UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Jennifer Altman

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date:02/04/15
Agency: MPM

Patient Initials: PQ

Age: 86

Admission Date: 01/23/15

Gender:

Marital Status: Widowed

Primary Medical Diagnosis: Pneumococcal

Pneumonia

Female

Primary Language: English

Level of Education: High school

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired, file clerk for the sheriffs
department
Number/ages children/siblings: Son 52, daughter 54, Son (died at
age 7)
Served/Veteran: No
If yes: Ever deployed? Yes or No

Code Status: Full Code

Living Arrangements: Lives with granddaughter and 2 great

grandchildren. In a one story home with no pets.

Advanced Directives: Living will & Health Care

Proxy (daughter)
If no, doDate:
they want to fillProcedure:
them out?
Surgery

Culture/ Ethnicity /Nationality:

Religion: Catholic

Type of Insurance: Medicare

1 CHIEF COMPLAINT:
I was having a really hard time breathing and was coughing uncontrollably and kept coughing up this yellow stuff.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Presented one month ago with bronchitis was sent home on antibiotics. Readmitted to the ER
which was thought to be bronchitis for the second time and turned out to be pneumococcal
pneumonia.
O= 01/23/15 is when it became unbearable but Ive been feeling bad for a month.
L= Lungs
D= Constant dyspnea
C= Feeling of something tightening around the lungs making them feel smaller
A= Physical exertion
R= Rest with head elevated
T= Seek medical help

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

Father

68

Mother

74

MI

Grandmother
71
(Maternal)

MI

Tumor

Stroke

Stomach Ulcers

Seizures

Kidney
Problems
Mental Health
Problems

Hypertension

(angina, MI, DVT etc.)

Heart Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable)
Colon
Cancer

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Alcoholism

Tonsillectomy
Appendectomy
Cholecystectomy
Total hysterectomy
Heart failure
Type 2 diabetes
Hypothyroidism

Age (in years)

1937
1951
1977
1977
2013
1981
1981

X
X

X
X

Comments: Both mother and Grandmother began to heart troubles in their early to mid-fifties. Patient stated Almost everyone on my
moms side including aunts, uncles and cousins have had trouble with their heart.

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) U
Adult Tetanus (Date) Is within 10 years? U
Influenza (flu) (Date) Is within 1 years? Yes 09/13/14
Pneumococcal (pneumonia) (Date) Is within 5 years? Yes 10/19/14
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

YES

NO
X
X

X
X
X
X

University of South Florida College of Nursing Revision September 2014

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Septra

Terrible stomach ache I just remember not liking the way I felt after

Tape

Itching, swelling, rash, and blisters

Medications

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 body uses nasal hair, mucociliary clearance, saliva, and cough as upper airway
protection; it uses epiglottic reflexes, immunoglobulin alveolar fluid, alveolar macrophages,
neutrophil recruitment and dendritic cells to prevent lower respiratory infections. It takes a
breakdown in these defenses to allow Streptococcus pneumonia access to the lungs where it
causes an infection (Osborn K et al., 2010). Risk factors include children younger than 5
or adults older than 65, as well as people with certain medical conditions such as chronic
heart, lung or kidney disease, sickle cell anemia, HIV/ AIDs, and organ transplant patients
(Pneumococcal Pneumonia, 2011). To diagnosis physicians consider symptoms, physical
exam, lab tests and finally a chest X-ray (Pneumococcal Pneumonia, 2011). Seventy
percent of patients recover from the infection and the other thirty percent have complications
with the bacteria entering the blood stream causing serious complications and other lung
problems (Pneumococcal Pneumonia, 2011). Treatment is to administer prescription antibiotics as soon as possible.

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

Concentration: 500 mg

Route: PO

Dosage Amount: 500 mg

Frequency: q12hr

Pharmaceutical class: aminopenicillins

Home

Hospital

or

Both

Indication: Treatment of respiratory infection

Adverse/ Side effects: diarrhea, N/V, anaphylaxis, rash, seizures
Nursing considerations/ Patient Teaching: Explaining signs and symptoms of anaphylaxis and the importance of reporting its symptoms
Name: sitagliptin (Januvia)

Concentration: 25mg

Route: PO

Dosage Amount: 25mg

Frequency: 1xDaily

Pharmaceutical class: enzyme inhibitors, anti-diabetic

Home

Hospital

or

Both

Indication: Glycemic control in pt with type 2 diabetes

Adverse/ Side effects: headache, pancreatitis, allergic reactions, stevens-johnson syndrome
Nursing considerations/ Patient Teaching: Observe the patient for signs of hypoglycemia.
Name: prednisone
Route: PO

