney injury) ICD 10 code: N17.9

Level of Education: High school

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): retired form being a firefighter

Complication of transplanted lungs, unspecified

complication ICD 10 code: T 86.819
Hypotension ICD 10 code I 95.9

Number/ages children/siblings: 2 children/ 50 and 52

1 brother - 72
Served/Veteran: 6 years served in the USA army
If yes: Ever deployed? No

Code Status: Prior

Living Arrangements: he lives in Venice, FL

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: 05/15/2015
Procedure: bilateral lung transplant

Culture/ Ethnicity /Nationality: white/ American

Religion: Luther

Type of Insurance: Medicare and Signa PPO

1 CHIEF COMPLAINT:
Patient presents for routine TBLB follow-up with the lung transplant coordinator and transplant pulmonologist.
Patient complains of generalized weakness and lower back pain.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is 76 years old white male s/p bilateral lung transplant who presents to the bronchoscopy suite on 10/27/2015
for routine TBLB follow up with the lung transplant coordinator and transplant pulmonologist. Upon arrival, patient
complains of feeling weak and fatigued. He has had nausea and vomiting. He has had very poor food intake over the past
2-3 days. The patient was found to be hypotensive with SBP of 65+. He was given IVF and his bronchoscopy was
cancelled. Labs are notable for acute renal failure attributed to probable dehydration. He was recently diagnosed with a
lumbar fracture at L4 by MRI. The patient was to have workup and care associated with this in Sarasota area, however
there have been scheduling issues. He has been having severe lower back pain and has remained uncomfortable with
decreased mobility. The pain started about 10 days ago becoming progressively worse. The patient has been taking some
ibuprofen for pain relief, which didnt help much. The level of pain is described as #6 - #7 on the scale of 0 to 10.

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

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

Cause
of
Death
(if
applicable
)

Anemia

2
FAMILY
MEDICAL
HISTORY

Age (in years)

01/10/2013
02/05/2015
05/22/2015
2/5/2015

Environmental
Allergies

Operation or Illness
Bilateral lung transplant hydrocortisone (slou-Cortef) 100mg every 8 hours, oral;
azathioprine (Imuran) 25mg oral, daily
Diabetes Miletus type 2 insulin aspart (Novolog) 2-10 units 3 times a day
DVT (deep vein thrombosis) warfarin (Coumadin) 3mg daily Subcutaneous injection
Squamous cell carcinoma of lung - bilateral lung transplant performed on 5/15/15
Lung cancer, right bilateral lung transplant performed on 5/15/15

Alcoholism

Date
05/15/2015

Father
Mother

Brother

Sister
relationship
relationship
relationship

Comments: Include age of onset

Mother breast cancer, diagnosed at age 57.
Brother Diabetes Mellitus type 2, diagnosed at age 63.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
U
X
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
X
Adult Tetanus (Date) Is within 10 years?
U
X
Influenza (flu) (Date) Is within 1 years?
10/7/2015
X
Pneumococcal (pneumonia) (Date) Is within 5 years?
U
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
X

 1 ALLERGIES
OR ADVERSE
REACTIONS

Medications

NAME of
Causative Agent

No Allergies Known

Type of Reaction (describe explicitly)

No Allergies Known

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)
Acute kidney injury (AKI) is a syndrome that is characterized with a sudden decrease in kidney function within a few
hours or days. It causes build up of waist product in the blood and makes it hard for the kidneys to keep a balance of fluid
in the body. It can also affect other organs brain, heart, and lungs.
AKI is diagnosed through simple blood and urine tests. Abrupt loss of kidney function will present as a rise in serum
creatinine of >0.3 mg/dL or a 50% increase within 48 hours. It can result in electrolyte, acid-balance, and volume
homeostasis abnormalities. Oliguria may be present (urine output less than 500 ml/day) (Osborn, Wraa, Watson, &
Holleran, 2014).
There are 3 categories of AKI: prerenal, intratenal and postrenal. Prerenal is secondary to decreased renal perfusion,
which leads to decreased GFR. It can progress to intrarenal, known as ischemic acute tubular necrosis. It presents with
arteriolar insults, cholesterol embolization, and intrarenal deposition uric acid nephropathy. Postrenal AKI is due to
extrinsic compression (carcinoma, pregnancy) , intrinsic obstruction (calculus, tumor, clot), or decrease function
neurogenic bladder (Waikar, Liu, & Chertow, 2011).
Risk factors that contribute to this condition are dehydration, chronic diseases such as: heart disease, liver disease,
lung disease, diabetes mellitus, peripheral artery disease, cancer, kidney stones, and if you already have chronic kidney
disease. Being older or African American increases your chances of developing AKI. There are many ways we can prevent
it. Always get your annual physical blood and urine tests performed (Unbound Medicine, Inc. 2015). A blood test of
creatinine will show how well your kidneys are working. Urine test will show weather or not there is protein leakage,
which is indicative for kidney damage. Stay well hydrated and avoid long-term use of nephrotoxic drugs NSAIDs and
herbal remedies.
In order to treat AKI we need to identify the underlying cause. General measures include: stopping nephrotoxic drugs;
recording daily weight, intake and output; following nutrition recommendations (low protein diet); avoid aspirin; be aware
of high risk for infections they need to be treated immediately. If AKI is diagnosed and severe, the patient may need
hemodialysis (Bellomo, Kellum, & Ronco, 2012). The client will present with volume overload, progressive
hyperkalemia, uremic complications or metabolic acidosis.
In treatment of AKI we always focus on the underlying cause. If they have a fluid overload we can use loop diuretics
to help with volume excretion. Hyperkalemia with ECG changes we can be treated with IV calcium gluconate, isotonic
sodium bicarbonate; glucose with insulin; Kayexalate; hemodialysis if severe. If they present with metabolic acidosis,
sodium bicarbonate can be given (Bagshaw, George, & Bellomo, 2012).
Depending on the cause, comorbidities, and age of the patient mortality ranges from 5 to 80%. The shorter the
duration of the AKI, the better the prognosis. Postrenal and prerenal failure have better prognosis in comparison to
intrarenal for that reason. Average recovery time can take from days to months.

