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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Rebecca Netjes


Assignment Date: October 11, 2016
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Florida Hospital Tampa
 1 PATIENT INFORMATION
Patient Initials: PMH Age: 72 years old Admission Date: October 8, 2016
Gender: Female Marital Status: Married Primary Medical Diagnosis: Intractable vomiting,
seizures
Primary Language: English
Level of Education: College Other Medical Diagnoses: Methicillin resistant
staphylococcus aureus (MRSA) of the nares
Occupation: Patient states she was never employed, she just would
“help her husband” who was a truck driver.
Number/ages children/siblings: Patient reports that she had a
miscarriage in 1963, and had no other children after that. Patient
reports a brother who is 83 years old and a sister who is 86 years
old.
Served/Veteran: “No.” Code Status: Do Not Resuscitate (DNR)
If yes: Ever deployed? Not applicable.
Living Arrangements: Patient currently resides at an assisted Advanced Directives: DNR and Living Will
living facility. She was unable to recall floor plan (i.e. If no, do they want to fill them out?
stairs/elevators), but states everyone is “always nice and wants to Surgery Date: None, as of yet.
help her”. Procedure: Endoscopy on 10/10/16
Culture/Ethnicity/Nationality: White
Religion: Methodist Type of Insurance: Medicare and AARP

 1 CHIEF COMPLAINT:
Upon questioning, patient did not recall a great deal about the day she presented to the Emergency Department on
10/08/2016. She stated “I am not really sure, they said I threw up, and was having a seizure, but I don’t remember that”.
Information in the medical record stated the staff at the assisted living facility brought her because she had fallen on
10/05/16, and the staff was concerned the vomiting and seizures were related to the fall.

 3 HISTORY OF PRESENT ILLNESS:


On 10/05/2016, the patient, a 72-year-old female, was brought to the Emergency Department at Florida Hospital Tampa
for evaluation of weakness and a syncopal episode. A CT of her head and brain was performed, as well as a chest x-ray,
with all findings within normal limits. Patient was discharged home to the assisted living facility. On 10/08/2016, after the
assisted living facility staff witnessed the patient have a seizure secondary to having prolonged nausea and then vomiting,
the patient presented to the Emergency Department again. Patient was admitted for assessment of the vomiting and
seizures. Since admission, the patient has not had another seizure and has had normal electroencephalograms (EEG). The
nausea/vomiting has subsided, and the patient’s x-ray of her abdomen and endoscopy study were within normal limits.
Patient reports that she has had a history of seizures “since her miscarriage” and the “baby’s waste caused brain damage”.
Currently, the neurologist believes that the acute seizure activity was a result of the patient not taking her medication
because of the nausea she experienced. This would then result in rebound seizures and vomiting. It is likely that the
patient will be discharged home within the next 2 days given that there is no seizure activity.
University of South Florida College of Nursing – Revision September 2014 1
 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY

Date Operation or Illness


“When I was little” Mumps: “I have no idea what my mom did when I was sick with that”.
“When I was little” Chicken Pox: “Just like everyone back then, we just had to wait for it to go away”.
1963 Miscarriage: Patient states she had no other pregnancies.
1963 Brain injury: Patient denies knowledge of treatment.
1963 Seizures: Currently managed with Vimpat, Keppra, and Topamax.
1963 Stroke: Patient denies knowledge of treatment.
2009 Motor Vehicle Accident: Patient was hospitalized for 2 months post-accident. She received surgery
on her neck and shoulder, as well as pins placed in her ankle.
“I’m not sure” Depression: Currently, this is managed with citalopram.
“I’m not sure” Dementia: Patient resides in an assisted living facility to assist in her management of dementia. At
this time, the patient is not oriented to place or time.
“I’m not sure” Hypertension: This is managed with atenolol.
“I’m not sure” Atrial fibrillation: Treated with diltiazem. During this admission, patient has been in sustained sinus
rhythm since admission.
“I’m not sure” Hypothyroidism: Currently, this is managed with levothyroxine.

2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Heart Trouble

Mental Health
Age (in years)

Hypertension
FAMILY
Bleeds Easily
Alcoholism

Cause
MEDICAL Glaucoma

Problems

Problems
Allergies

Arthritis

Diabetes

of

Seizures
Anemia

Asthma

Cancer

Kidney

Tumor
HISTORY

Stroke
Death
(if Gout
applicable)
Father 80 Stroke
Mother “Unknown”
Not
Brother 83
applicable
Not
Sister 86
applicable
Comments:
The patient’s father had arthritis, but patient denies knowledge of age of onset. She stated it was “as long as she could remember”.
The patient’s mother has passed away, but patient denies knowledge of when or what cause of death was. She states she “was very
healthy”.
Patient denies knowledge of siblings’ medical history, says she “thinks they are healthy, but can’t say for sure”.

 1 IMMUNIZATION HISTORY
YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria: “Within 10 years, I think.”
Adult Tetanus: “Within 10 years, I think.”
Influenza (flu)
Pneumococcal (pneumonia)
Have you had any other vaccines given for international travel or
occupational purposes?

