UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Rebecca Netjes

Assignment Date: January 24, 2017
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Florida Hospital Tampa
 1 PATIENT INFORMATION
Patient Initials: MLW Age: 41 years old Admission Date: January 23, 2016
Gender: Female Marital Status: Single Primary Medical Diagnosis: Shortness of breath,
tachycardia
Primary Language: English
Level of Education: 9th Grade Other Medical Diagnoses: None.

Occupation: Patient states she is no longer employed and that she

recently applied for disability.
Number/ages children/siblings: Patient reports that she has five
children- two boys (11 and 25 year-old) and three girls (16, 18, and
27 year-old). She reports having four siblings- one brother (43
years old) and three sisters (39, 44, and 49 years old).
Served/Veteran: “No.” Code Status: Full Resuscitation
If yes: Ever deployed? Not applicable.

Living Arrangements: Patient currently resides in an apartment Advanced Directives: None

that is accessed only by stairs. She lives with her 11-year-old son, If no, do they want to fill them out? “No.”
12 and 18-year-old daughters, and “sometimes her boyfriend’s Surgery Date: None.
stays over”. She reports she will be moving “soon”. Procedure: None.
Culture/Ethnicity/Nationality: African American
Religion: Baptist Type of Insurance: Staywell

 1 CHIEF COMPLAINT:
Patient states she presented to the Emergency Department at Florida Hospital Tampa because of “shortness of breath and
a cough”. She also reported a “very bad headache”, stating it was the “worst thing I have ever experienced”.

 3 HISTORY OF PRESENT ILLNESS:

On January 23, 2017, the patient, a 41 year-old female, presented to the Emergency Department (ED) for evaluation of a
persistent, mildly productive cough and shortness of breath. She states the cough has been present for “about two and a
half weeks” but that it got significantly worse on 1/22/17. The cough is productive “at times”, producing light yellow
mucus. The patient reports that the cough is aggravated by “moving around too much or talking too long”. Her symptoms
are relieved with supplemental oxygen. She stated that before presenting to the emergency department, she had tried a
“steroid dose pack given to her by her doctor, and that it helped for a few days, but it just went back to how it was before”.
Her shortness of breath began that morning as the cough got worse and progressed throughout the day. Upon examination
in the emergency department it was noted she had sustained sinus tachycardia. During admission, the patient would have a
2D echocardiogram to assess for physiologic changes that may be causing the tachycardia. Cardiac enzymes were drawn
in the ED. A chest x-ray was performed to evaluate her shortness of breath, with results not indicating any active disease
process. A CT was then preformed as the patient experienced an increase in shortness of breath and “chest tightness”. The
CT with contrast showed no sign of a pulmonary embolism and that her lungs were clear. Finally, a CT without contrast
University of South Florida College of Nursing – Revision September 2014 1
of her head was performed to address her severe headache, which produced normal findings. A thyroid function test was
ordered. The patient was then admitted for treatment of a possible respiratory infection with steroids and antibiotics. Since
admission, the patient’s chest pain and headache are resolved, the tachycardia has decreased, and her shortness of breath is
only on exertion. Blood cultures were ordered to assess for a bacterial infection.

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY

Date Operation or Illness

“When I was little.” Measles: “I don’t know, but I am fine”.
“At least the last 10 years.” Hypertension: managed with lisinopril 40 mg
“Since my 20’s.” Migraine: “I just take Tylenol and sleep.”
2000 Fibromyalgia: managed with pregabalin (Lyrica) 150 mg
2014 Depression: managed with duloxetine (Cymbalta) 60 mg and sertraline (Zoloft) 100 mg
2016 Right Knee Surgery for torn meniscus
“Since I was young.” Anemia: “I don’t do anything because of it, I just know I have it.”