Concentration: 30mg

Dosage Amount: 90mg

Frequency: BID

University of South Florida College of Nursing Revision September 2014

Pharmaceutical class: steroidal anti-inflammatories

Home

Hospital

or

Both

Indication: Used for pt chronic arthritis

Adverse/ Side effects: depression, euphoria, hypertension, N/V, adrenal suppression, thromboembolism, cushingoid appearance, hyperglycemia
Nursing considerations/ Patient Teaching: Inform the patient that increased glucose is common and that the blood glucose must be monitored closely
Name: albuterol- ipratropium (DuoNeb)

Concentration: 3 ml

Route: Soln

Dosage Amount: 3ml

Frequency: rtq6h

Pharmaceutical class: adrenergics, bronchodilators

Home

Hospital

or

Both

Indication: Control and prevent airway obstruction caused by COPD

Adverse/ Side effects: nervousness, restlessness, tremor, paradoxical bronchospasm, chest pain, palpations
Nursing considerations/ Patient Teaching: asses lung function before and periodically during treatment
Name: warfarin (Coumadin)

Concentration: 4mg

Route: PO

Dosage Amount: 4mg

Frequency: 1xDaily

Pharmaceutical class: coumarins, anticoagulants

Home

Hospital

or

Both

Indication: Prophylaxis of pulmonary embolism

Adverse/ Side effects: cramps, nausea, bleeding
Nursing considerations/ Patient Teaching: regular blood tests are needed to ensure INR is in desired range
Name: amlodipine

Concentration: 10mg

Route: PO

Dosage Amount: 20mg

Frequency:1xDaily

Pharmaceutical class: calcium channel blockers, antihypertensive

Home

Hospital

or

Both

Indication: Management of hypertension

Adverse/ Side effects: dizziness, peripheral edema, flushing
Nursing considerations/ Patient Teaching: BP monitoring should be done before, and after administration
Name: aspirin

Concentration: 81mg

Route: PO

Dosage Amount: 81mg

Frequency: 1xDaily

Pharmaceutical class: salicylates, nonopioid analgesics

Home

Hospital

or

Both

Indication: relieve pain cause by arteritis

Adverse/ Side effects: GI bleeding, dyspepsia, epigastric distress, nausea, anaphylaxis and laryngeal edema
Nursing considerations/ Patient Teaching: Pain must be assessed before and after administration
Name: furosemide

Concentration: 40mg

Route: PO

Dosage Amount: 40mg

Frequency: 1xDaily

Pharmaceutical class: loop diuretic

Home

Hospital

or

Both

Indication: hypertension
Adverse/ Side effects: stevens-johnson syndrome, dehydration, electrolyte insufficiency, metabolic alkalosis
Nursing considerations/ Patient Teaching: assess I&Os, edema, skin turgor, weakness, lethargy to ensure pt is not losing to much fluid
Name: losartan

Concentration: 100mg

Route:PO

Dosage Amount: 200mg

Frequency: 1xDaily

Pharmaceutical class: angiotensin II receptor antagonists

Home

Hospital

or

Both

Indication: Management of hypertension

Adverse/ Side effects: diarrhea, hypotension, angioedema
Nursing considerations/ Patient Teaching: Assess BP and look for signs of angioedema

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?
Diet patient follows at home?
24 HR average home diet:
Breakfast: Toast with jelly, creamed eggs, glass of 2% milk

Analysis of home diet (Compare to My Plate and

Consider co-morbidities and cultural considerations):
Receives over target for grains, protein, fruits, and dairy
and under target for vegetables

Lunch: Grilled ham and cheese sandwich, potato chips,

apple, ice tea
Dinner: fried chicken, chicken noodle soup, dinner
role, green beans
Snacks: : bananas, chocolate covered raisins, grapes, apple
slices
Liquids (include alcohol): milk 2%, ice tea, water, coffee
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.
See other attachment

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? The granddaughter I live with
How do you generally cope with stress? or What do you do when you are upset?
I usually just keep to myself and wait it out until I dont feel upset anymore.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Ive just been a bit angry because I keep ending up in the hospital, I am so over being sick all the time.

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

University of South Florida College of Nursing Revision September 2014

Are you currently in a safe relationship? I am not currently in a relationship.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Intimacy vs. Isolation

Autonomy vs.
Generativity vs.