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 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction
Causative Agent
REACTIONS
Ativan Unknown
Dilantin “Rash”
Medications Felbatol Unknown
Sulfadiazine “Vomiting”
Valproic Acid Unknown
Other (food, tape, Seafood “Break out in hives”
latex, dye, etc.)

 5 PATHOPHYSIOLOGY:
Seizures are commonly understood to be the result of neurons discharging or firing in an unorganized manner that results
in various manifestations such as alteration in cognition, motor or sensory dysfunction, or a decrease in level of arousal
(Huether, S. E., & McCance, K. L. 2012). Seizures can be caused by a variety of occurrences such as febrile states,
hypoglycemia, trauma. If there is no identifiable cause of seizure activity that can be addressed, the individual may
receive a diagnosis of epilepsy. It is believed that there is a genetic predisposition in these individuals that is triggered by
an event in their environment. After identifying that an individual is suffering from seizures, they must be classified
accordingly. Seizures are typically classified by “clinical manifestations, site of origin, EEG correlates, or response to
therapy” (Huether, S. E., & McCance, K. L. 2012, p. 355). Clinical manifestations for seizures, in general, include auras
and prodromas. A prodroma is a term used to describe any variety of symptoms such as nausea, headache, etc. that will
present hours to days before seizure activity. Auras are partial seizures that a patient may notice prior to a generalized
seizure. Auras may present as “gustatory, visual, or auditory experiences”, or may be noted as nonspecific occurrences
such as “a feeling of dizziness numbness, or just a ‘funny feeling’” (Huether, S. E., & McCance, K. L. 2012, p. 356).
Within seizures, there are generally three phases that physicians and patients note: tonic, clonic, and postictal. The tonic
phase is evidenced by unrelenting muscle contraction. Clonic phase is characterized by the repeated alteration between
muscular contraction and relaxation. Finally, the postictal phase is identified as the time between the end of seizure
activity and return to the previous level of arousal. Evaluation of seizures typically involves a comprehensive history and
examination, blood tests for the various metabolic alterations that could lead to seizures, radiographic studies, and
electroencephalograms to assess for type of seizure. Seizures may be considered partial, generalized, or unclassified
epileptic. Partial seizures are considered to those that are begin in one, single location. They may be further classified as
simple in that they do not cause a change in consciousness. Complex partial seizures are those that do result in an
alteration in consciousness. Furthermore, they may identify the seizure as secondarily generalized partial; meaning that
they begin in one location, but progress to bilateral activity in the cortex. Generalized seizures are those that result in
activity in the right and left hemispheres of the brain, without onset in a single, localized area. The unclassified epileptic
seizures are those in which the characteristics are not identifiable. (Huether, S. E., & McCance, K. L. 2012). Treatment of
seizures includes removing or correcting the underlying cause or anticonvulsant medications. Also, it is recommended that
the patient and family receive counseling or therapy as it will impact their life greatly.

 5 MEDICATIONS:
Name: atenolol (Tenormin) Concentration: Dosage Amount: 50 mg

Route: oral Frequency: One time daily


Pharmaceutical class: beta blocker Home Hospital or Both
Indication: hypertension
Adverse/ Side effects: bradycardia, hypotension, dizziness, cold extremities, bronchospasm, lightheadedness, lethargy, drowsiness, vertigo
Nursing considerations/ Patient Teaching: Caution in patients with bronchoconstriction diseases as a result of nonselective action on beta 2 receptors. Hold for heart
rate under 60 bpm. Hold for systolic blood pressure less than 110 mmHg. Teach patient to stand slowly from a sitting position. Teach patient to monitor blood pressure at
home.

University of South Florida College of Nursing – Revision September 2014 3


Name: citalopram (Celexa) Concentration: Dosage Amount: 20 mg

Route: oral Frequency: One time daily


Pharmaceutical class: selective serotonin reuptake inhibitor (SSRIs) Home Hospital or Both
Indication: depression
Adverse/ Side effects: nausea, somnolence, tremors, ejaculatory dysfunction, anorexia, suicidality, serotonin syndrome, hyponatremia
Nursing considerations/ Patient Teaching: Teach patient to report all other medications to health care provider (i.e. St. John’s Wort). Teach patient/monitor for signs or
symptoms of serotonin syndrome. Assess for increased suicidality in the first few weeks of treatment.

Name: diltiazem (Cardizem) Concentration: Dosage Amount: 30 mg

Route: oral Frequency: four times a day


Pharmaceutical class: calcium channel blocker (CCB) Home Hospital or Both
Indication: atrial fibrillation
Adverse/ Side effects: peripheral edema, headache, dizziness, orthostatic hypotension, bradycardia, arrhythmias, hepatic injury, erythema multiforme
Nursing considerations/ Patient Teaching: Teach patient to rise slowly from sitting position. Monitor liver function tests. Hold medication for heart rate under 60 bpm.
Hold for systolic blood pressure less than 100 mmHg. Preform frequent skin assessments. Monitor EKGs.