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: azathioprine (Imuran)

Concentration

Dosage Amount: 25 mg

Route: oral

Frequency: daily

Pharmaceutical class: immunosuppressant

Both

Indication: Prevention of renal transplant rejection. Management of Crohns disease or ulcerative colitis
Adverse/ Side effects: retinopathy, pulmonary edema, anorexia, hepatotoxicity, nausea, vomiting, malignancy
Nursing considerations/ Patient Teaching: If a dose is missed on a once-daily regimen omit the dose. Consult a health care professional if more than one dose is
missed or if vomiting occurs shortly after dose is taken. Do not discontinue without consulting a health care professional. Its a life long therapy to avoid
transplant rejection. This drug may have teratogenic properties.
Name: azithromycin (Zithromax)

Concentration:

Dosage Amount: 250 mg

Route: oral

Frequency: M W F

Pharmaceutical class: antibiotic

Hospital

Indication: Upper respiratory tract infections, lower respiratory tract infections, bronchitis, pneumonia, acute otitis media, skin stricture infections.
Adverse/ Side effects: Torsades de Pointes, Hepatotoxicity, pseudomembranous colitis. Steven-Johnson syndrome, Toxic epidermal necrosis, Angioedema
Nursing considerations/ Patient Teaching: Take medication as directed and finish drug completely. Take missed doses as soon as possible, do not double dose.
Take with food or antacids. May cause drowsiness and dizziness. Avoid driving until response to medication is known. Advise patient to use sunscreen and
protective clothing to prevent photosensitivity reaction. Advise patients to report symptoms of chest pain, palpitations, yellowing of skin or eyes, or signs of
superinfection or rash. Notify health care provider if fever and diarrhea develop.
Name: calcitonin (Miacalcin)

Concentration

Dosage Amount: 1 spray in alternating nares

Route: nasal spray

Frequency: daily

Pharmaceutical class: hormones

Hospital

Indication: Treatment of Pagets disease of bone. Adjunctive therapy for hypercalcemia. Management of postmenopausal osteoporosis.
Adverse/ Side effects: headaches, rhinitis, epistaxis, nasal irritation
Nursing considerations/ Patient Teaching: If dose missed take as soon as you remember, do not double dose. Advise patients to report signs of hypercalemic
relapse or allergic response promptly. Nausea and vomiting after injection tends to decrease with continued therapy.
Name: clotrimazole (Mycelex) troche

Concentration:

Dosage Amount: 10 mg

Route: oral

Frequency: 3 times daily after meal

Pharmaceutical class: antifungal

Both

Indication: Treatment of oropharyngeal candidiasis. Prevention of that disease in immunocompromised patients.

Adverse/ Side effects: nausea, vomiting, pruritis
Nursing considerations/ Patient Teaching: Allow each troche to slowly dissolve in mouth.
Name: ducosate sodium (Colace)

Concentration:

Dosage Amount: 100 mg

Route: oral

Frequency: 2 times daily

Pharmaceutical class: stool softener

Hospital

Indication: Prevention of constipation

Adverse/ Side effects: throat irritation, diarrhea, mild cramps
Nursing considerations/ Patient Teaching: Use only for short-term therapy. Do not use if abdominal pain, nausea, vomiting, or fever is present.
Name: hydrocortisone (solu cortef)
Route: IV

Concentration: 100 mg/2ml

Dosage Amount: 100 mg

Frequency: every 8 hours

Pharmaceutical class: corticosteroids

Hospital

Indication: management of adrenocortical insufficiency. Used for disorders including: inflammatory, allergic, hematologic, neoplastic, autoimmune disorders,
septic shock.
Adverse/ Side effects: depression, euphoria, headache, intracranial pressure, hypertension, peptic ulceration, adrenal suppression, thromboembolism,
anaphylaxis

University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching: Stopping the medication suddenly may result in adrenal insufficiency anorexia, nausea, weakness, fatigue, dyspnea,
hypotension. If these signs appear notify health care professional immediately.
Name: insulin aspart (Novolog)

Concentration:

Dosage Amount: 2 -10 units

Route: Subcutaneous

Frequency: 3 times daily after meals and at bedtime

Pharmaceutical class: antidiabetic, pancreatic hormone

Hospital

Indication: control of hyperglycemia in patients with type 1 or type 2 diabetes mellitus.