2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Heart Trouble

Mental Health
Age (in years)

Hypertension
FAMILY
Bleeds Easily
Alcoholism

Cause

Glaucoma
MEDICAL

Problems

Problems
Allergies

Arthritis

Diabetes
of

Seizures
Anemia

Asthma

Cancer

Kidney

Tumor
HISTORY

Stroke
Death

Gout
(if
applicable)
Father 70 Sepsis
Not
Mother 64
applicable
Not
Brother 43
applicable
Not
Sister 49
applicable
Not
Sister 44
applicable
Not
Sister 39
applicable
Comments:
The patient’s father had colon cancer (patient was “not sure when he got it”), diabetes (“for a long time”), glaucoma (January 2014),
congestive heart failure and hypertension (2008). The patient reported that he had a leg amputated due to complications from diabetes
in 2014, and this was “when his seizures and kidney problems begin”. He died from infection secondary to the amputation in 2014.
The patient’s mother had anemia and arthritis (patient was “not sure when it started”), COPD (2010), diabetes (“since she was young”),
gout (2013), a MI (2014), hypertension (1981), and a stroke (2015).
Her brother and sisters were all diagnosed with hypertension “around 2007”.

 1 IMMUNIZATION HISTORY
YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria:
Adult Tetanus: “Yeah, I think it is within 10 years.”
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

Medications

Other (food, tape, Latex “I get really itchy and sometimes I get welts”.
latex, dye, etc.)

 5 PATHOPHYSIOLOGY:
This patient was admitted for evaluation for an acute disease process involving the respiratory system, with likely
diagnoses being pneumonia. Pneumonia is characterized by an infection of the lower respiratory structures related to a
microorganism. This can occur prior to hospitalization, in which case it is considered community-acquired pneumonia, or
in the hospital, known as a nosocomial infection of pneumonia. Risk factors associated with the development of
pneumonia are an increased age, suppressed immune system, dysphagia, endotracheal intubation, etc. (Huether &
McCance, 2012). In pneumonia, macrophages will recognize the foreign pathogen and initiate an immune response. This
leads to inflammation of the lung and an increase in neutrophils in the bronchioles and alveoli. Prolonged inflammation
and presence of immune cells can damage the membranes and allow for an accumulation of fluid. This causes dyspnea
and hypoxemia. Clinical manifestations of pneumonia can range from mild disturbances such as a cough, malaise, or
chills to more alarming symptoms such as fever, pain, dyspnea, and hemoptysis (Huether & McCance, 2012). The milder
form of pneumonia is often community acquired and referred to as “walking pneumonia” as the patient is able to perform
most activities of daily living. Diagnosis of pneumonia is typically made with information taken from physical
examination, chest radiographs, cultures, and serology. Patients with previous medical condition that are then diagnosed
with pneumonia typically recover the same functional status, but if the patient is immunocompromised there is an
increased risk of mortality. Treatment for pneumonia consists largely of antibiotic therapy, steroids or anti-inflammatory
therapy, supplemental oxygen, and rest. It is likely that this patient fell into the category of community acquired or
“walking pneumonia” as her cultures and chest radiographs were negative. Physicians would likely still treat with
antibiotics and other interventions to prevent the patient from developing a severe case of pneumonia (Centers for Disease
Control and Prevention, 2016). Follow up care with a primary care physician would be highly stressed for patients with
clinical manifestations of a respiratory disease process, such as pneumonia, without laboratory data or radiographic
evidence. This would ensure the absences of new or worsening infection.

 5 MEDICATIONS:
Reference:
Epocrates. (2014). Epocrates Reference Tools for Healthcare Professionals (16.8) [Mobile application software]. Retrieved from http://itunes.apple.com

Name: azithromycin (Zithromax) Concentration: 500 mg Dosage Amount: 500 mg

Route: IV Frequency: Every 24 hours

Pharmaceutical class: macrolides Home Hospital or Both
Indication: bacterial infection
Adverse/ Side effects: diarrhea, nausea, vaginitis, pruritus, angioedema, Stevens-Johnson syndrome, anaphylaxis
Nursing considerations/ Patient Teaching: Teach patient to take medication with food to decrease GI upset. Assess for allergy. Preform frequent skin and
genitourinary assessments to assess for superinfection.

