UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Aliscia Laliotis-Torres
Assignment Date: 1/20/17
MSI & MSII PATIENT ASSESSMENT TOOL .
1 PATIENT INFORMATION Agency: TGH
Patient Initials: PS Age: 75 Admission Date: 1/11/17
Gender: Male Marital Status: Married Primary Medical Diagnosis: Urinary Tract
Infection
Primary Language: English
Level of Education: 10th grade Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): retired from Supermarket Distributor
Number/ages children/siblings: Daughter (50); 6 brothers, 4 sisters
(cant remember the ages)

Served/Veteran: Yes Code Status: Full Code

If yes: Ever deployed? Yes or No
Living Arrangements: With wife in a 55+ community Advanced Directives: yes
If no, do they want to fill them out?
Surgery Date: Procedure:
Culture/ Ethnicity /Nationality: French
Religion: Catholic Type of Insurance: AARP

1 CHIEF COMPLAINT: I got dizzy.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) 75 y.o. male with PMH IgA nephropathy s/p kidney transplant (most recent 10/2016), obstructive uropathy with
chronic foley, prostate CA s/p XRT, and CAD h/o PCI who presents for evaluation of syncope. He was at TGH ED 1/10
with complaints of penile/bladder pain. At that time, he was discharged as he was afebrile and symptoms resolved. He
noted dizziness upon return home and had episode of resultant fall from dizziness on 1/11. He denies any pain after fall
but was concerned and brought to ER by wife and neighbor. He denies loss of consciousness, palpitations, blurred vision,
chest pain, dyspnea, nausea associated with the event. Family felt pt has been confused today but is currently improving
after receiving IVFs. He denies fevers at home but was noted to be clammy yesterday. Currently with rigors (not present
at home).

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
N/A Anxiety
2008 CAD with bare metal stents to RCA
10/24/2016 Deceased-donor kidney transplant recipient
2012 Diverticulosis per colonoscopy
N/A End Stage Renal Disease
N/A Gout, Hyperlipidemia, Hypertension
2009 Appendectomy
1995 Left ear drum removed
1981 Kidney transplanted
2008 Chronic IgA nephropathy
04/2016 Prostate Cancer treated with seed implants
2015 Multiple Basal Cell skin cancers
Age (in years)

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
)
Father 63 MI
Mother 86 ESRD
U
Brother
nk
U
Sister
nk
relationship

relationship

relationship

Comments: Include age of onset

Pts memory is slightly impaired so retrieving FMH was difficult and is therefore incomplete and unreliable.

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)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years? 2015
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

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 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Diazepam Nausea and vomiting
Methyldopa Palpitations
Methydopate Palpitations
Medications Tetanus vaccine &
Flu-like symptoms
toxoid

NKA
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)
Urinary tract infections are caused when bacteria (usually E. coli) make their way up the urinary tract and cause
inflammation and irritation. Risk factors of UTIs include use of straight or indwelling catheters, being a woman, and
improper perineal care. UTIs are diagnosed by taking a urine sample for urinalysis and looking for white or red blood.
cells and/or bacteria It is treated with antibiotics like the one my patient is on, ertapenem (INVANZ). Antibiotics should
completely resolve the infection. Genetic factors dont necessarily affect whether or not one gets a UTI unless they are
immunosuppressed. What made this patient most susceptible to acquiring this infection was the fact that he is
immunosuppressed and that he has a chronic indwelling catheter (Osborn, Wraa, & Watson, 2010).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name Acetaminophen (Tylenol) Concentration n/a Dosage Amount 650 mg

Route Oral Frequency every 6 hr PRN

Pharmaceutical class Non-opioid Analgesic Home Hospital or Both
Indication Mild to Moderate pain
Adverse/ Side effects Hepatotoxicity, acute generalized exanthematous pustulosis, Steven Johnsons Syndrome, Toxic Epidermal Necrolysis
Nursing considerations/ Patient Teaching Assess alcohol use (avoid), assess for rash, avoid chronic/excessive use

Name ertapenem (Invanz) Concentration 1g/10mL of 0.9% NaCl Dosage Amount 1 g

Route intravenous Frequency every 24 hr.