Name: gabapentin (Neurotin) Concentration: Dosage Amount: 300 mg

Route: oral Frequency: every eight hours


Pharmaceutical class: anticonvulsant Home Hospital or Both
Indication: nerve pain
Adverse/ Side effects: dizziness, somnolence, tremor, diplopia, headache, amnesia, depression, suicidality, Stevens-Johnson syndrome, angioedema
Nursing considerations/ Patient Teaching: Avoid abrupt withdrawal, as it can cause adverse effects. Assess for behavioral changes in suicidality. Assist patients when
ambulating as there is an increase in risk for falls. Monitor pain level before, during, and after medication administration.

Name: lacosamide (Vimpat) Concentration: Dosage Amount: 200 mg

Route: oral Frequency: two times a day


Pharmaceutical class: anticonvulsant Home Hospital or Both
Indication: epilepsy/seizures
Adverse/ Side effects: dizziness, headache, blurred vision, tremor, nystagmus, depression, pruritus, suicidality, Stevens-Johnson syndrome, toxic epidermal necrolysis,
withdrawal seizure if abruptly discontinued
Nursing considerations/ Patient Teaching: Teach patient to stand slowly to avoid falling. Teach patient to continue to take medication as prescribed to prevent seizures.
Preform frequent skin assessments.

Name: levetiracetam (Keppra) Concentration: 1500 mg/400 mL/ 1 hour Dosage Amount: 1500 mg

Route: IV Frequency: two times a day


Pharmaceutical class: anticonvulsants Home Hospital or Both
Indication: epilepsy/seizures
Adverse/ Side effects: headache, vomiting, irritability, anxiety, leukopenia, amnesia, psychosis, Stevens-Johnson syndrome, hyponatremia, withdrawal seizures if
abruptly discontinued
Nursing considerations/ Patient Teaching: Teach patient to continue to take medication as prescribed to prevent seizures. Preform frequent behavioral assessments.
Teach family to report change in patient’s behavior.

Name: levothyroxine (Synthroid) Concentration: Dosage Amount: 50 mcg

Route: oral Frequency: one time daily


Pharmaceutical class: synthetic T4 Home Hospital or Both
Indication: hypothyroidism
Adverse/ Side effects: palpitations, nervousness, weight loss, diaphoresis, fever, alopecia, menstrual irregularities, arrhythmias, seizures
Nursing considerations/ Patient Teaching: Monitor EKG changes. Assess level of T4 as they may need dose adjustment. Assess for signs of hyperthyroidism.

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Name: mupirocin topical (Bactroban 2% topical) Concentration: Dosage Amount: one application

Route: transdermal (nares) Frequency: twice a day in each nostril


Pharmaceutical class: topical antibacterial Home Hospital or Both
Indication: MRSA of the nares
Adverse/ Side effects: nausea, burning, headache, pruritus, anaphylaxis, superinfection with prolonged use
Nursing considerations/ Patient Teaching: Assess for allergies. Assess for nasal drainage, mucus, or other factors that could lead to poor absorption. Teach patient not
to blow nose immediately following application to allow for absorption.

Name: phenobarbital Concentration: Dosage Amount: 64.8 mg

Route: oral Frequency: twice a day


Pharmaceutical class: anticonvulsant Home Hospital or Both
Indication: epilepsy/seizures
Adverse/ Side effects: drowsiness, lethargy, nausea, rash, urticaria, physical dependence, respiratory depression, Stevens-Johnson syndrome, suicidality, withdrawal
symptoms if abruptly discontinues.
Nursing considerations/ Patient Teaching: Assess for dependence on the medications. Assess the frequency and duration of frequency of seizures before, during, and
after therapy. Teach patient/family to report change in behavior.

Name: topiramate (Topamax) Concentration: Dosage Amount: 200 mg

Route: oral Frequency: twice a day


Pharmaceutical class: anticonvulsant Home Hospital or Both
Indication: epilepsy/seizures
Adverse/ Side effects: paresthesia, dizziness, weight loss, fatigue, cognitive dysfunction, anxiety, taste changes, psychosis, suicidality, maculopathy, withdrawal seizures
if abruptly discontinued
Nursing considerations/ Patient Teaching: Teach patient to continue to take medication as prescribed to prevent seizures. Preform mini-mental-status-exams to assess
level of cognitive functioning. Teach patient to report change in behavior or increased suicidality.