Adverse/ Side effects: Hypoglycemia, anaphylaxis, erythema, lipodystrophy
Nursing considerations/ Patient Teaching: Instruct patient on proper technique for administration. Discuss the importance of not changing brands of insulin or
syringes. Insulin pens should not be shared with others. This medication does not cure diabetes. Therapy is long term. Instruct patient on signs and symptoms of
hyperglycemia and what to do if they occur.
Name: lidocaine (Lidoderm)

Concentration:

Dosage Amount: 700 mg patch

Route: transdermal

Frequency: daily

Pharmaceutical class: anesthetic, antiarrhythmic

Hospital

Indication: Ventricular arrhythmias. Topical anesthetic.

Adverse/ Side effects: Seizures, confusion, drowsiness, dizziness, cardiac arrest
Nursing considerations/ Patient Teaching: May cause drowsiness or dizziness. Advise patient to call for assistance during ambulation and transfer. Apply patch
to intact skin to cover the most painful areas. If irritation or burning sensation occurs during application, remove patch until irritation subsides. Wash hands
after application; avoid contact with eyes.
Name: magnesium oxide (MAG Ox) tablet

Concentration:

Route: oral

Dosage Amount: 400 mg

Frequency: daily

Pharmaceutical class: mineral and electrolyte

Both

Indication: treatment/prevention of hypomagnesaemia

Adverse/ Side effects: diarrhea, flushing, sweating
Nursing considerations/ Patient Teaching: advice patient not to take this medication within 2 hours of taking other medications, especially fluoroquinalones,
nitrofurantoin, and tetracyclines.
Name: pantoprazole (Protonic) EC tablet
Concentration:
Dosage Amount: 40 mg
Route: oral

Frequency: every morning before breakfast

Pharmaceutical class: proton pump inhibitor

Both

Indication: Erosive esophagitis associated with GERD.

Adverse/ Side effects: headache, Pseudomembranous colitis, abdominal pain, diarrhea, eructation, hyperglycemia, bone fracture.
Nursing considerations/ Patient Teaching: Instruct patient to notify health care professional immediately if rash, diarrhea, abdominal pain, or bloody stools
occur. Advice client to avoid alcohol, NSAIDs or foods that may cause GI irritation.
Name: sirolimus (Rapamune)

Concentration:

Route: oral

Dosage Amount: 1 mg
Frequency: daily

Pharmaceutical class: immunosuppressant

Hospital

Indication: Prevention of organ rejection.

Adverse/ Side effects: progressive multifocal leukoencephalopathy; insomnia; ascites, hepatotoxicity, acne, rash, hypokalemia, tremor
Nursing considerations/ Patient Teaching: Advice patients to notify health care professional if swelling of your face, eyes, or mouth, trouble breathing or
wheezing; throat tightness; chest pain; feeling dizzy or faint; rash or peeling of skin; swelling of hands or feet
Name: tamsulosin (Flomax)
Concentration:
Dosage Amount: 0.4 mg
Route: oral

Frequency: daily

Pharmaceutical class: peripherally acting antiadrenergic

Hospital

Indication: management of outflow obstruction in male patients with prostatic hyperplasia

Adverse/ Side effects: dizziness, headache, rhinitis, orthostatic hypotension, priapism
Nursing considerations/ Patient Teaching: Advice patient to avoid driving dizziness may occur. Change position slowly to minimize orthostatic hypotension.
Notify health care professional of all RX and OTC medications that you are taking.
Name: hydrocodone acetaminophen (Norco)

Concentration:

Dosage Amount: 5 325 mg

University of South Florida College of Nursing Revision September 2014

Route: oral

Frequency: PRN every 6 hours

Pharmaceutical class: opioid analgestic

Hospital

Indication: Management of pain that is severe enough to warrant daily, around the clock.
Adverse/ Side effects: confusion, dizziness, sedation, blurred vision, hypotension, bradycardia, constipation, nausea, vomiting, sweating
Nursing considerations/ Patient Teaching: Medication is hepatotoxic in high doses. Do not stop taking it without discussing with a health care professional; may
cause withdrawal symptoms if discontinued abruptly. Prevent constipation.
Name: methocarbamol (Robaxin)
Concentration:
Dosage Amount: 750 mg
Route: oral

Frequency: 2 times daily

Pharmaceutical class: skeletal muscle relaxant

Both

Indication: Adjunctive treatment of muscle spasm associated with acute painful musculoskeletal conditions.
Adverse/ Side effects: seizures, dizziness, drowsiness, light headedness, anaphylaxis, urticarial, pain at MI site, anorexia, GI upset
Nursing considerations/ Patient Teaching: Take missed doses within 1 hr; if not, return to regular dosing schedule. Do not double dose. Change positions slowly.
Advise patient to avoid concurrent use of alcohol and other CNS depressants. Inform patients that urine may turn black, brown, or green, especially if left
standing. Instruct patient to notify health care professional if skin rash, itching, fever, or nasal congestion occurs.
Name: ondansetron HCl (Zofran)

Concentration:

Route: IV

Dosage Amount: 4 mg
Frequency: PRN every 6 hours

Pharmaceutical class: antiemetic

Hospital

Indication: Prevention of nausea and vomiting.