Pharmaceutical class carbapenems (antibiotic) Home Hospital or Both
Indication complicated UTI
Adverse/ Side effects seizures, C-Diff, anaphylaxis
Nursing considerations/ Patient Teaching Observe for s/s of anaphylaxis, monitor bowels, notify doctor if diarrhea occurs

Name amlodipine (Norvasc) Concentration n/a Dosage Amount 5 mg

Route oral Frequency once daily

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Pharmaceutical class calcium channel blocker Home Hospital or Both
Indication Hypertension, angina, vasospasm
Adverse/ Side effects peripheral edema, hypotension
Nursing considerations/ Patient Teaching know BP and pulse before admin, comply with other interventions to decrease BP

Name dutasteride (Avodart) Concentration n/a Dosage Amount 0.5 mg

Route oral Frequency once daily

Pharmaceutical class androgen inhibitor Home Hospital or Both
Indication Benign Prostate Hyperplasia
Adverse/ Side effects prostate cancer, allergic reaction, angioedema
Nursing considerations/ Patient Teaching regular digital rectal exams, avoid blood donation, follow up regularly to verify effectiveness

Name famotidine (Pepcid) Concentration n/a Dosage Amount 20 mg

Route oral Frequency twice daily

Pharmaceutical class histamine h2 antagonist Home Hospital or Both
Indication prevents ulcers
Adverse/ Side effects confusion, arrhythmia, agranulocytosis, aplastic anemia
Nursing considerations/ Patient Teaching monitor CBC, if drowsiness occurs avoid driving, avoid alcohol, report signs of flu, diarrhea and/or black stools

Name metoprolol (Lopressor) Concentration n/a Dosage Amount 25 mg

Route oral Frequency once daily

Pharmaceutical class beta blocker Home Hospital or Both
Indication hypertension and angina
Adverse/ Side effects fatigue, weakness, bradycardia, heart failure, pulmonary edema, erectile dysfunction, hypotension
Nursing considerations/ Patient Teaching monitor BP, ECG and pulse; monitor intake and output; daily weights, dont administer if pulse is less than 50, take as
directed

Name mycophenolate (CellCept) Concentration n/a Dosage Amount 500mg

Route oral Frequency twice daily

Pharmaceutical class immunosuppressant Home Hospital or Both
Indication prevent organ transplant rejection
Adverse/ Side effects progressive multifocal leukoencephalopathy, anxiety, dizziness, headache, insomnia, GI bleeding
Nursing considerations/ Patient Teaching assess for PML (apathy, confusion, ataxia), take as directed, lifelong therapy, avoid getting sick, no live vaccines

Name prednisone (Deltasone) Concentration n/a Dosage Amount 5 mg

Route oral Frequency once daily

Pharmaceutical class corticosteriod Home Hospital or Both
Indication used for inflammatory, allergic, hematologic, neoplastic chronic diseases and autoimmune disorders
Adverse/ Side effects depression, euphoria, HTN, peptic ulcer, thromboembolism, decreased wound healing
Nursing considerations/ Patient Teaching Do not stop taking suddenly, tell doctor about tarry stools and/or severe abdominal pain

Name ropinirole (Requip) Concentration n/a Dosage Amount 0.25 mg

Route oral Frequency once daily

Pharmaceutical class dopamine agonist Home Hospital or Both
Indication manage Parkinsons disease or restless leg syndrome
Adverse/ Side effects sleep attack, dizziness, syncope
Nursing considerations/ Patient Teaching assess for drowsiness/sleep attack, no alcohol, dont drive
Name sertraline (Zoloft) Concentration n/a Dosage Amount 100 mg

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Route oral Frequency once daily
Pharmaceutical class SSRI Home Hospital or Both
Indication depression, panic disorder, OCD, PTSD
Adverse/ Side effects NMS, suicidal thoughts, dizziness, fatigue, headache, insomnia, diarrhea, dry mouth, tremor, increased sweating, serotonin syndrome
Nursing considerations/ Patient Teaching do not use with MAOI, assess suicidal thoughts, assess mental changes that could be associated with serotonin syndrome