Name: ceftriaxone (Rocephin) Concentration: 1 gram Dosage Amount: 1 gram

Route: IV Frequency: Every 24 hours

Pharmaceutical class: cephalosporins Home Hospital or Both
Indication: bacterial infection
Adverse/ Side effects: diarrhea, leukopenia, ALT/AST elevated, thrombocytosis, anaphylaxis, bronchospasm, superinfection, seizures

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

Nursing considerations/ Patient Teaching: Teach patient to take medication with food to decrease GI upset. Assess bowel movements. Monitor lab levels and
trend values to assess for alteration in blood counts. Assess for signs and symptoms of superinfection (thrush).

Name: duloxetine (Cymbalta) Concentration: Dosage Amount: 60 mg

Route: PO Frequency: Every 24 hours

Pharmaceutical class: serotonin norepinephrine reuptake inhibitor Home Hospital or Both
Indication: depression
Adverse/ Side effects: nausea, headache, somnolence, fatigue, insomnia, erectile dysfunction, flushing, blurry vision, hypotension, serotonin syndrome,
withdrawal symptoms if abruptly discontinued, suicidality
Nursing considerations/ Patient Teaching: Assess for suicidal ideation regularly. Assess blood pressure at baseline and throughout treatment. Report signs or
symptoms of serotonin syndrome to health care provider. Teach patient not to stop taking medication without informing provider.

Name: fluctisone nasal (Flonase) Concentration: Dosage Amount: 100 mcg

Route: intra nasal Frequency: Every 24 hours

Pharmaceutical class: corticosteroid nasal spray Home Hospital or Both
Indication: allergic rhinitis symptoms
Adverse/ Side effects: headache, epistaxis, nasal irritation, dizziness, nasal/oral candidiasis, anaphylaxis, immunosuppression, adrenal suppression
Nursing considerations/ Patient Teaching: Assess effectiveness of medication after administration. Assess for superinfection in nasal cavity. Inform patient to
rise slowly to avoid falls related to dizziness.

Name: levalbuterol (Xopenex) Concentration: Dosage Amount: 1..25 mg solution

Route: nebulizer Frequency: Three times, daily

Pharmaceutical class: beta-2 adrenergic receptor stimulator Home Hospital or Both
Indication: bronchospasm
Adverse/ Side effects: headache, nervousness, tachycardia, dizziness, anaphylaxis, hypertension, hypotension, arrhythmia
Nursing considerations/ Patient Teaching: Inform patient that mild increase in heart rate and tremors are expected. Teach patient to rise slowly to prevent falls
related to dizziness. Assess all vital signs before and after treatment. Assess cardiac waveforms if on continuous telemetry.

Name: lisinopril (Prinivil) Concentration: Dosage Amount: 40 mg

Route: PO Frequency: Every 24 hours

Pharmaceutical class: angiotensin-converting enzyme inhibitor Home Hospital or Both
Indication: hypertension
Adverse/ Side effects: hypotension, cough, fatigue, hyperkalemia, angioedema, Stevens-Johnson syndrome, agranulocytosis
Nursing considerations/ Patient Teaching: Assess blood pressure before and after administration. Teach patient not to abruptly stop taking medications.
Monitor electrolyte levels. Assess for cough.

Name: methylprednisolone (Solumedrol) Concentration: Dosage Amount: 40 mg

Route: IV Frequency: Two times, daily

Pharmaceutical class: corticosteroid Home Hospital or Both
Indication: inflammation
Adverse/ Side effects: increase blood glucose, weight gain, hypokalemia, nausea, insomnia, psychosis, decrease white blood cells, Cushing’s syndrome
Nursing considerations/ Patient Teaching: Teach patient the importance of glucose monitoring while on this medication. Explain purpose of insulin coverage, if
added. Assess for metabolic abnormalities. Teach patient and family good hand hygiene and infection prevention.