Adverse/ Side effects: headache, dizziness, drowsiness, weakness, Torsade de Pointes, constipation, diarrhea, abdominal pain, dry mouth
Nursing considerations/ Patient Teaching: Take as directed. Notify health care professional immediately if irregular heart beat or involuntary movement of eyes,
face, or limbs occur.
Name: eszopiclone (Lunesta)
Concentration:
Dosage Amount: 1 mg
Route: oral

Frequency: nightly PRN

Pharmaceutical class: sedative/hypnotic

Home

Indication: Insomnia
Adverse/ Side effects: behavior changes, depression, hallucinations, headache, chest pain, peripheral edema, dry mouth, unpleasant taste, rash
Nursing considerations/ Patient Teaching: Daytime drowsiness avoid driving, avoid alcohol and CNS depressants. Notify health care professional if pregnancy
is planned orsuspected.
Name: prednisone (Deltasone)
Concentration:
Dosage Amount: 5 mg
Route: oral

Frequency: daily

Pharmaceutical class: anti-inflammatory; immune modifier

Home

Indication: Used systemically and locally in a wide variety of chronic diseases including: inflammatory, allergic, hematologic, neoplastic, autoimmune disorders.
Replacement therapy in adrenal incufficiency.
Adverse/ Side effects: depression, euphoria, headache, peptic ulceration, anorexia, vomiting, adrenal suppression.
Nursing considerations/ Patient Teaching: Do not stop the medication suddenly, it may result in adrenal insufficiency - nausea, weakness, hypotension if these
signs appear, notify health care professional immediately. This can be life threatening. Inform health care professional if severe abdominal pain or tarry stools
occur. Report unusual swelling, weight gain, tiredness, bone pain, bruising.
Name: primidone (Mysoline)
Concentration:
Dosage Amount: 50 mg
Route: oral

Frequency: daily

Pharmaceutical class: anticonvulsant

Home

Indication: tonic-colonic, complex partial, and focal seizures.

Adverse/ Side effects: suicidal thoughts, ataxia, drowsiness, vertigo, excitement, anorexia, vomiting, rash, folic acid deficiency
Nursing considerations/ Patient Teaching: Abrupt withdrawal may lead to status epilepticus. Avoid alcohol and other CNS depressants. Advice patient and
family to notify health care professional if thoughts about suicide or dying, attempts commit suicide; new or worsen depression, new of worse anxiety occurs.
Name: tramadol
Concentration:
Dosage Amount: 50 mg
Route: oral

Frequency: every 6 hours PRN

Pharmaceutical class: analgesic

Home

Indication: moderate to moderately severe pain

Adverse/ Side effects: seizures, dizziness, headache, anxiety, CNS stimulation, confusion, visual disturbances, vasodilation, constipation, nausea, abdominal pain,
dry mouth, serotonin syndrome, physiological dependance
Nursing considerations/ Patient Teaching

University of South Florida College of Nursing Revision September 2014

Name: valganciclovir (valcyte)

Concentration:

Route: oral

Dosage Amount: 450 mg

Frequency: 2 times daily

Pharmaceutical class: antiviral

Home

Indication: Treatment of cytomegalovirus retinitis in patients with AIDS. Prevention of CMV disease in kidney, pancreas, and heart transplant patients at risk.
Adverse/ Side effects: seizures, headache, insomnia, agitation, confusion, dizziness, renal impairment, neutropenia, thrombocytopenia, anemia, aplastic anemia,
fever, ataxia
Nursing considerations/ Patient Teaching: Take medication with food. Its not a cure for CMV renitis. Progression may continue in immunosuppressed patients
during and following therapy. Advice patient to notify health care professional if fever; chills; sore throat; other signs of infection occur. Caution patient to avoid
crowds and persons with known infections.
Name: warfarin (Coumadin)
Concentration:
Dosage Amount: 3 mg
Route: oral

Frequency: daily

Pharmaceutical class: anticoagulant

Home

Indication: prophylaxis and treatment of: venous thrombosis, pulmonary embolism; atrial fibrillation with embolization. Management of myocardial infarction.
Adverse/ Side effects: Bleeding, cramps, nausea
Nursing considerations/ Patient Teaching: Instruct patient to take medication as directed; report any symptoms of unusual bleeding or bruising, and pain, color
or temperature changes to any area of your body to health care professional immediately.

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 diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: bagel (245 calories 50g carbs; 10g protein, 2g
The patient caloric intake is adequate for the age and level
fats) and cream cheese (290 calories 16g fat, 3g carbs, 5g of activities performed when he is outside of the hospital.
protein
Its very important that he learns to manage his DM trough
Total: 535 calories
diet and exercise. Modified eating habits are essential it
Lunch: 6 oz roasted turkey (177 calories 3g fats, 7g carbs,
order to avoid drastic insulin spikes and drops mainly
30g protein) with cup of green beans (34 calories 8g
caused by inappropriate carbohydrate consumption. I would
carbs, 2g protein) and cup of roasted potatoes (200 calories teach the patient how to balance his diet with a variety of
9g fats, 26g carbs, 3g protein)
foods, including fruits, vegetables, whole grain foods, low
Total: 411 calories
diary products, lean meat, fish and poultry. It is very
Dinner: 6oz Grilled Steak (429 calories 25g fat, 46g
important that he maintains low fat and low sugar diet and
protein) and 2 cups French fries (364 calories 16g fat,
avoids saturated fats and simple sugars. Mr. Smith will
42g carbs, 4g protein)
need to increase fiber and water intake, and lower salt. He
Total: 793
will learn how to read the products labels and avoid
Total for the day: 1739 calories
processed foods as much as possible. Currently the patient
Liquids (include alcohol): about 1.5 liters of water, small
is diagnosed with AKI. Recommendations include 20-30
diet coke (12 oz)
kcal/kg/day to avoid catabolism. The sodium consumption
needs to be minimized to 2g/kg/day (unless hypovolemic)
no additional salt when preparing meals, be aware and
check the labels when buying foods at the grocery store. In
cases of hyperkalemia we need to restrict the potassium
dietary consumption as well (bananas, avocados, apricots).
Avoiding magnesium and aluminum compounds will be
beneficial.
The liquid consumption is somewhat adequate. Higher
water intake would be recommended and avoidance of
carbonated, artificially sweetened beverages.

Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My neighbor helps me. He drove me here for my appointment. Unfortunately my wife
has Alzheimers disease and she lives in an assisted facility.
How do you generally cope with stress? or What do you do when you are upset?
I have been trying breathing techniques. I try to be outdoors, that helps me clear my head.

University of South Florida College of Nursing Revision September 2014

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I feel fine, the kids are helping when they can.

+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, never.___________________
Have you ever been talked down to?__
Not that I remember._____________
Have you ever been hit punched or slapped? _When I was a kid my dad slapped us around._____________
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? I feel safe. My wife no logger lives with me. She is in Alzheimers assisted
facility.

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. X 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:
The patient is in stage Integrity vs. Despair. This stage occurs after the age of 65 till the end of life. During that period people reflect
on their life. They either feel fulfilled from a life well lived or sense of regret and despair over a life misspent. Those who feel proud
of their accomplishments will feel a sense of integrity.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patience experiences a sense of integrity. He looks back with a few regrets and a general feeling of satisfaction. He is
a very nice, well-spoken, confident gentleman. He treats everyone with respect. He shared that he is proud that he served
the country for 6 years and also very happy that he had a fulfilling personal life and successful children. The client is
proud of his accomplishment as a fire fighter.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The patient likes to be active garden, take walks, and being outdoors. His mobility is still limited and he is working his way up
towards progress with the help of his nurses and physical therapy.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? It all started with the lung cancer. Cancer can happen to anyone.

What does your illness mean to you? It means that Im getting old. Im not giving up yet.

University of South Florida College of Nursing Revision September 2014

+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?
Females only.
Are you aware of ever having a sexually transmitted infection? __
No, I dont have any._____________________________________________
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? __Im not sexually active anymore. I have only slept with my wife for the last 50 years. When we didnt
want anymore kids she was on oral birth control.________________________________
How long have you been with your current partner?___
_Me and my wife have been married for 50 years.____________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity?
___No.________________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No.

University of South Florida College of Nursing Revision September 2014

10

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

What importance does religion or spirituality have in your life?
I pray sometimes, but I havent been in church in a long time.
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?
How much?(specify daily amount)
He smoked tobacco cigarettes.
A pack a day

Yes
No
For how many years? 40 years
(age 28

thru

68

If applicable, when did the

patient quit? Patient quit 8 years
ago.

Pack Years:

Does anyone in the patients household smoke tobacco? If

so, what, and how much?
No one smokes around the patient.

Has the patient ever tried to quit?

He quit 8 years ago.
If yes, what did they use to try to quit?
He just stopped smoking. Used his strong will.

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?

No
For how many years?
(age

thru

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?
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
I worked as a firefighter. Even though we wore the protective outfits, there was always a risk of inhaling smoke.

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

University of South Florida College of Nursing Revision September 2014

11

 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: patient does not use
sunscreen.
SPF:
Bathing routine: daily
Other: edema on lower extremities +2

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
2 times a day

X Nausea, vomiting, or diarrhea

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

Immunologic
Chills with severe shaking
Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction

Appendicitis
Abdominal Abscess
Last colonoscopy?
Other: abdomen appearance - distended

Enlarged lymph nodes

Other: None

Genitourinary

Anemia
Bleeds easily
Bruises easily
X Cancer lung cancer in the past
Blood Transfusions
Blood type if known:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 960
ml/day
Bladder or kidney infections

Hematologic/Oncologic

Other: Patient underwent lung transplant

Metabolic/Endocrine
Patient had a low urine output upon
admission. He has a ureteral catheter
placed. Flomax administered urine out
put measures 30ml/h.

Routine dentist visits

Twice a year
Vision screening once a year
Other:

X Diabetes

Type: 2

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
X Cough - productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 10/7/2015
Other:

Cardiovascular
X Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD

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?
No infection detected
Frequency of prostate exam? Once a
year
Date of last prostate exam? Unknown
BPH
X Urinary Retention upon admission

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other: None

University of South Florida College of Nursing Revision September 2014

12

urinary output was lower than 500ml/day

due to AKI

Musculoskeletal

CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other: 7/10/2015

X Injuries or Fractures spinal lumbar

fracture
X Weakness generalized weakness
X Pain lower back #3 out of #10
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:None

General Constitution
Recent weight loss or gain. - None
How many lbs?
Time frame?
Intentional?
How do you view your overall health? I feel like my health has declined a lot.