Name tamsulosin (Flomax) Concentration n/a Dosage Amount 0.4 mg

Route oral Frequency once daily after a meal

Pharmaceutical class peripheral antiadrenergic Home Hospital or Both
Indication signs and symptoms of BPH
Adverse/ Side effects dizziness, headache
Nursing considerations/ Patient Teaching watch for first dose hypotension, rectal exams regularly

Name valganciclovir (Valcyte) Concentration n/a Dosage Amount 900 mg

Route oral Frequency once daily

Pharmaceutical class antiviral Home Hospital or Both
Indication prevent CMV in transplant patients
Adverse/ Side effects seizure, headaches, insomnia, abdominal pain, diarrhea, nausea, vomiting, neutropenia, thrombocytopenia, anemia, fever
Nursing considerations/ Patient Teaching signs of infection, bleeding, monitor neutrophil and platelets, no alcohol

Name gabapentin (Neurontin) Concentration n/a Dosage Amount 100 mg

Route oral Frequency three times daily
Pharmaceutical class anticonvulsant, analgesic adjunct, mood stabilizer Home Hospital or Both
Indication restless leg syndrome, partial seizures, post herpetic neuralgia
Adverse/ Side effects suicidal thoughts, confusion, depression, dizziness, drowsiness, rhabdomyolysis, multiorgan hypersensitivity reactions, ataxia
Nursing considerations/ Patient Teaching monitor for suicidal thoughts, do not take if pregnant, take exactly as directed

Name sulfamethoxazole-trimethoprim (Bactrim, Septra) Concentration n/a Dosage Amount 800mg/160 mg

Route oral Frequency once daily

Pharmaceutical class folate antagonists (antibiotic) Home Hospital or Both (this medication did not work, he had to switch to
Invanz)
Indication urinary tract infection
Adverse/ Side effects C-Diff, hepatic necrosis, nausea, comiting, erythema mutiforme, Steven Johnson syndrome, toxic epidermal necrolysis, rash, agranulocytosis,
aplastic anemia, phlebitis at IV site, acute kidney injury
Nursing considerations/ Patient Teaching monitor bowels, assess for skin changes, monitor CBC and urinalysis, use sunscreen due to photosensitivity

Name tacrolimus (Prograf) Concentration n/a Dosage Amount 0.3 mg/kg/day

Route oral Frequency two times daily

Pharmaceutical class immunosuppressant Home Hospital or Both
Indication prevent organ rejection in transplant patients
Adverse/ Side effects posterior reversible encephalopathy, seizures, GI bleeding, anaphylaxis, acute kidney injury
Nursing considerations/ Patient Teaching No grapefruit juice, no alcohol, need for lifelong therapy

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular
Diet patient follows at home? Regular
24 HR average home diet:
Breakfast: cereal, juice, coffee, banana
Lunch: hamburger, sandwich
Dinner: pork chop, chicken, veggies
Snacks: ice cream
Liquids (include alcohol): club soda
Analysis of home diet (Compare to My Plate and
Consider co-morbidities and cultural considerations):
According to what the patient reported as his regular diet,
he isnt consuming a healthy amount of dairy or fruits. He
gets his fill of grains through cereal and bread. He gets
vegetables at dinner and in his sandwiches. He gets enough
protein at lunch and dinner. I would recommend that he
makes sure he uses whole grain bread for his sandwiches
and burgers. I would also recommend yogurt and milk to
fulfill his dairy needs as well as a variety of fruits he enjoys
to accompany his breakfast.

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? Wife and daughter

How do you generally cope with stress? or What do you do when you are upset?
Sit quietly and think

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
none really

+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? __yes_________

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

Are you currently in a safe relationship? yes

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 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: Integrity: sense of integrity and fulfillment; willingness to face death; wisdom. Despair: dissatisfaction with
life; denial of or despair over prospect of death (Varcarolis & Halter, 2014, p. 23)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient is in the integrity stage of life. This is a stage where older people begin to look back at their lives and lives. My
determine whether they are pleased with where theyve come or are in despair because they feel they have wasted their
patient exhibits integrity through his character. He has a daughter with grandchildren that he loves. Hes been with his
wife for almost 40 years. He was very proud of where life had brought him.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
My patient has an extensive list of past medical history, yet his attitude about his health is one of acceptance. From what I
analyzed during our interview, his conditions have strengthened his mental health. He has had healthy support from his
family.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I was born with it

What does your illness mean to you?