Name: pregabalin (Lyrica) Concentration: Dosage Amount: 150 mg

Route: PO Frequency: Three times daily

Pharmaceutical class: analgesic/antiseizure Home Hospital or Both
Indication: nerve pain
Adverse/ Side effects: dizziness, somnolence, peripheral edema, blurry vision, constipation, angioedema, rhabdomyolysis, suicidality, seizures if abruptly
discontinued
Nursing considerations/ Patient Teaching: Teach patient not to operate machinery until they know how the medication affects them. Teach patient to rise slowly
to prevent falls related to dizziness. Assess frequency of bowel movements. Teach patient not to discontinue medication quickly. Assess pain before and after
administration.
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Name: sertraline (Zoloft) Concentration: Dosage Amount: 100 mg

Route: PO Frequency: Every 24 hours

Pharmaceutical class: selective serotonin reuptake inhibitor Home Hospital or Both
Indication: depression
Adverse/ Side effects: nausea, headache, insomnia, somnolence, tremor, anxiety, suicidality, serotonin syndrome, hyponatremia, seizures, abnormal bleeding
Nursing considerations/ Patient Teaching: Asses for suicidal ideation regularly. Assess for, and report, signs or symptoms of serotonin syndrome. Analyze and
trend lab values to assess for electrolyte imbalances. Preform frequent assessments to check for bleeding (bruising).

 5 NUTRITION:
Diet ordered in hospital? General Healthful Diet
Diet patient follows at home? The patient states she is trying
to eat “better” because her doctor told her she “is in danger of
getting diabetes”. She does not frequently eat breakfast and
“almost always” skips lunch.
24 HR average home diet:
Breakfast: Patient reports that she may eat “cheese grits, an
egg, sausage, and orange juice”.
Lunch: Patient states that “if she eats it would be a turkey
sandwich”, consisting of turkey, bread and a cheese slice.
Dinner: Patient states “I like baked chicken with green
beans, mashed potatoes, and cornbread”.
Snacks: Patient states she “never snacks”.
Liquids: Patient states she drinks two sodas each day,
“some water”, and “maybe a coffee or tea in the morning”.
Analysis of home diet:
This patient does not have any cultural or ethnic
considerations that apply to her diet, per her report. Her
medical history includes a diagnosis of hypertension. With
this in mind, the patient should be taught to consume a diet
low in salt and fat – or the DASH diet. Also, this patient
reported that her doctor is concerned “she may be
developing diabetes like everyone else in her family”. I
would encourage the patient to consider a diet low in
carbohydrates and to monitor her blood glucose level.
With attention to what she is consuming now, she is
meeting goals for grain and vegetable intake. However,
she does not consume an adequate level of fruit. I would
encourage her to either incorporate this in her meals or to
have light snacks throughout the day. Her dairy intake is
slightly low, so I would encourage her to substitute a glass
of soda with a glass of milk, or incorporate yogurt or
cheese. Finally, the patient is consuming more protein than
what is recommended. I would educate her that a sustained
increase of protein intake can be harmful to her kidneys
and predispose her to various forms of kidney dysfunction.

1 COPING ASSESSMENT/SUPPORT SYSTEM:

Who helps you when you are ill?
Patient reported that her “oldest daughter is very helpful, her sister is good about helping with the kids, and her
boyfriend”. She also stated that her “little kids always run in to check on her right when they get home from school”.

How do you generally cope with stress? or What do you do when you are upset?
Patient states “I guess I don’t really [cope with stress]”. She stated that if anything “she may eat something she probably
shouldn’t or watch TV.”
University of South Florida College of Nursing – Revision September 2014 5
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life):
Patient stated that “if anything, the most difficult thing has been her dad’s death”. She described him as the “rock of the
family” and her best friend. She stated sometimes it is “hard to feel happy without him, but that she knows he would want
her to be happy. She “knows that he is with her and her kids”.

+2 DOMESTIC VIOLENCE ASSESSMENT:

Have you ever felt unsafe in a close relationship? “Not recently, no.”

Have you ever been talked down to? “In the past.”
Have you ever been hit punched or slapped? “In the past.”