Doubt & Shame

Initiative vs. Guilt
Industry 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: People reflect back on the life they lived and come away with either a sense of regret and despair over a life
misspent.(Brown & Lowis, 2003)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
A period of time that patient contemplates their accomplishments and are able to develop integrity if they see themselves as leading a
successful life, or they see their lives as unproductive, feel guilt about their past, or feel that we did not accomplish our life goals, they
become dissatisfied with life and develop despair, often leading to depression and hopelessness (Brown & Lowis, 2003). My patient
expressed on many different occasions that she was experiencing despair. She continually brought up the fact that she is always sick
and she feels as though there is nothing she can do to make it better. She was very hesitant to discuss her children and their possible
success or failures and when asked about them she was very general and brief. This lead me to believe she feels she was not a good
mother.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
My patient is very spiritual and believes every time she gets sick or ends up in the hospital it is Gods way of telling her
she has messed up in her life. This in turn makes my patient feel as though she deserves everything she is getting and
deserves to suffer for as long as God believes she should. In thinking this way the patient doesnt try as hard to make herself feel better
during the time she is sick.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I believe I have made many mistakes in my life and making me ill is Gods way of making me pay for all of my
mistakes.
What does your illness mean to you?
Being this sick means I need to be a better person now, because there is nothing I can do about the past but maybe if I do
better God will not make me this 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?______________Yes____________________________________
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?
_________NA_________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? ________________NA________________
How long have you been with your current partner?__Not currently in a realtionship_____________________________
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

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

What importance does religion or spirituality have in your life?
____Very important, all my decisions are made based off of what I believe God planned for me. _______________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
___In a sense because I know there is nothing more I can do, and I just have to trust God will take care of me. ____________
______________________________________________________________________________________________________

+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)
Cigarettes
Pack a day

Yes
No
For how many years? 20 years
(age 20

thru

40

If applicable, when did the

patient quit? 40

Pack Years: 20
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? Yes

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

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What?
How much? Occasionally
Beer
Volume: 2 beers
Frequency: 1-2 times a week
If applicable, when did the patient quit?
59 years old

No
For how many years?
(age 18

thru

59

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
No

5. For Veterans: Have you had any kind of service related exposure?
NA

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal
Integumentary
Changes in appearance of skin
Problems with nails
X Dandruff
Psoriasis
Hives or rashes
Skin infections
X Use of sunscreen
SPF: 30
Bathing routine: 1XDaily
Other:

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
X Appendicitis (removed 1951)

Chills with severe shaking

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

Abdominal Abscess

Other:

HEENT

Hematologic/Oncologic

Difficulty seeing
Cataracts or Glaucoma
X Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
X Routine brushing of teeth
2 x/day
X Routine dentist visits
4 x/year
XVision screening 11/14
Other:

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

x/day

Anemia
X Bleeds easily (anticoagulants)
X Bruises easily
Cancer
Blood Transfusions
Blood type if known: AOther:

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

Pulmonary
X Difficulty Breathing (with activity)
X Cough - dry
Asthma
Bronchitis
Emphysema
X Pneumonia
Tuberculosis
Environmental allergies
last CXR? NA
Other:

Cardiovascular
X Hypertension
X Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
X CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
X Arrhythmias (A-FIB)
X Last EKG screening, when? 01/28/15
Other:

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
X Monthly self breast exam
Frequency of pap/pelvic exam. Never
Date of last gyn exam? 1977
menstrual cycle
regular
irregular
X menarche
age? 9
X menopause
age? 48 (Hysterectomy)
Date of Mammogram &Result: 2014, clear
Date of DEXA Bone Density & Result:NA
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
X 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
X Arthritis
Other:

Childhood Diseases
X Measles
X Mumps
Polio
Scarlet Fever
X Chicken Pox
Other: Diphtheria

University of South Florida College of Nursing Revision September 2014

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health? I think I am doing pretty bad right now, but I am 86 so I guess that is to be expected.

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?
Nothing specified

University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:
General Survey:
Breathing unlabored
while resting
Temperature: 97.2 Oral

Height: 53
Pulse: 146
Respirations: 16
SpO2: 92

Weight: 165
BMI: NA
Blood Pressure: 131/69 right upper
arm
Is the patient on Room Air or O2

Pain: (include rating and

location) 0

2L

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]

X 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 X cheerful
X talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
X Skin is warm, dry, and intact
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
Skin turgor showed tenting

Central access device

Fluids infusing?
no

Type:
yes - what?