 5 NUTRITION:
Diet ordered in hospital? Pureed Analysis of home diet:
Diet patient follows at home? The patient lives in an assisted Patient currently resides in an assisted living facility, so
living facility. Initially when asked about what she typically she is required to select food from their menu. The 24-hour
eats at home, she said “whatever the people make me”. home diet reported by the patient is higher in both whole
Patient reports that the diet is “pretty good” but “not fruit and protein, according to My Plate recommendations.
as good as she used to make it”. She has low intake of refined grains, vegetables, and
24 HR average home diet: cheese or dairy. I would inform the patient that while fruit
Breakfast: Patient reports that she “usually eats nothing” as is a wonderful addition to her diet, she must consider that
she is not “really a breakfast kind of girl”. they have many simple sugars and could contribute to a
higher glucose level. Also, prolonged high intake of
Lunch: Patient states that she normally eats “a hamburger protein can be damaging to her kidneys. As the patient
with lettuce, tomato, on a bun” with “fresh fruit”. must take several medications to manage her various
conditions, her kidneys are already at risk for impairment
Dinner: Patient states “sometimes they give us a grilled later in life. Excessive protein could exacerbate this, so I
chicken with sour cream and more fruit”. would encourage her to be mindful of that. In regards to
her vegetable intake, I would speak with the patient about
Snacks: Patient reported “Ooh, I am a big snacker. I love the benefits in that she will receive essential vitamins and
chips and cottage cheese with fruit”. minerals. To make this practical for the patient, I would
suggest that she replaces one of her fruit servings with a
serving of vegetables. I would then educate that whole
Liquids: Patient states she has “a lot of water during her
grains contain carbohydrates that her body utilizes for
day”. She also drinks Coke, tea and coffee “when they let
energy. I would suggest having a bagel or toast for
her”. Patient denies alcohol consumption. When questioned
breakfast. Finally, I would provide education about dairy
regarding the volume of her beverages, patient states
in that it provides calcium for bone integrity, as well as
“whatever cups they have there”.
other things. Lastly, I would educate the patient that it is
not suggested for her to consume caffeinated beverages if
she is experiencing an increase in seizure activity.
University of South Florida College of Nursing – Revision September 2014 5
1 COPING ASSESSMENT/SUPPORT SYSTEM:
Who helps you when you are ill?
Patient reported that her “neighbors are good about helping her”. She stated that: “Debbie is real close by and wants to
help me a lot”. The patient also lives an assisted living facility, and she said that “they are really nice and she likes it
there”.

How do you generally cope with stress? or What do you do when you are upset?
Patient states that she “plays the piano” when she is sad. She reported that she majored in piano at the University of South
Mississippi. She stated she likes to play with her husband who is a vocalist. Patient said this helps to “calm her”.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life):
Patient stated that: “My husband’s truck broke down when we were out on the road and we had to get it towed to be fixed.
I don’t really remember where or when but it was really hard. We had to stay in that place over night. We got through it
but it was really frustrating.”
Patient denies any other difficulties.

+2 DOMESTIC VIOLENCE ASSESSMENT:

Have you ever felt unsafe in a close relationship? “Of course, when I was with my first husband. I don’t see him
anymore now, though.” When questioned regarding whether she is in a relationship currently that makes her feel this way,
patient stated: “No, not now, my husband is wonderful”.

Have you ever been talked down to? “Yes, my first husband definitely did that.”
Have you ever been hit punched or slapped? “Yes, he did that too.”

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? “Yes,
that was my whole first marriage.” Again, patient states she does not feel this way about her current husband though.

If yes, have you sought help for this? “Well, at first I put up with it. I did go speak to my doctor about it eventually. He
told me to see if it would get better and to stick it out. It didn’t though- it got worse. Then he told me to get out of that, so
I did. Now I have a wonderful husband.”

Are you currently in a safe relationship? “Oh yes, my husband is wonderful. I met him at University of South
Mississippi when I was majoring in piano and he was majoring as a vocalist. He was talking to someone one day and said
he was looking for someone to play for him, and so I tapped him on the should and said I would do it. Then we were just
kind of always together.”

University of South Florida College of Nursing – Revision September 2014 6


 4 DEVELOPMENTAL CONSIDERATIONS:

Erikson’s 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 of both parts of Erickson’s developmental stage for your patient’s
age group:
Patient in the stage of ego integrity versus despair are tasked with “looking back over one’s life and accepting its
meaning”. If the patient can resolve this conflict in a healthy manner they will feel a “sense of integrity and fulfillment”,
“willingness to face death, and wisdom”. If the patient does not feel this way, they will likely identify with the resolution
of despair characterized by “dissatisfaction with one’s life”. (Halter & Varcarolis, 2014, p.23)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
I believe that my patient is in this stage because she speaks fondly of her life with her husband. She told many stories
about her previous experiences and how they affected her. She is involved in her community and has many healthy
relationships. She did, at times, express sadness related to the changes in her life from her illness. However, she also
reported many healthy coping mechanisms she employed when she felt sad. The best indicator of my patient being in this
stage is that even in the midst of her illness, she is able to still find meaning in her relationships and does not focus solely
on her struggles. She acknowledges that it did change her life, but overcame it with resilience.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
Her seizures have impacted her life greatly. She speaks to the fact that it has created a level of memory impairment for
her, and therefore she is unable to perform activities of daily living independently. This has been “a little sad”, as the
patient said, but that she is able “to see God’s plan” in her whole life. She understands that it is acceptable to mourn for
what she lost, but that it is critical that she does not dwell there. The patient states she gets meaning “from her God and
her family” and that this is “all that matters in the end”.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“The baby’s blood going into my blood stream and then into my brain after the miscarriage.”

What does your illness mean to you?


“They [the seizures] certainly changed my life. I can’t remember well enough to plan to know for sure what will happen
to me next week. It bothers me. When I married [my husband] I wasn’t sure he would accept that. But he is strong enough
to do it. I am thankful for that.”

+3 SEXUALITY ASSESSMENT:

Have you ever been sexually active? “Yes.”