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? “Yes,
in the past.”

If yes, have you sought help for this? “I didn’t go talk to anyone about it if that is what you mean. But yeah, the police
were called. I got out.”

Are you currently in a safe relationship? “Yes, my boyfriend is better.”

 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:
The stage of intimacy versus isolation focuses on the goal to establish “intimate bonds of love and friendship”. Intimacy is
defined as the “ability to love deeply and commit oneself”, while isolation is characterized by “emotional isolation and
egocentricity”. (Halter, M. J., & Varcarolis, E. M., 2014, p.23)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
Typically, the stage of intimacy versus isolation is resolved in the later 20s to 30s. I believe at one time my patient had
likely resolved this stage and was focused on generativity versus stagnation. However, the death of her father a few years
prior seems to have made the patient regress. She described a very close relationship with him and how his death has been
exceptionally challenging for her. The patient stated it is sometimes difficult for her to be happy and that she tries to focus
on her children and family. She seems to long for the same closeness she once had with her father. Now, the patient states
she is “doing better with her father’s death, even though it is hard”. She is recently involved in a committed relationship
and says “he is a good one”. I believe my patient is still working through the grief surrounding her father’s death, but will
truly recover when she can truly find that same level of closeness with someone else.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The patient did not indicate that this hospitalization has had a profound impact on her developmental stage of life. She
indicated that she missed her children and family, but did not seem exceptionally distraught by this. The patient did state
“she wished her mom could come visit”, though. Overall, this hospitalization may have intensified her feelings of love
and closeness with her family because she realized she missed them.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“I think just the upper respiratory infection. I guess this cough just won’t go away. The doctor said it was something I
probably got from my kids.”

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

 What does your illness mean to you?
“Well, I am going to miss the move. I had an appointment and my son had an appointment. Now I am going to have to
figure out how to switch all of that. It was definitely unexpected.”

+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? “Yes, in 2000.”
Have you or a partner ever had an abnormal pap smear? “Yes, in 2000.”
Have you or your partner received the Gardasil (HPV) vaccination? “No.”

Are you currently sexually active? “Yes.”

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? “Yeah, just condoms.”

How long have you been with your current partner? “We were together for a bit in 1995, then off again. We have been
together now for four months.”

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.”

±1 SPIRITUALITY ASSESSMENT:

What importance does religion or spirituality have in your life?

“I mean it is really important to me. I believe in it for my family and my kids. And my dad.”

Do your religious beliefs influence your current condition?

“No.”
____________________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? 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? Wine, Vodka, Beer How much? “Only occasionally.”
For how many years? 23 years
Volume: “It depends on my day.”

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 Frequency: “1 time every 3 months
or if there is a special occasion like (age 18 through 41)
Thanksgiving”.
If applicable, when did the patient quit?
Not applicable.

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
How much? “I tried marijuana
For how many years? Less than one.
one time when I was 17.”
(age 17 through 17 )
If not, when did he/she quit?
Is the patient currently using these drugs?
The patient states she only
Yes No
“tried it the one time”.

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?
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.”
Bathing routine: “Every day.” 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.”
Normal frequency of urination: “16-18”
Post-nasal drip Other:
x/day
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Other: Metabolic/Endocrine
Routine brushing of teeth: “2” x/day Diabetes Type:
Routine dentist visits: “I need to go
Hypothyroid /Hyperthyroid
again”.
Vision screening: “I need to go to them
Intolerance to hot or cold
too.”
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? “February 2016.” Seizures
Tuberculosis menstrual cycle: Regular Ticks or Tremors
Environmental allergies menarche: 11 years-old Encephalitis
last CXR? 1/23/2017 menopause Meningitis
Other: Date of last Mammogram & Result: “I Other:
have no idea”
Date of DEXA Bone Density & Result:
“I’ve never had 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
Myocardial Infarction BPH Bipolar