I dont know. I just tolerate it.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record

Have you ever been sexually active?___yes___________________________________________________________

Do you prefer women, men or both genders? __women___________________________________________________
Are you aware of ever having a sexually transmitted infection? ____no______________________________________
Have you or a partner ever had an abnormal pap smear? _dont think so_______________________________________
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?
____yes_____________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? ___no______________________________

How long have you been with your current partner?____39 years_________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? _Yes (chronic catheter)_______

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
no

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
____much importance___________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
____yes_______________________________________________________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much?(specify daily amount) For how many years? 10 years
cigarettes pack a day (age 15 thru 25 )

If applicable, when did the

Pack Years: 10
patient quit? age 25

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit? yes
so, what, and how much? no If yes, what did they use to try to quit? cold turkey

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? beer How much? One beer For how many years?
Volume: one drink (12 ounces) (age 18 thru 32 )
Frequency: one night per week
If applicable, when did the patient quit?
At age 32

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 )

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Yes, I was locked in a freezer at the supermarket once for about half an hour

5. For Veterans: Have you had any kind of service related exposure?
No, kicked out of military because of my bad hearing

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 10 REVIEW OF SYSTEMS NARRATIVE

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: not used 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?
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: AB
Post-nasal drip Normal frequency of urination: n/a 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 1 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? Sept. 2016 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? 1x/year Schizophrenia
Chest pain / Angina Date of last prostate exam? 10/2016 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? 1/2017 Arthritis Chicken Pox

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Other: Stent in 2008 Other: Other:

General Constitution
Recent weight loss or gain
How many lbs? 20
Time frame? May 2016 to Jan 2017
Intentional? no
How do you view your overall health? Good except the Foley is in the way

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

University of South Florida College of Nursing Revision September 2014 10

10 PHYSICAL EXAMINATION:

General Survey: Pt is Height 5 5 Weight 182.5lbs BMI 30.4 Pain: (include rating and
A&O x 4, equal Pulse 57 Blood Pressure: (include location) location)
symmetry bilaterally, Respirations 18 163/89 (right arm) No pain
well groomed, engaged
in surroundings
Temperature: (route SpO2 100% Is the patient on Room Air or O2
taken?) Oral 98.1 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
Hard of Hearing

Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]

awake, calm, relaxed, interacts well with others, judgment intact

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]

clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: Midline Location: left bicep Date inserted: 1/16/17
Fluids infusing? no yes - what? ertapenem (Invanz)

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 4 inches & left ear- 4 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: missing 10 teeth; dentures at home
Comments: left ear has mole

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 No sputum production
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL CL LUL CL
RML CL LLL CL
RLL CL

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

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Cardiovascular: No lifts, heaves, or thrills
Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

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: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: pitting non-pitting
Extremities warm with capillary refill less than 3 seconds

GI Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 1 / 20 / 17 ) 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 Not assessed, patient alert, oriented, denies problems
Other Describe:

GU Urine output: Clear Cloudy Color: yellow Previous 24 hour output: 975 mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

Musculoskeletal: Full ROM intact in all extremities without crepitus

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]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: +2 Biceps: +2 Brachioradial: +2 Patellar: +2 Achilles: +2 Ankle clonus: positive negative Babinski: positive negative

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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 Dates Trend Analysis