Location:

flat
loud

Date inserted:

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 /2 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: All original teeth are present. No dentures
Comments: Whisper test was not heard
Pulmonary/Thorax:
Respirations regular and unlabored X Transverse to AP ratio 2:1 X Chest expansion symmetric
X Percussion resonant throughout all lung fields, dull towards posterior bases
X 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 D
LLL WH
RLL WH
Respirations are unlabored while patient is resting. However are very labored when the patient is active
CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent

Cardiovascular: X No lifts, heaves, or thrills

Heart sounds:
S1 S2 audible X Regular
Irregular X No murmurs, clicks, or adventitious heart sounds

University of South Florida College of Nursing Revision September 2014

X No JVD

10

Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

X Calf pain bilaterally negative

X Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 2+ Carotid: 2+ Brachial: 2+ Radial: 2+ Femoral: 2+ Popliteal: 2+
DP: 2+ PT: 2+
X No temporal or carotid bruits
Edema:
0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-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 01 / 27 / 2015 )
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:

X Not assessed, patient alert, oriented, denies problems

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

Previous 24 hour output: 2000 mLs N/A

without assistance

or

with assistance

Musculoskeletal: X Full ROM intact in all extremities without crepitus

X Strength bilaterally equal at __5___ RUE __5___ LUE ___5__ RLE & ___5__ 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
X Rombergs Negative
X Stereognosis, graphesthesia, and proprioception intact X 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

11

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):

Lab
WBC

Dates

Normal
(4.5-11.0)

1/23/15
11.3H
1/24/15
12.8H
1/25/15
10.4
1/26/15
8.7
1/28/15
16.6

Chest X-Ray

1/23/15
10.2 L
1/24/15
14.0 L
1/25/15
11.6 L
1/26/15
13.6 L
1/28/15
3.4 L
1/23/15
9.1 H
1/24/15
9.7 H
1/25/15
8.3
1/26/15
6.4
1/28/15
15.8 H
1/23/15

Sputum test

1/23/15

Lymphs

Normal
(24.0-44.0)

Neutrophil

Normal
(1.4-8.5)

Trend

Analysis

The patient was admitted with

slightly elevated WBC count.
While diagnostic testing was
being performed the count
increased slightly. Then the
count began to trend
downwards. Being as the trend
was promising the doctor did
not schedule another CBC
until the 28th where we see a
sudden spike in the WBC
count.
Upon admission the patients
lymphocytes were low. They
increased, decreased and
increased again in the
following days. By the 28th
there was a sudden significant
decrease from 13.6 to 3.4.

The patient may have had a

very mild infection when she
was first admitted after
beginning treatment the
infection seemed to have been
terminated. After the antibiotic
dosage was decreased we saw
an increase in WBC indicating
either a returning infection or a
new infection had developed.

Upon admission the patients

neutrophils were slightly
elevated. They gradually
decreased until 1/28/15 when
their numbers sharply
increased.

Only one X-Ray was done. No

trend can be determined.

Only one sputum culture was

taken. No trend can be
determined.

For this patient the low

lymphocytes can indicate
either sepsis or a side effect of
the corticosteroids the patient
is on. I believe the patient was
low because of her
corticosteroid use. The sudden
drop in levels was due to the
increased dosage of her
corticosteroid on the 27th.
The slight increase in the
neutrophils numbers indicated
an acute infection. When the
numbers were gradually
decreasing it showed
progression in defeating the
infections. The infection either
returned of a new one formed
on the 28th when the numbers
increased.
When the X-ray was examined
there was lobar consolidation
in both lungs. There was
increased density with illdefined borders within the
lungs. This indicated
pneumonia.
The sputum culture revealed
the patient had Streptococcus
pneumonia.

+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.)

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

1. Risk for activity intolerance r/t imbalance between oxygen supply/demand as evidenced by exertional dyspnea (Ackley &
Ladwig, 2011).
2. Risk for deficiency of cognitive information related to unfamiliarity with disease process as evidenced by verbalization
of the problem (Ackley & Ladwig, 2011).
3. Risk for impaired gas exchange r/t ventilation-perfusion imbalance as evidenced by abnormal breathing (Ackley &
Ladwig, 2011).
4.
5.