Do you prefer women, men or both genders? “Men.”
Are you aware of ever having a sexually transmitted infection? “No.”
Have you or a partner ever had an abnormal pap smear? “No.”
Have you or your partner received the Gardasil (HPV) vaccination? “No.”

Are you currently sexually active? “No.”


If yes, are you in a monogamous relationship? Not applicable.
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an
unintended pregnancy? “Well, that doesn’t really apply to me anymore.”

How long have you been with your current partner? “Well, since we met in college. He is great.”

Have any medical or surgical conditions changed your ability to have sexual activity? “Oh, no.”

University of South Florida College of Nursing – Revision September 2014 7


Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended
pregnancy? “No, I miss my baby.”

±1 SPIRITUALITY ASSESSMENT:

What importance does religion or spirituality have in your life?


“It definitely plays a role in my life. My husband was gonna be a preacher, but he transferred to being a trucker because
we needed more money. I used to help him a lot. I was always a passenger, just along for the ride.”

Do your religious beliefs influence your current condition?


It helps me. We go to church when we can. We used to go to all kinds of churches- little ones or big ones. Whatever was
in the town we were visiting.”
____________________________________________________________________________________________________________

+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?

(age through )
If applicable, when did the
Pack Years:
patient quit?
Does anyone in the patient’s household smoke tobacco?
Has the patient ever tried to quit? Not applicable.
“No.”
If yes, what did they use to try to quit?
If so, what, and how much?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No

What? How much?


For how many years?
Volume:
Frequency: (age through )
If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
How much? For how many years?
(age through )
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?
“No, me and my husband are odd balls. We don’t do anything too risky.”

5. For Veterans: Have you had any kind of service related exposure?
Not applicable.

University of South Florida College of Nursing – Revision September 2014 8


 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:
Diverticulitis Life threatening allergic reaction
“I don’t use it anymore.”
Bathing routine: “When I can.” Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy? “Never had one”.
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: “I don’t know.”
Post-nasal drip Normal frequency of urination: “3” x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Other: Metabolic/Endocrine
Routine brushing of teeth: “1” x/day Diabetes Type:
Routine dentist visits: Hypothyroid /Hyperthyroid
Vision screening: Intolerance to hot or cold
Other: “I have had a dentist visit and have
been to the eye doctor, but it has been a Osteoporosis
long time”.
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? “No clue.” Seizures
menstrual cycle: “Well, it used to be
Tuberculosis Ticks or Tremors
normal, but it’s gone now.”
Environmental allergies menarche Encephalitis
menopause “Maybe around my mid
last CXR? 10/05/2016 Meningitis
50s”.
Other: Date of last Mammogram & Result: Other:
“Honey, it has been a while.”
Date of DEXA Bone Density & Result: “I
have never had to that.”
Other: Miscarriage
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? Anxiety

University of South Florida College of Nursing – Revision September 2014 9


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: Atrial fibrillation Osteomyelitis Scarlet Fever
Last EKG screening: Patient is on Arthritis Chicken Pox
continuous telemetry monitoring,
sustaining sinus rhythm.
Other: Other: Other:
General Constitution
Recent weight loss or gain
How many lbs? Not applicable.
Time frame? Not applicable.
Intentional? Not applicable.

How do you view your overall health? “I am doing the best I can.”

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
“Sometimes I have memory loss. I haven’t seen anyone about it, but I think it is just from everything else”.

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: Patient is a Height: 158 cm Weight: 65.4 kg BMI: 26.3 Pain: 0 per patient report.
well-developed 72-year-old Pulse: 71 Blood Pressure: 146/71 mmHg
female with no visible signs Respirations: 18 Left Arm
of distress.
Temperature: 98 F- Oral SpO2: 99% Is the patient on Room Air or O2
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

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


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

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


clear, crisp diction
Other: Patient presents with confusion/memory impairment related to history of seizures and dementia. Occasionally,
patient will pause for a period of time to attempt to gather her words. 3 times during the interview the patient meant to
state one word, but stated another with a similar sound. She would always identify her error after the fact.

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

Central access device Type: Location: Date inserted:


Fluids infusing? no yes - what?

Peripheral IV site Type: 22 gauge Location: Right AC Date inserted: 10/8/2016


no redness, edema, or discharge
Fluids infusing? no yes – Normal Saline 75 mL/hour

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 3 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Other: Whisper test not conducted. Throughout interview, patient did not report difficulty hearing.
Dentition: Upon examination, patient’s teeth appeared to be of a normal color with appropriate level of hygiene. Patient
did not have dentures and denied history of artificial teeth.

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 RLL: CL (Auscultated anteriorly and posteriorly)
University of South Florida College of Nursing – Revision September 2014 11
RML: CL LLL: CL
CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent
Cardiovascular: No lifts, heaves, or thrills
Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No
JVD
Rhythm:
The PR interval as measured as 0.136 seconds, the QRS complex was 0.076 seconds, the QT interval was 0.372
seconds, and the rate was 71 beats per minute at the time of this recording. All measurements are within normal limits.
This is expected as the patient does not exhibit signs or symptoms of cardiac arrhythmia. Throughout admission she
has sustained normal sinus rhythm. Continuous cardiac monitoring was ordered as a result of the patient’s history of
atrial fibrillation.