CT Head without contrast 1/11/17 WDL The CT was done post
admission with a report of
a fall. No abnormalities
were found.
Doppler ultrasound 1/15/17 Patent vasculature, air in Analysis of the patients
kidney transplant collecting system transplanted kidneys
(normal) revealed no
abnormalities.
Na, K, Cl, CO2, Glucose, 1/11/17 1/20/17 WDL Patients fluid and
BUN electrolyte values have
been maintained at their
normal levels with no
significant fluctuations or
abnormalities.
WBC 1/12/17 -1/20/17 5.75, 4.13, 3.26, 3.42, These values are either
4.40, 4.58, 5.25, 4.95, too low (highlighted) or
4.99 trending toward low
(normal= 4.6-10) normal. Leukopenia is a
common side effect of
tacrolimus (PROGRAF)
and mycophenolate
(CELLCEPT)
RBC 1/12/17 -1/20/17 3.16, 3.02, 3.22, 3.27, All of these values are
3.45, 3.30, 3.42, 3.40, below the normal range.
3.45 Anemia is a common side
(normal= 4.32-5.72) effect of tacrolimus
(PROGRAF).
Hemoglobin 1/12/17 -1/20/17 9.7, 9.4, 9.9, 10.0, 10.7, All of these values are
10.4, 10.8, 10.6, 10.7 below the normal range.
(normal= 13.5-17.5) Anemia is a common side
effect of tacrolimus
(PROGRAF).
Hematocrit 1/12/17 -1/20/17 28.9, 28.6, 30.1, 30.3, All of these values are
32.2, 30.7, 31.9, 31.7, below the normal range.
32.7 Anemia is a common side
(normal= 38-50) effect of tacrolimus
(PROGRAF).

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,

University of South Florida College of Nursing Revision September 2014 13
multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.) BMP, CBC, GI pathogens, tacrolimus level,
Regular diet, no BP/IV to LUE, vitals q 6hr, weight, OT/PT consult

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

1. Risk for infection related to use of immunosuppressive therapy to control organ rejection.

2. Impaired urinary elimination related to impaired renal function as evidenced by the need for a chronic Foley catheter.

3. Risk for decreased cardiac output as evidenced by elevated blood pressure (hypertension).

4. Disturbed sensory perception: auditory related to removal of left eardrum as evidenced by hearing in right ear is greater
than in his left ear.
5. Risk for falls related to orthostatic hypotension side effects of medications.

University of South Florida College of Nursing Revision September 2014 14

 15 CARE PLAN #1
Nursing Diagnosis: Risk for infection related to use of immunosuppressive therapy to control organ rejection and chronic indwelling catheter.
Patient Goals/Outcomes Nursing Interventions to Achieve
Goal
Patient will demonstrate 1. Teach patient and family
appropriate care to prevent frequent and effective hand
acquiring infections by the end of washing.
shift. 2. Teach the client risk factors
contributing to infection.
Patient demonstrates no signs of 1. Assess temperature of
infection and is able to discharge neutropenic clients; report a single an infection (Ackley & Ladwig,
by the end of the day. temperature of greater than
100.5
2. Note and report laboratory
values.
Rationale for Interventions Evaluation of Goal on Day Care
Provide References is Provided
1. Meticulous infection prevention Patient demonstrated handwashing
precautions are required to prevent for 20 seconds with proper
infection, with particular attention technique. Patient and family
to hand hygiene and standard members name the risk factors
precautions (Ackley & Ladwig, associated with acquiring
2011, p. 492). infections.
2. Smoking and high body mass
index are some of the factors
associated with risk of infections
(Ackley & Ladwig, 2011, p. 495).
1. Fever is often the first sign of Patients temperature was 98.1
WDL. His white blood cell count
2011, p. 492). was 4.99 WDL.
2. The white blood cell count and
the automated absolute neutrophil
count are better diagnostic tests for
adults and most children (Ackley &
Ladwig, 2011, p. 492).