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

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

University of South Florida College of Nursing Revision September 2014

13

10 PHYSICAL EXAMINATION:
General Survey:
Height:172.7 cm
Weight: 76.8 kg
BMI: 25
Pain: (include rating and
76 years old white male.
(57.99)
169 lbs
location): chronic lower
Alert and oriented x4. No Pulse: 63
back pain at #3 out of #10
Blood Pressure: (include location)
signs of distress.
123/73 right arm
Respirations: 18
Temperature: (route
SpO2: 99%
Is the patient on Room Air or O2:
Room air
taken?)98 F - oral
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
X clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
X clear, crisp diction
Mood and Affect: X pleasant X cooperative
cheerful
X talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
X Skin is warm, dry, and intact X Skin turgor elastic X No rashes, lesions, or deformities
X Nails without clubbing X Capillary refill < 3 seconds X Hair evenly distributed, clean, without vermin
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 IV Location: right brachial vein
Date inserted: 10/27/2015
Fluids infusing?
no X yes - what? 0.9% Saline

flat
loud

HEENT: X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ X Trachea midline
X Thyroid not enlarged
X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge
X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
X PERRLA pupil size / mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmus
X Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
X Nose without lesions or discharge X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: WDL
Comments:
Pulmonary/Thorax: X Respirations regular and unlabored X Transverse to AP ratio 2:1 X Chest expansion symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
X Sputum production:
thin
Amount:
small
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL - clear
LUL - diminished
RML - clear
LLL - diminished
RLL - diminished
CL Clear; WH Wheezes; - in lower posterior lobes CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent

University of South Florida College of Nursing Revision September 2014

14

Cardiovascular: X No lifts, heaves, or thrills

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

Calf pain bilaterally negative X Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
Carotid:
Brachial:
Radial: 1
Femoral:
Popliteal:
DP: 1
PT:1
X No temporal or carotid bruits
Edema: yes
+1 and +3 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm)
Location of edema: left leg +1; right leg +1; left ankle +3; right ankle +3; left foot +3; right foot +3
pitting
X Extremities warm with capillary refill less than 3 seconds
GI
X Bowel sounds active x 4 quadrants; no bruits auscultated
X No organomegaly
X Percussion dull over liver and spleen and tympanic over stomach and intestine
X Abdomen non-tender to palpation
Last BM: (date 11 /04 / 2015 ) Soft
Color: Light brown
Nausea
emesis Describe if present: None
Genitalia: X Clean, moist, without discharge, lesions or odor
Other Describe:
GU
Urine output: X Clear
Cloudy
X Foley Catheter
Urinal or Bedpan
CVA punch without rebound tenderness

Color:
Bathroom Privileges

Not assessed, patient alert, oriented, denies problems

Previous 24 hour output:

750 mLs

without assistance

Musculoskeletal: X Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ____3___ RUE ____3___ LUE ___3____ RLE

& ___3____ in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

X vertebral column without kyphosis or scoliosis

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

Gate weak, patient needs assistance to ambulate.

University of South Florida College of Nursing Revision September 2014

15

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
WBC
2.90
2.23
2.20
Normal (4.6 10.2)

RBC
3.43
3.04
Normal (4.7 6.13)

HGB
10.6
9.3
9.2
Normal (14.1 18.1)
HCT
34.1
30.0
29.8
Normal (43.5 53.7)

Dates
(10/27/2015)
(10/28/2015)
(10/29/2015)

(10/27/2015)
(10/28/2015)

(10/27/2015)
(10/28/2015)
(10/29/2015)
(10/27/2015)
(10/28/2015)
(10/29/2015)

Trend
The WBCs are low in
count and are
continuously decreasing.

Analysis
Patient is
immunosuppressed
because he is taking
medications in order to
avoid lung transplant
rejection. He is
experiencing medication
educed leukocytopenia.
Upon admission he was
swithed to sirolimus
(Rapamune) which is less
nephrotoxic, instead of
azathioprine (Imuran).
This may be contributing
to the current trend.
This could be indicative
Patients RBC are
for anemia. In this case
declining in count.
its related to AKI in
which the kidneys dont
produce enough EPO. If
we dont have enough of
that hormone the bone
marrow is not stimulated
to produce RBCs.
Patients hemoglobin is
The patient presents with
low and shows trend to be acute kidney failure,
decreasing.
which is indicative for the
low hemoglobin.
Hematocrit is low and
progressively worsening.
That may lead to
impaired oxygenation and
tissue perfusion.

A low hematocrit with

low RBC count and low
hemoglobin indicates
anemia. In some causes
kidney failuresevere
and chronic kidney
diseases lead to decreased
production of
erythropoietin, a hormone
produced by the kidneys
that stimulates RBC

University of South Florida College of Nursing Revision September 2014

16

The p
acute
whic
low h

NA
133
131
135
Normal (135 146)

K
5.3
5.1
4.9
Normal (3.5 5.3)
CL
100
98
101
Normal (97 107)
CO2
16
23
27
Normal (22 29)
BUN
56
73
68
Normal (7 25)
GLU
178
225
194
Normal (65 99)
Creatinine
4.9
5.8

(10/27/2015)
(10/28/2015)
(10/29/2015)

(10/27/2015)
(10/28/2015)
(10/29/2015)
(10/27/2015)
(10/28/2015)
(10/29/2015)

(10/27/2015)
(10/28/2015)
(10/29/2015)
(10/27/2015)
(10/28/2015)
(10/29/2015)
(10/27/2015)
(10/28/2015)
(10/29/2015)

(10/27/2015)
(10/28/2015)

The sodium levels are

low. The trend is showing
a slight improvement.

