Professional Documents
Culture Documents
COLLEGE OF NURSING
Student: Kelly Cullinan
Assignment Date: 1/15/16
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: SMH
1 PATIENT INFORMATION
Patient Initials: CS Age: 76 Admission Date: 1/12/16
Gender: Male Marital Status: Married Primary Medical Diagnosis: Complete tear of ACL
Primary Language: English
Level of Education: Bachelors degree Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired from school teaching
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is a 76-year-old male admitted to the emergency room on 1/12/16 at 1400 following a motor vehicle accident.
The patient was the restrained driver and denied a loss of consciousness. He sustained a complete ACL tear to the left
knee that did not require any surgery.
Kidney Problems
Environmental
Trouble
Health
Stomach Ulcers
Bleeds Easily
Hypertension
Cause
etc.)
FAMILY
Alcoholism
Glaucoma
Diabetes
Arthritis
Seizures
Anemia
Asthma
of
Cancer
Problems
Tumor
Stroke
Allergies
MI, DVT
Gout
MEDICAL Death
Mental
Heart
HISTORY (if
(angina,
applicable
)
Myocardi
Father 81 al
infarction
Mother 75 Cancer
Brother
Sister 72
Relationship
relationship
relationship
Father was diagnosed with hypertension and hypercholesterolemia in his 60s. Mother diagnosed with lung cancer at age 74. Unknown
when exactly sister was diagnosed with hypertension.
1 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) Date unknown
Adult Tetanus (Date) Is within 10 yearsWithin past 10 yrs, date unknown
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
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
Medications
None
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)
The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee, which usually occurs in
athletes and the younger population (Maguire, n.d.). This injury can occur from rapidly changing direction, suddenly
stopping, slowing down while running, landing from a jump incorrectly, or direct contact or collision (Maguire, n.d.).
Symptoms of an ACL tear include pain with swelling in the knee, loss of full range of motion, tenderness along the joint
line, and discomfort while walking (Maguire, n.d.). An ACL tear is diagnosed with an X-ray to rule out any bone injury
and an MRI. There are both surgical and nonsurgical treatments for a complete ACL tear. The ACL will not heal without
surgery, but may be a good option for elderly patients or those who have a low activity level (Maguire, n.d.). The doctor
may recommend a knee brace and physical therapy. Surgical treatment requires reconstruction of the ligament with a
tissue graft (Maguire, n.d.). Almost all ACL injuries will require physical therapy.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name citalopram (Celexa) Concentration Dosage Amount 20 mg
Route Oral Frequency Daily
Pharmaceutical class SSRI Home Hospital or Both
Indication Depression
Adverse/ Side effects Neuroleptic malignant syndrome, suicidal thoughts, torsade de pointes, serotonin syndrome,
apathy, confusion, drowsiness, insomnia, weakness, sweating, tremor
Nursing considerations/ Patient Teaching Advise patient, family, and caregivers to look for suicidality, especially during early
therapy or dose changes.
Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Route Frequency
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My wife
How do you generally cope with stress? or What do you do when you are upset? I like to go play golf or relax at the
beach. I also love spending time with my children and grandchildren.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I didnt really have any until I got in this accident.
Have you ever been talked down to?__No_____________ Have you ever been hit punched or slapped?
____No________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_____________No_____________________________ If yes, have you sought help for this? ______________________
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: The task of this stage is the acceptance of ones life, worth, and eventual death. Ego integrity reflects a
satisfaction with life and an understanding of ones place in the life cycle. A sense of loss, discomfort with life and aging, and a fear of
death are seen in despair (Treas & Wilkinson, 2014).
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 ego integrity stage. He seemed to be satisfied with the life he has lead and was in good spirits. He had
a very positive outlook on life in general and was accepting of his age.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The only impact it has had will that it will limit his mobility and he will have to have home health with physical therapy
for a while, but he is expected to make a full recovery and be able to walk as he did before .
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? My car accident
What does your illness mean to you? I guess it means I need to be a little more careful driving.
+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
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?_______52 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
Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? No If yes, what did they use to try to quit?
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Usually beer, liquor on occasion How much? 1-3 bottles For how many years?
Volume: (age 16 thru present )
Frequency: 1-2 times a week, socially
If applicable, when did the patient quit?
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 thru )
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No
5. For Veterans: Have you had any kind of service related exposure? N/A
Gastrointestinal Immunologic
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
Use of sunscreen SPF: 50 Diverticulitis Life threatening allergic reaction
Bathing routine: Daily Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy? Date unknown
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: Unknown
Post-nasal drip Normal frequency of urination: 8-9 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2 x/day Diabetes Type:
Routine dentist visits x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY 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 regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? 1/12/16 menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Unknown Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 1/12/16 Arthritis Chicken Pox
General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health? I think I am pretty healthy overall besides the high blood pressure.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No
Any other questions or comments that your patient would like you to know? No
General Survey: Height 510 Weight 186 BMI 26.7 Pain: (include rating and
Pulse 76 Blood Pressure: 166/84 Left Arm location) 2/10 in left knee
Respirations 17
Temperature: (route SpO2 95% Is the patient on Room Air or O2 :
taken?) 98.6 Oral Room Air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
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: 20 gauge Location: Right forearm Date inserted:
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 / 3 mm 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: WNL
Comments:
Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL CL LUL CL
RML CL LLL D
RLL D
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: [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: Bilateral lower extremities pitting non-pitting
Extremities warm with capillary refill less than 3 seconds
GU Urine output: Clear Cloudy Color: Yellow Previous 24 hour output: N/A mLs
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
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
MRI of Left Knee 1/12/16 There is no trend. The MRI of the left knee
showed a complete tear
of the anterior cruciate
ligament (ACL).