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: Carotid: Brachial: Radial: 3 Femoral: Popliteal: DP: 3 PT:
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: (10/05/2016) 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: Nausea present on admission has subsided, per patient report.
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies
problems
Other – Describe:

GU: Urine output: Clear Cloudy Color: Light Yellow Previous 24 hour output: mLs
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: 4 RUE 4 LUE 4 RLE & 4 in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Other: Strength in handgrip, dorsiflexion, and dorsiextension noted as 4/5.

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 Romberg’s 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]

University of South Florida College of Nursing – Revision September 2014 12


Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative
Other: Patient is awake and alert. She is consistently oriented to person and, at times, to place. Patient is not oriented to
time or date. Patient denies numbness or tingling, reports being dizzy only on exertion, and a generalized weakness is
noted. Romberg’s test was not performed as the patient had a weak, unstable gait requiring nurse assistance to ambulate.
±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS

Lab Dates Trend Analysis


WBC (normal 4.5-11) The patient’s white blood The patient did not present to the
cells were normal upon emergency department for an infective
4.6 k/mcL 10/05/2016 admission, but have been process, so it is expected that her WBC
trending upwards. be within range. Since admission she
7.7 k/mcL 10/08/2016 has received treatment for MRSA, so it
expected that an immune response
7.7 k/mcL 10/09/2016 would be noted.
RBC (normal 4.2-5.4) The patient’s red blood The patient does not have a history of
cells were low upon anemia, and did not present with
3.37 million/mcL (Low) 10/05/2016 admission, and have been symptoms of low red blood cells. It is
trending upwards. likely that the patient has a low
3.69 million/mcL (Low) 10/08/2016 baseline level of red blood cells. I
would continue to monitor for
3.62 million/mcL (Low) 10/09/2016 symptoms and observe labs.
Hemoglobin (normal 12-16) The patient’s hemoglobin The patient did not exhibit any signs or
has been within normal symptoms of alteration in hemoglobin.
12.1 gm/dL 10/05/2016 limits throughout Therefore, it is expected that her
admission. hemoglobin is within normal limits. I
13.0 gm/dL 10/08/2016 would continue to monitor lab values.

12.4 gm/dL 10/09/2016


Hematocrit (normal 36-47) The patient’s hematocrit Upon admission, the patient’s
was initially slightly lower hematocrit was slightly below normal,
35.8 % (Low) 10/05/2016 than normal, but has and she had no signs or symptoms
increased since admitted. associated with a decreased hematocrit.
39.2% 10/08/2016 During admission it returned to normal
level and the patient continued to be
39.0 % 10/09/2016 free of symptoms. I would continue to
monitor lab values.
Platelets (normal 150- 450) The patient’s platelets The patient did not exhibit any signs or
have been within normal symptoms of alteration in platelets.
183 k/mol 10/05/2016 limits throughout Therefore, it is expected that her
admission. platelets is within normal limits. I
223 k/mol 10/08/2016 would continue to monitor lab values.

163 k/mol 10/09/2016


Sodium (normal 133-145) The patient’s sodium was During admission, the patient’s sodium
normal upon admission, fell to a low level however she did not
134 mEq/L 10/05/2016 decreased to an abnormal exhibit signs or symptoms of this. The
low level, and increased physician determined that we would
130 mEq/L (Low) 10/08/2016 again during the continue to monitor her and treat if it
admission. worsened. I would continue to monitor
134 mEq/L 10/09/2016 lab values.

University of South Florida College of Nursing – Revision September 2014 13


Potassium (normal 3.5-5) The patient’s potassium The patient did not exhibit any signs or
was within normal limits symptoms of alteration in potassium.
4.3 mEq/L 10/05/2016 throughout the admission. Therefore, it is expected that her
potassium is within normal limits. I
4.0 mEq/L 10/08/2016 would continue to monitor lab values.

3.6 mEq/L 10/09/2016


Chloride (normal 95-105) Upon admission, the During admission, the patient’s
patient’s chloride was chloride fell to a low level however she
98 mEq/L 10/05/2016 normal, with a slight did not exhibit signs or symptoms of
decrease during admission this. The physician determined that we
92 mEq/L (Low) 10/08/2016 that trended back upwards. would continue to monitor her and
treat if it worsened. I would continue
99 mEq/L 10/09/2016 to monitor lab values.
Calcium (normal 8.5-10.2) The patient’s calcium was The patient did not exhibit any signs or
within normal limits symptoms of alteration in calcium.
9.7 mg/dL 10/05/2016 throughout the admission. Therefore, it is expected that her
calcium is within normal limits. I
9.7 mg/dL 10/08/2016 would continue to monitor lab values.

9.2 mg/dL 10/09/2016


CO2 (normal 21-32) The patient’s CO2 was The patient did not exhibit any signs or
within normal limits symptoms of alteration in CO2.
23 mEq/L 10/05/2016 throughout the admission. Therefore, it is expected that her CO2
is within normal limits. I would
24 mEq/L 10/08/2016 continue to monitor lab values.