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

 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 tachycardia.
Other: Chest pain is only when she “has
the cough”, and “she had a murmur when Other: Other:
she was little, but not anymore”.
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?
“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: Patient is a Height: 183 cm Weight: 147.9 kg BMI: 44.2 Pain: 0, per patient report, at
well-developed 41-year-old Pulse: 83 Blood Pressure: 123/74 mmHg time of examination.
female with no visible signs Respirations: 18 Left Arm
of distress.
Temperature: 97.8 F- Oral SpO2: 100% Is the patient on Room Air or O2 –
2L Nasal Cannula
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:

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: 18 gauge Location: Right Forearm Date inserted: 01/23/2017
no redness, edema, or discharge
Fluids infusing? no yes – Normal Saline 100 mL/hr

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. Patient reported
“pressure” in her sinus region
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 (with supplemental oxygen therapy)
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: D LUL: D RLL: D (Auscultated anteriorly and posteriorly)
University of South Florida College of Nursing – Revision September 2014 11
RML: D LLL: D
CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent
Other: Without supplemental oxygen therapy, the patient becomes dyspneic. Her SpO 2 would decrease to 87-90%. The
patient’s respirations would become labored and she would state she felt pain in her chest.

Cardiovascular: No lifts, heaves, or thrills

Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No
JVD
Rhythm:
All measurements were within normal limits but rate is accelerated, mildly. This is expected as the patient does not
exhibit signs or symptoms of cardiac arrhythmia, decreased cardiac output, or decreased perfusion. Throughout
admission she has sustained sinus tachycardia. Continuous cardiac monitoring was ordered as a result of the
tachycardia noted in the ER.

Rate: 102/min

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 hypoactive 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: (01/21/2016) 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:
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: 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: 5 RUE 5 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 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

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

 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: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative
Other: Romberg’s test was not performed as the patient would become dyspneic upon exertion, creating weakness and
dizziness.

±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS

Lab Dates Trend Analysis

WBC (normal 4.5-11) The patient’s WBC count The patient is currently taking
was normal on admission methylprednisolone to decrease
5.7 k/mcL 01/23/2017 and trended downwards inflammation. A side effect of this
throughout her stay. medication is a decrease in white blood
2.9 k/mcL (Low) 01/24/2017 cell count. I would continue to monitor
for signs of infection, practice
universal precautions, and monitor her
WBC count.
RBC (normal 4.2-5.4) The patient’s RBC count The patient states that she has been
was low throughout anemic since she was “little”. It is
3.96 million/mcL (Low) 01/23/2017 admission. expected that her RBC would be low.
She is not symptomatic, so I would
3.78 million/mcL (Low) 01/24/2017 continue to monitor her response to the
lower level.
Hemoglobin (normal 12-16) The patient’s hemoglobin The patient states that she has been
was low throughout anemic since she was “little”. It is
11.2 gm/dL (Low) 01/23/2017 admission. expected that her hemoglobin would be
low. She is not symptomatic, so I
10.7 gm/dL (Low) 01/24/2017 would continue to monitor her
response to the lower level.
Hematocrit (normal 36-47) The patient’s hematocrit During her stay, the patient’s
was low-normal on hematocrit did decrease, but she did
36.3 % 01/23/2017 admission and trended not exhibit any signs or symptoms. I
down slightly during the would continue to monitor her
34.3 % (Low) 01/24/2017 stay. response and her labs.
Platelets (normal 150- 450) The patient’s platelet The patient’s platelet count remained
count was normal normal. This is expected as she did not
252 k/mol 01/23/2017 throughout admission. exhibit any signs or symptoms of an
alteration in platelet count.
246 k/mol 01/24/2017
Sodium (normal 133-145) The patient’s serum The patient’s serum sodium remained
sodium level was normal normal. This is expected as she did not
134 mEq/L 01/23/2017 throughout admission. exhibit any signs or symptoms (i.e.
lethargy, confusion) of an alteration in
138 mEq/L 01/24/2017 sodium.
Potassium (normal 3.5-5) The patient’s serum The patient’s serum potassium
potassium level was remained normal. This is expected as
4.6 mEq/L 01/23/2017 normal throughout she did not exhibit any signs or
admission. symptoms (i.e. muscle cramps,
3.8 mEq/L 01/24/2017 elevated T segments on EKG) of an
alteration potassium.