The potassium levels are

on the higher end of the
normal values. The trend
is showing improvement.
Chloride is in normal
ranges.

CO2 was low upon

admission, but came back
up to a normal value.

production by the bone

marrow.
A low level of blood
sodium is usually due to
loss of too much sodium,
too much water intake or
retention, or to excess
fluid accumulation in the
body (edema). The
patient has lower
extremities pitting edema.
Hyponatremia is rarely
due to decreased sodium
intake. In this case it is
due to the AKI,
dehydration, and
vomiting.
The increased potassium
levels are indicative for
the ongoing AKI,
dehydration, and DM.
It is usually ordered as
part of an electrolyte
panel, a basic metabolic
panel, or a comprehensive
metabolic panel, which
are ordered frequently as
part of a routine physical.
Low CO2 is indicative for
the presence of kidney
disease and metabolic
acidosis.

The values were

extremely high upon
admission and continued
to go up.

Increased BUN levels

suggest impaired kidney
function and dehydration.

The blood glucose is high

upon admission and
remains high.

It is indicative for the DM

type 2, which is not very
well controlled. Another
reason for the high values
is medication-induced
hyperglycemia
corticosteroids.
Creatinine is a waste
product produced by
muscles from the

Just like the BUN, the

creatinine values are very
high.

University of South Florida College of Nursing Revision September 2014

17

4.9
Normal (0.7 1.18)

(10/29/2015)

breakdown of a
compound called creatine.
Almost all creatinine is
filtered from the blood by
the kidneys and released
into the urine, so blood
levels are usually a good
indicator of how well the
kidneys are working.The
reason for the high
creatinine levels is AKI
and dehydration.

+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.)
1. Diabetes mellitus: sliding scale insulin. Pharmaceutical management of type 2 diabetes. Given daily.
Accu checks performed 3 times a day.
2. Osteoporosis prophylaxis performed Pharmaceutical management: calcium and vitamin D.
3. DVT prevention sequential compression devices applied; Coumadin (Warfarin) administered 3ml daily.
4. Lung transplant rejection prevention immunosuppression therapy: sirolimus (Rapamune).
5. Nephrology consult scheduled in order to find out weather of not hemodialysis is necessary.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Pain in lower back, related to lumber fracture at L4, as evidenced by patient states Im in pain.
2. Decreased urinary output, related to acute kidney injury, as evidenced by less than 500 ml in the foley bag for the first
24 hours.
3. Unstable blood glucose, related to Diabetes Mellitus type 2, as evidenced by fasted blood glucose levels higher than 120.
4. Abrupt loss of kidney function, related to acute kidney injury, as evidenced by rise in creatinine of > 1.18 and BUN >25.
5. Risk for infections, related to immunosuppression, as evidenced by low WBC count, lower than 4.6.

University of South Florida College of Nursing Revision September 2014

18

 15 CARE PLAN
Nursing Diagnosis: Abrupt loss of kidney function, related to acute kidney injury, as evidenced by rise in creatinine of
> 1.18 and BUN >25.

Patient Goals/Outcomes
Homeostasis achieved.
Patient laboratory results
and vital signs will be in
normal limits.
Complications prevented
or minimized. Disease
process, prognosis, and
therapeutic regimen
understood. Display
appropriate urinary output
with specific
gravity/laboratory studies
near normal; stable weight,
vital signs within patients
normal range; and absence
of edema (Ackley &
Ladwig, 2014).
Patient will have normal
urine output.

Nursing Interventions to
Achieve Goal

Rationale for
Interventions
Provide References
Accurately record intake
Decrease in output (to
and output (I&O) noting
less than 400 ml per 24
to include hidden fluids hours) may indicate acute
such as IV antibiotic
failure, especially in highadditives, liquid
risk patients. Accurate
medications, frozen treats, monitoring of I&O is
ice chips. Religiously
necessary for determining
measure gastrointestinal
renal function and fluid
losses and estimate
replacement needs and
insensible losses
reducing risk of fluid
(sweating), including
overload. Do note that
wound drainage,
hypervolemia usually
nasogastric outputs, and
occurs in anuric phase of
diarrhea(Ackley &
ARF and may mask the
Ladwig, 2014) .
symptoms (Ackley &
Ladwig, 2014).
Weigh daily at same time
of day, on same scale,
with same equipment and
clothing (Ackley &
Ladwig, 2014).
Assess skin, face,
dependent areas for
edema. Evaluate degree
of edema (on scale of +1
+4) (Ackley & Ladwig,
2014).

Monitor heart rate (HR),

BP, and JVD/CVP
(Ackley & Ladwig,

Daily body weight is best

monitor of fluid status. A
weight gain of more than
0.5 kg/day suggests fluid
retention (Ackley &
Ladwig, 2014).
Edema occurs primarily
in dependent tissues of
the body, (hands, feet,
lumbosacral area). Patient
can gain up to 10 lb (4.5
kg) of fluid before pitting
edema is detected.
Periorbital edema may be
a presenting sign of this
fluid shift because these
fragile tissues are easily
distended by even
minimal fluid
accumulation (Ackley &
Ladwig, 2014).
Tachycardia and
hypertension can occur
because of: (1) failure of

Evaluation of Goal on
Day Care is Provided
Upon admission the first
24h showed urinary
output of 500. The
following 24h showed
1500. Goal was
achieved. Patient has
regular urine output.