21 mEq/L 10/09/2016
Glucose (normal 70-100) The patient’s glucose was Throughout her admission, the
normal upon admission, patient’s glucose rose. This is likely a
97 mg/dL 10/05/2016 and trended upwards result of stress from being in the
throughout admission. hospital. The glucose is released in
122 mg/dL (High) 10/08/2016 times of stress as a source for energy. I
would continue to monitor for signs
127 mg/dL (High) 10/09/2016 and symptoms of hyperglycemia and
lab values.
BUN (normal 7-20) The patient’s BUN was The patient did not exhibit any signs or
within normal limits symptoms of alteration in BUN.
10 mg/dL 10/05/2016 throughout the admission. Therefore, it is expected that her
hemoglobin is within normal limits. I
10 mg/dL 10/08/2016 would continue to monitor lab values.

9 mg/dL 10/09/2016
Creatinine (normal 0.6 to 1.1) The patient’s creatinine The patient did not exhibit any signs or
was within normal limits symptoms of alteration in creatinine.
0.9 mg/dL 10/05/2016 throughout the admission. Therefore, it is expected that her
hemoglobin is within normal limits. I
0.9 mg/dL 10/08/2016 would continue to monitor lab values.

0.8 mg/dL 10/09/2016

University of South Florida College of Nursing – Revision September 2014 14


CT Head/Brain on 10/05/16: indicated for dizziness
No intracranial hemorrhage

XR Chest 1V on 10/05/16: indicated for dizziness, weakness, and syncope


No acute cardiopulmonary disease

XR Abdomen Flat on 10/09/16: indicated for vomiting


Nonspecific bowel gas pattern, prominence of stool in colon

Endoscopy on 10/10/16: indicated for vomiting


Hiatal hernia, esophagus ring dilated, gastritis
Biopsy to rule out candida infection

Electroencephalogram on 10/10/16: to assess for new brain injury that could contribute to seizures
Mild diffuse encephalopathy
No electrographic seizures

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:


Vital signs every 4 hours
Full neurological assessments every 3 hours
Seizures precautions
Continuous cardiac monitoring for history of atrial fibrillation
Pureed diet for dysphagia
Normal saline 20 mL/hr. to maintain IV patency
Occupation therapy and physical therapy daily
Gastrointestinal consult for nausea and vomiting
Neurology following for assessment and treatment of seizures

 8 NURSING DIAGNOSES:
1. Ineffective self-health management related to medication noncompliance as evidenced by acute seizure
activity and patient stating “I was nauseous, there was nothing else I could do”.
2. Activity intolerance related to acute seizure activity as evidenced by generalized weakness, strength noted
as 4/5, and need for assistance when ambulating.
3. Impaired memory related to history of seizures as evidenced by patient report, need for reorientation, and
diagnosis of dementia.
4. Risk for injury related to acute seizure activity.
5. Risk for complicated grieving related to memory impairment.

University of South Florida College of Nursing – Revision September 2014 15


± 15 CARE PLAN

Reference: Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An evidence-based guide to planning care (10th ed.). Maryland Heights, MO:
Mosby/Elsevier.

Nursing Diagnosis: Ineffective self-health management related to medication noncompliance as evidenced by acute seizure activity and patient
stating “I was nauseous, there was nothing else I could do”.

Patient Goals/Outcomes Nursing Interventions to Rationale for Interventions Evaluation of Goal on Day Care
Achieve Goal Provide References is Provided
Patient will verbalize two *Nurses will use a variety of Utilizing a variety of educational Verbal instruction was provided
statements describing necessity of methods (verbal, brochures, group materials will ensure that the by the nurse, physician, and
taking her anticonvulsant education) to communicate the information is reinforced to student nurse. Furthermore,
medication by end of shift. therapeutic regimen. promote better understanding. information regarding seizures,
management, and medications was
printed.

*Nurse with assistance from If a patient understands the reason The nurse provided adequate
pharmacist will communicate for taking medication, they will be information at the initial
purpose of anticonvulsant more likely to do so on their own. administration of medication.
medications prior to first
administration.

Nurse will request patient to Ability to recall of information is The patient was able to recall a
explain purpose of anticonvulsant associated with incorporation into limited amount of information.
medication at each administration, long term memory. Nurse will encourage the night
following the first. shift nurse to continue education
on medications.
Patient will collaborate with health Nurse will establish a therapeutic Established a therapeutic The patient stated that she
provider to establish a therapeutic relationship with the patient. relationship with patients promotes “thought her nurses were all
regimen congruent with lifestyle open, honest communication. wonderful and would talk to
by end of week. anyone at Florida Hospital”.

University of South Florida College of Nursing – Revision September 2014 16


Nurse will assist patient in Active listening to the patient’s Nurse listened to patient’s
identifying the factors contributing experience will allow the nurse to explanation of events that
to her inability to maintain identify components that are preceded the acute seizure activity,
therapeutic regimen. potentially the source of acute and identified two potential
complications. sources for complications.