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

Chloride (normal 95-105) The patient’s serum The patient’s serum chloride remained
chloride level was normal normal. This is expected as she did not
97 mEq/L 01/23/2017 throughout admission. exhibit any signs or symptoms of an
alteration in chloride.
105 mEq/L 01/24/2017
Calcium (normal 8.5-10.2) The patient’s serum The patient’s calcium remained
calcium level was normal normal. This is expected as she did not
9.3 mg/dL 01/23/2017 throughout admission. exhibit any signs or symptoms (i.e.
bone weakness) of an alteration in
8.7 mg/dL 01/24/2017 calcium.
CO2 (normal 21-32) The patient’s CO2 level The patient’s CO2 was slightly low
was normal at admission, during admission. She did not exhibit
21 mEq/L 01/23/2017 but trended down slightly any signs of low CO2, but this could be
during admission. due to her rapid breathing related to
20 mEq/L (Low) 01/24/2017 feeling short of breath. I would
continue to monitor, and if she did
exhibit symptoms, I would provide a
bag for her to practice a re-breathing
technique.
Glucose (normal 70-100) The patient’s glucose was The patient was started on
elevated at admission, and methylprednisolone during her
117 mg/dL (High) 01/23/2017 trended upwards during admission. A side effect of this
her stay. medication is an increase in blood
198 mg/dL (High) 01/24/2017 glucose. I would continue to stay in
communication with the provider and
assess the need for additional
interventions to control her glucose.
BUN (normal 7-20) The patients BUN level The patient’s BUN remained normal.
was normal throughout This is expected as she did not exhibit
7 mg/dL 01/23/2017 admission. any signs or symptoms (i.e. change in
urination patterns) of an alteration in
7 mg/dL 01/24/2017 BUN.
Creatinine (normal 0.6 to 1.1) The patient’s creatinine The patient’s creatinine remained
level was normal normal. This is expected as she did not
0.8 mg/dL 01/23/2017 throughout admission. exhibit any signs or symptoms of an
alteration in creatinine.
0.7 mg/dL 01/24/2017
Thyroid Stimulating Hormone The patient’s thyroid The patient’s thyroid stimulating
(normal 0.27-4.20) stimulating hormone was hormone was within normal range;
normal at admission. This therefore, her thyroid is likely
0.91 U/mL 01/23/2017 lab was not ordered again functioning appropriately. This was
during her admission. ordered to assess for a cause of the
tachycardia the patient experienced. I
would continue to assess.
Troponin T (normal 0.00-0.03) The patient’s troponin T The patient’s troponin level was drawn
level was normal at to assess for an alteration in cardiac
< 0.01 ng/L 01/23/2017 admission. This lab was functioning that could be contributing
not ordered again during to her tachycardia and “chest
her admission. tightness”. I would continue to monitor
her for other signs or symptoms of
alteration in functioning, as her
troponins were normal.
pro BNP (normal 0-450) The patient’s pro BNP The patient’s pro BNP level was drawn
level was normal at to assess for an alteration in cardiac