University of South Florida College of Nursing Revision September 2014 15
+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 a regular diet. He is scheduled to have vitals taken every 4 hours. He is able to ambulate to the
bedside commode or bathroom with assistance. He also ambulates with physical therapy and occupational
therapy as tolerated.
2.Impaired physical mobility r/t to complete ACL tear as evidenced by mildly compromised ambulation
3.
4.
15 CARE PLAN
Nursing Diagnosis: Acute pain related to knee injury as evidenced by patient complaining of 2/10 pain on a numeric pain scale
Patient Nursing Interventions to Achieve Goal Rationale for Interventions Evaluation of Interventions
Goals/Outcomes Provide References on Day care is Provided
Patient will report a -Assess pain level using a valid and reliable self-report -The first step in pain The goal was met. Patient
pain level of 4 or less pain tool, such as the 0-10 numerical pain rating scale. assessment is determining reported 2/10 aching pain in
on a scale of 0-10 this Ask the patient to rate pain intensity and OLDCART. whether the client can provide a his left knee on the numeric
shift -Assess the patient for pain routinely at frequent self-report. Single dimension pain scale.
intervals and during activity and rest, as well as during pain ratings are valid and
interventions or procedures reliable as measures of pain
-Administer prescribed pain medications; monitor vital intensity levels (Ackley, 2010)
signs, I&Os, and labs -Pain assessment is as important
-Use nonpharmacological methods to help control pain as physiological vital signs.
such as repositioning, distraction, imagery, relaxation, Acute pain should be reliably
and application of heat or cold* assessed both at rest (important
for comfort) and during
University of South Florida College of Nursing Revision September 2014 17
movement (important for
function and decreased client
risk of cardiopulmonary and
thromboembolic events)
(Ackley, 2010)
-Cognitive-behavioral strategies
can restore the clients sense of
self-control, personal efficacy,
and active participation in his or
her own care
Notify member of the -When notified, use pharmacologic and Goal was met. Patient notified
health care team nonpharmacologic measures to relieve pain nurse when experiencing
promptly for pain level unmanageable pain.
greater than the
comfort-function goal,
or occurrence of
adverse effects
Nursing Diagnosis: Impaired physical mobility r/t to complete ACL tear as evidenced by mildly compromised ambulation
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will verbalize feeling of -Screen for mobility skills: bed -The nursing assessment should The goal was not met. The patient
increased strength and ability to mobility; supported and include factors related to mobility was being discharged and did not
move unsupported sitting; transition problems with nursing goals and feel comfortable going home
movements such as sit to stand, interventions to determine how to without home health nursing care.
sitting down, and transfers; and best facilitate the movement of the Home health physical/occupational
standing and walking activities patient and protect the nurse from therapy had already been ordered.
(Ackley, 2010) harm (Ackley, 2010)
-Monitor and record the clients -It is proven that a regimen of
ability to tolerate activity and use regular physical activity that
all four extremities (Ackley, 2010) includes both aerobic exercise and
-Help the client achieve mobility muscle strengthening activities is
and start walking as soon as beneficial to minimizing impaired
possible if not contraindicated mobility (Ackley, 2010)
(Ackley, 2010)
University of South Florida College of Nursing Revision September 2014 18
-Consult with physical therapist for
further evaluation, strength
training, gait training, and
development of a mobility plan
(Ackley, 2010)
Patient will demonstrate use of -Obtain any assistive devices -Assistive devices can help The goal was met. The patient
adaptive equipment to increase needed for activity such as a gait increase mobility (Ackley, 2010) demonstrated transferring from the
mobility belt, weighted vest, walker, cane, -Braces support and stabilize a wheelchair to the bedside
crutches, or wheelchair, before the body part, allowing increased commode.
activity begins (Ackley, 2010). mobility (Ackley, 2010)
-Apply any ordered brace before
mobilizing the client (Ackley,
2010)
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:
The patient would like to have home health physical and occupational therapy. He needs orders for a wheelchair and bedside commode.
Ackley, B. (2010). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). Maryland
Heights, MO: Mosby.
Maguire, J. (n.d.). Anterior Cruciate Ligament Pathology. Retrieved March 11, 2016, from
http://emedicine.medscape.com/article/1252414-overview
Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning. Philadelphia, PA: F.A. Davis
Company.