Patient, nurse, and physician will Interdisciplinary collaboration Patient met with nurse and
meet to determine if there are with the patient promotes a greater physician daily to discuss the
alterations in the regimen that can sense of patient control and therapeutic regimen, and
be made. participation. adjustments were made
accordingly (i.e. addition of a new
medication).
Patient will verbalize ability to Each day, nurse will provide Providing written information, At the beginning of shift, nurse
manage therapeutic regimen by patient with a written plan of care, following verbal instruction, provided verbal instruction as well
discharge. after verbalizing it, that patient promotes long term retention of as printed information for the plan
will follow. information. of care.

Each day, nurse should ask patient Employing a numerical scale will On 10/08/16, the patient stated she
on a scale of 0-10 how prepared provide the nurse with quantitative felt she was a six out of ten on a
she is to manage her health (0 information on which she can base scale of competency in health
being completely unprepared, and future interventions. management.
10 feeling completely competent).

At discharge, nurse should ensure Waiting to discharge individuals Nurses will continue to
that patient rates self as 10 on until they are prepared will result communicate to the next nurse
scale of 0-10 in regards to how in a decrease in readmissions caring for the patient, that this
prepared she is. related to difficulty in managing must be done prior to discharge.
therapeutic regimens.

University of South Florida College of Nursing – Revision September 2014 17


Nursing Diagnosis: Activity intolerance related to acute seizure activity as evidenced by generalized weakness, strength noted as 4/5, and need for
assistance when ambulating.

Patient Goals/Outcomes Nursing Interventions to Rationale for Interventions Evaluation of Goal on Day Care
Achieve Goal Provide References is Provided
Patient will ambulate to the 20 *Nurse will explain the benefits of Providing information about the Along with PT, nurse provided
feet, twice a shift, with assistance exercise in regards to prevention benefits of exercise will increase instruction on why exercise was
from a nurse or assistive of pneumonia and other adverse patient motivation. beneficial prior to first ambulation.
personnel. situations.

Nurse will ask patient to explain Recall of information indicates Patient was able to explain how
benefits of exercise after providing understanding of education in exercise will benefit her within the
teaching. regards to long term memory. hospital, and outside as well.

PT will be consulted to assist in Interdisciplinary approaches Patient successfully ambulated to


ambulation or other strength ensure that the patient receives the hallway, as well as three rooms
building exercises. care from those most specialized down with assistance from PT
in that area.
Patient to will perform *Nurse will explain the benefits of Providing information about the Nurse provided verbal instruction
active/passive range of motion range of motion prior to initiating benefits of range of motion as well as written information as
exercises with assistance every with patient. exercises will increase patient to why range of motion exercises
day, once a day, prior to discharge. motivation. are beneficial.

PT and/or the nurse will assess Creating an individualized plan of PT created a plan of range of
patient’s ability to perform range care will target the specific areas motion exercises. Patient declined
of motion exercises and create a in which the patient needs doing them on 10/08/2016 because
plan of care accordingly. improvement. she was “tired”. Patient stated she
would do them tomorrow.
Patient will perform two activities Nurse will assess patient’s A thorough baseline assessment Nurse performed assessment of
of daily living independently prior baseline ability to perform will allow for the creation of a client’s abilities, and allowed
to discharge. activities of daily living. unique plan tailored to the client to verbalize their own
patient’s skill set. concerns with regards to
completing activities of daily
living.

University of South Florida College of Nursing – Revision September 2014 18


Nurse will obtain or recommend Assistive devices will promote Nurse obtained a shower chair for
assistive devices for the patient to patient comfort while engaging in the client to use, and spoke with
use during activity. activity, which will in turn case management about doing so
increase motivation. when discharged.

Nurse will remain with patient Promoting patient safety is Patient completed a shower
while she performs activities of priority, and remaining with the without assistance from nurse. She
daily living to maintain safety. patient will increase their stated she was “too tired” to do
confidence. anything further. Patient will be
encouraged to continue to perform
activities of daily living as
tolerated.

±2 DISCHARGE PLANNING: (put a * in front of any patient education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT: Patient will benefit from assistance from PT/OT as she is currently coping with activity intolerance and needs assistance with activities of daily
living.
Pastoral Care
Durable Medical Needs: Depending on evaluation from PT/OT, patient may benefit from equipment such as a walker or cane for assistance when
ambulating.
F/U appointments: Establishing consistent follow up appointments will promote open communication between the patient and the provider so that
adjustments to her plan of care can be made when needed.
Med Instruction/Prescription: A component to the admission of the patient was her inability to take her medication/lack of understanding regarding the
importance of them, so instruction will help to prevent this in the future.
Are any of the patient’s medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing – Revision September 2014 19


References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An evidence-based guide to

planning care (10th ed.). Maryland Heights, MO: Mosby/Elsevier.

Choose MyPlate. (n.d.). Retrieved September, 25, 2016, from https://www.supertracker.usda.gov

Epocrates. (2014). Epocrates Reference Tools for Healthcare Professionals (16.8) [Mobile application

software]. Retrieved from http://itunes.apple.com

Halter, M. J., & Varcarolis, E. M. (2014). Varcarolis' Foundations of Psychiatric Mental Health

Nursing: A Clinical Approach (7th ed.). St. Louis, MO: Elsevier.

Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology (5th ed.). St.

Louis, MO: Mosby/Elsevier.

University of South Florida College of Nursing – Revision September 2014 20