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 15 CARE PLAN
Nursing Diagnosis: Risk for activity intolerance r/t imbalance between oxygen supply/demand as evidenced by
exertional dyspnea (Ackley & Ladwig, 2011).
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will participate in
1 .Determine cause of activity
1.Determining the problem can
1.It was determined the patient had
prescribed physical activity with
intolerance and address the
help direct appropriate
pneumonia that was close to being
appropriate breathing rate
problem.
interventions
cleared
2. Gradually increase activity by
2.To allow for small movements
2.Patient was able to assist with
allowing the client to assist with
without over exerting the patient
positioning and most ACLs
positioning and transferring from
3. To ensure the patients breathing without dyspnea
bed to chair
does not become more difficult
3. Patients respirations increased
3. Assess patients breathing as they upon exertion
slightly (from 14-19) but remained
perform activities
within normal limits
Verbalize the understanding of the 1.Monitor vitals and observe the
1. Ensure the patients body is
1. Patient did express a slight sign
need to gradually increase activity
client for signs of: dyspnea,
prepared for the increase in activity of fatigue and lightheadedness but
based on testing, tolerance, and
palpations, excessive fatigue,
and we are not progressing to
was free of any dyspnea upon
symptoms
lightheadedness, dysrhythmias, and quickly
exertion.
hypotension ect.
2. Teaching the client what to look 2. Client was able to explain the
2.Educate the client on the possible out for when beginning physical
importance of slowly beginning to
adverse effects of increasing
activities can prevent adverse
participate in activities. As well as
activity to swiftly
effects from occurring
express the adverse effects to look
for when first beginning to move
on her own.

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
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X PT/ OT
Pastoral Care
Durable Medical Needs
X F/U appointments
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? X Yes No
Rehab/ HH
Palliative Care

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 15 CARE PLAN
Nursing Diagnosis: Deficiency of cognitive information related to unfamiliarity with disease process as evidenced by verbalization of the
problem (Ackley & Ladwig, 2011).
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will explain disease state,
1.Consider the clients ability and
1. If the client is not able or not
1. The client shows a willingness to
recognize need for medications,
readiness to learn.
willing to learn then the risk of
learn more about why she keeps
and understand treatments
2.Monitor how client process
reoccurrence is high
getting respiratory related
information over a period of time
2. If we develop a sense of how the infections
3. Use individualized approaches
patient process information we will 2. The client needs to hear
that support clients priorities
be better able to deliver critical
information multiple times before
4. Engage the client as a partner in information.
she is able to express
the educational process.
3. Understanding the patients
understanding
priorities can allow us to express
3. I used religion to reach my
the information in a way that will
patient because of her strong
most likely result in the best
religious background
understanding of the topic
4. The client seemed to be more
4. Relating to the patient can make engaged in the learning experience
them feel less like they are being
when I made it so I was learning
taught and more like they are
with her.
learning
Patient will describe the rationale
1. Teach the client about the
1. Patients frequently simply nod
1. The patient was more engaged in
for treatment options
disease process by simplifying the
their heads as things are being
our conversation when the content
content
explained even though they do not was simplified and asked valid
2. Repeat the content multiple
understand. Presenting the topic in questions that indicated her
times with the client until she is
a simplified manor will allow the
understanding
able to repeat rationale back
client to understand more
2. Previous interactions indicated
3. Encourage patient to seek further 2. Repetition allows for more
the client learned with repetition so
educational sessions in the
content to be absorbed without
I used this with my patient and
community
much extra learning
each addition session proved to
3. Patients frequently leave with
have a additional effect on the
unanswered questions, encouraging patient
them to seek out more information 3. The patient said she was not
can allow them to get an even
aware of places she was able to go
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better understanding of the disease

for help. Once I provided the

information she seemed interested.

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
X F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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References
Ackley, B. J., Ladwig, G.B. (2011). Nursing diagnosis handbook: As evidenced- based guide to planning care
(8th edu.). St. Louis, MO: Mosby Elsevier
Brown, C., & Lowis, M. J. (2003). Psychosocial development in the elderly: An investigation into Erikson's
ninth stage. Journal Of Aging Studies, 17415-426. doi:10.1016/S0890-4065(03)00061-6
Osborn, K., Wraa, C., Watson, A., & Holleran, R. (2010). Nursing Management of Patients
with Respiratory Disorders. In Medical-surgical nursing: Preparation for practice (2nd Ed.
ed., pp. P.740-741). Upper Saddle River, N.J.: Pearson Prentice Hall.
Pneumococcal Pneumonia. (2011, September 22). Retrieved February 10, 2015, from
http://www.niaid.nih.gov/topics/pneumonia/Pages/Default.aspx

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