Patient will understand the risk of
acquiring a UTI with a chronic
indwelling catheter.
University of South Florida College of Nursing Revision September 2014
1. Teach the client to recognize
symptoms of UTI (dysuria,
suprapubic discomfort, fever,
chills, flank pain)
2. Advise clients with indwelling
catheters that bacteria in the urine
is an almost universal finding after
the catheter has remained in place
for a period of 30 days or longer
and that only symptomatic
infections warrant treatment
(Ackley & Ladwig, 2011, p. 868).
3. Educate the patient about the
1. There are a variety of typical and Patient has told me the symptoms
unexpected symptoms in patients to recognize for a UTI and has
with UTI (Ackley & Ladwig, 2011, demonstrated an understanding of
p. 861) the teachings provided on how to
2. Most bacteriuria does not properly care for the indwelling
produce significant infection, and catheter.
attempts to eradicate bacteriuria
often produce subsequent
morbidity because resistant
bacteria are encouraged to
reproduce while more easily
managed strains are eradicated
(Ackley & Ladwig, 2011, p. 868).
15
 risks of catheter-associated UTIs
and specific strategies to reduce
this risk (regularly cleanse the
urethral meatus with a gentle
cleanser to remove soiling, change
the catheter every 4 weeks)
3. These strategies are supported
by sufficient evidence to
recommend routine use (Ackley &
Ladwig, 2010, p. 869).

CARE PLAN #2
Nursing Diagnosis: Risk for decreased cardiac output as evidenced by elevated blood pressure (hypertension).
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 activities 1. Teach patient relaxation 1. Can reduce stressful stimuli, Patient performed effective non-
that reduce blood pressure and techniques, guided imagery and produce calming effect, thereby pharmacological techniques that
prevent stress. distractions. reducing BP (Vera, 2017). decreased stress. Blood pressure
2. Provide comfort measures such 2. Decreases discomfort and may was rechecked after these
as back and neck massage or reduce sympathetic stimulation techniques were done and the
elevating the head of the bed. (Vera, 2017). results were found to be lower.
3. Limit activities with bedrest or 3. Lessens physical stress and
chair rest; schedule periods of tension that affect blood pressure
uninterrupted rest; assist patient and the course of hypertension
with self-care activities as needed. (Vera, 2017).
Blood pressure medications will be 1. Administer blood pressure 1. Specific actions of these drugs Blood pressure meds were given 15
administered within 15 minutes of medications as indicated vary, but they generally reduce BP minutes after the abnormal value
finding a high value. (amlodipine/metoprolol). through the combined effect of was found. Blood pressure was
2. Recheck blood pressure in decreased total peripheral rechecked after 30 minutes and was
response to medications. resistance, reduced cardiac output, found to be lowered.
inhibited sympathetic activity, and
suppression of renin release (Vera,
2017).
2. Response to drug therapy is
dependent on both the individual as
well as the synergistic effects of the
drugs (Vera, 2017).
Patient will demonstrate normal 1. Note presence and quality of 1. Bounding carotid, jugular, Heart rate was 57 and pulses were
cardiac rate and rhythm within his pulses. radial, and femoral pulses may be 3+ bilaterally. Normal rate and
baseline range. 2. Auscultate heart tones and breath observed and palpated. Pulses in rhythm.
University of South Florida College of Nursing Revision September 2014 16
 sounds. the legs and feet may be
3. Observe skin color, moisture, diminished, reflecting effects of
temperature, and capillary refill vasoconstriction and venous
time. congestion (Vera, 2017).
2. S4 heart sound is common in
severely hypertensive patients
because of the presence of atrial
hypertrophy (increased atrial
volume and pressure).
Development of S3 indicates
ventricular hypertrophy and
impaired functioning. Presence of
crackles, wheezes may indicate
pulmonary congestion secondary to
developing or chronic heart failure
(Vera, 2017).
3. Presence of pallor; cool, moist
skin; and delayed capillary refill
time may be due to peripheral
vasoconstriction or reflect cardiac
decompensation and decreased
output (Vera, 2017).
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
*Dietary Consult
PT/ OT
Pastoral Care
*Durable Medical Needs
*F/U appointments
*Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014 17

 References

Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical surgical nursing: Preparation for

practice. Boston, MA: Pearson.

Halter, M. J., & Varcarolis, E. M. (2014). Varcarolis' foundations of psychiatric mental health

nursing: A clinical approach. St. Louis, MO: Elsevier.

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook. St. Louis, MO: Elsevier

Mosby.

Vera, M., RN. (2017). 6 Hypertension Nursing Care Plans Nurseslabs. Retrieved from

https://nurseslabs.com/6-hypertension-htn-nursing-care-plans/

University of South Florida College of Nursing Revision September 2014 18