Patient doesnt shoe

more than 1kg
fluctuation within 24
hours.
Patient still presents with
pitting edema of +2 in
the ankles and +1 in
legs.

Vital signs are stable BP

123/73; RR 18; HR 63.
Pin level is down to #3

University of South Florida College of Nursing Revision September 2014

19

2014).

Blood urea nitrogen

(BUN), creatinine (cr)
(Ackley & Ladwig,
2014).

Insert indwelling catheter,

as indicated (Ackley &
Ladwig, 2014).

the kidneys to excrete

urine, (2) excess fluid
resuscitation during
efforts to treat
hypovolemia and/or
hypotension or convert
oliguric phase of renal
failure, (3) changes in the
renin-angiotensin system.
Invasive monitoring may
be needed for assessing
intravascular volume,
especially in patients with
poor cardiac function
(Ackley & Ladwig,
2014).
BUN assess management
of renal dysfunction. Both
values may increase but
creatinine is a better
indicator of renal function
because it is not affected
by hydration, diet, and
tissue catabolism.
Dialysis is usually
indicated if ratio is higher
than 10:1 or if therapy
fails to indicate fluid
overload or metabolic
acidosis (Ackley &
Ladwig, 2014).
Catheterization excludes
lower tract obstruction
and provides means of
accurate monitoring of
urine output during acute
phase (Ackley & Ladwig,
2014).

BUN and creatinine

remain high. Patient may
need dialysis. Consult
with nephrologist
scheduled for this
afternoon.

Urinary catheter is
inserted. Patient states he
feels relieved.

Include a minimum of one

Long term goal per care
plan
University of South Florida College of Nursing Revision September 2014

20

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
15 CARE PLAN
Nursing Diagnosis: Pain in lower back, related to lumber fracture at L4, as evidenced by patient states, Im in
pain.

Patient Goals/Outcomes

Nursing Interventions
to Achieve Goal

The patient will report

improvement of back pain
and an increase in daily
activities by next follow-up
appointment (Ackley &
Ladwig, 2014).
The patient will verbalize
expectation of course of
pain treatment and his
desired outcomes of
treatment goals (Ackley &
Ladwig, 2014).

The nurse will assess the

patients report of
improvement of back
pain and an increase in
daily activities (Ackley &
Ladwig, 2014).
The nurse will assess the
patients expectation of
the course of pain
treatment and his desired
outcome of treatment
goals (Ackley & Ladwig,
2014).
The nurse will educate
the patient on 5
noninvasive pain relief
measures to help manage
the patients pain (Ackley
& Ladwig, 2014).
The nurse will educate
the patient on how to
correctly take the
prescribed prn medication
for his back pain (Ackley
& Ladwig, 2014).

The patient will list 5

noninvasive pain relief
measures to help manage
the pain (Ackley &
Ladwig, 2014).
The patient will verbalize
how to correctly take
prescribed prn medication
for his back pain (Ackley
& Ladwig, 2014).

Rationale for
Interventions
Provide References
It is important to keep the
pain in control in order to
promote increase of daily
activities and patient
independence.

Evaluation of Goal on
Day Care is Provided
Patient states that the
pain level is now #3 on
the scale of 0-10 in
comparison to #7 on
admission.

Patient desired outcome

in the course of treatment
are discussed. Patient
desires to be able to
ambulate without
assistance and no pain.

Patient ambulates with

walker. Patient showing
improvement in mobility.

It is important to teach
the patient different
relaxation methods which
may help with pain relief
instead of depending solo
on medications.
Patient receives
hydrocodone (Norco)
every 6 hours as
prescribed. Sometimes he
refuses the medication.

Patient states, I enjoy

meditation and breathing
exercises, they help me
relax and forget about my
back pain.
Patient states, I dont
need the medication as
often as 6 hours, if I
dont experience as much
pain.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include
for discharge teaching)
University of South Florida College of Nursing Revision September 2014

21

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

22

References
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed.). Maryland Heights, MO: Elsevier.
Bellomo R, Kellum JA, Ronco C. Acute kidney injury. Lancet. (2012);
380(9843):756-766.
Bagshaw SM, George C, Bellomo R. (2012). Early acute kidney injury and sepsis: a
multicenter evaluation. Crit Care;12(2):R47.
Osborn, K.S., Wraa, C.W., Watson, A.B., & Holleran, R. (2014). Medical-surgical nursing: Preparation for practice (2nd ed.). Upper Saddle River, NJ: Pearson Education,
Inc.:1211-1231
Unbound Medicine, Inc. (2015). Nursing Central (Version 1.26). [Mobile application software]. Retrieved from http://itunes.apple.com
Waikar SS, Liu KD, Chertow GM (2011). Diagnosis, epidemiology and outcomes of
acute kidney injury. Clinical journal of the American Society of Nephrology:
CJASN; 3(3):844-861.

University of South Florida College of Nursing Revision September 2014

23