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

 105 pg/mL 01/23/2017 admission. This lab was
not ordered again during
her admission.
Culture, Blood Only one of the vials
collected for the blood
Gram Positive Cocci in cultures 01/23/2017 culture revealed evidence
in only one of two vials. of gram positive cocci. No
follow up cultures were
ordered.
Influenza Serology The patient was only
tested for influenza
Negative 01/23/2017 infection at admission, as
the result was negative.
Mycoplasma pneumoniae The patient was only
Serology tested for mycoplasma
Negative 01/23/2017 pneumoniae infection at
admission, as the result
was negative.
Rhino Enterovirus Serology The patient was only
tested for rhino enterovirus
Negative 01/23/2017 infection at admission, as
the result was negative.
Respiratory Syncytial Virus The patient was only
Serology tested for respiratory
01/23/2017 syncytial virus infection at
Negative admission, as the result
was negative.
01/23/2017 XR Chest 1V: indicated for shortness of breath
Cardiac silhouette not enlarged. Lungs clear with no infiltrates. No active disease.
01/23/2017 CT Chest PE with contrast: indicated for shortness of breath and chest pain
No CT evidence of pulmonary embolism. Lungs are clear. Nonspecific 1.7 cm right hilar lymph node.
01/23/2017 CT Head/Brain without contrast: indicated for severe headache
Normal non-contrast CT of brain.
01/24/2017 Echo 2D Doppler: indicated for evaluation of sustained tachycardia
Systolic function normal. EF 55-60%. No regional wall abnormalities.
University of South Florida College of Nursing – Revision September 2014
functioning that could be contributing
to her tachycardia and “chest
tightness”. I would continue to monitor
her for other signs or symptoms of
alteration in functioning, as her pro
BNP was normal.
Since both vials did not show the
bacteria, it is likely that the vial was
contaminated. The patient does not
exhibit other signs and symptoms of a
bacterial infection (i.e. fever, increased
WBC). I would continue to monitor
her, but it is likely that this positive
result was due to contamination.
The patient was negative for influenza
infection. I would continue to assess
for signs and symptoms of infection,
and educate her on prevention.
The patient was negative for
mycoplasma pneumoniae infection. I
would continue to assess for signs and
symptoms of infection, and educate her
on prevention.
The patient was negative for rhino
enterovirus infection. I would continue
to assess for signs and symptoms of
infection, and educate her on
prevention.
The patient was negative for
respiratory syncytial virus infection. I
would continue to assess for signs and
symptoms of infection, and educate her
on prevention.
15
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:
1. Vital Signs every 4 hours, per unit routine.
2. Activity up ad lib with at least one assist. The patient is dizzy/weak on exertion, at times. Therefore, it is
required she have one assist when ambulating.
3. General healthful diet. The patient does not have any comorbidities that would indicate a need for her to
be on a unique diet.
4. Continuous telemetry monitoring. On admission, it was noted that the patient was in sustained sinus
tachycardia. Continuous monitoring was ordered to assess for any other arrhythmia the patient may
experience.
5. Continuous pulse oximetry. On admission, the patient was extremely short of breath. Continuous
monitoring was ordered to assess for how activity affected her. Also, the plan was to wean her off
supplemental oxygen prior to discharge, so her response needed to be evaluated.
6. Respiratory therapy, nebulizer treatment three times a day.
7. The patient is being followed by pulmonologist and cardiologist for evaluation of her shortness of breath
and tachycardia, respectively.

 8 NURSING DIAGNOSES:

1. Ineffective gas exchange related to potential infection as evidenced by diminished breath sounds, mucus
production, and need for supplemental oxygen therapy to maintain SpO2 greater than 90%.
2. Ineffective breathing pattern related to potential infection as evidenced by tachypnea and dyspnea on
exertion with a decline in SpO2.
3. Activity intolerance related to potential infection as evidenced by dyspnea on exertion, weakness when
ambulating, and inability to perform activities of daily living (ADLs) without assistance and supplemental
oxygen.
4. Complicated grieving related death of father as evidenced by depression, patient report that it is “hard to
feel happy without her dad”, and persistent emotional distress.
5. Risk for powerlessness related to undiagnosed illness as evidenced by patient report that “she just wants to
know what it is so she can go” and that this “was so unexpected”.

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

± 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 gas exchange related to potential infection as evidenced by diminished breath sounds, mucus production, and need
for supplemental oxygen therapy to maintain SpO 2 greater than 90%.

Patient Goals/Outcomes
Patient will list three alternative
interventions that will help to
increase oxygenation by end of
shift.
Nursing Interventions to
Achieve Goal
*Teach patient that when they are
acutely dyspneic, they can lean
forward over the bedside table
(tripod positioning).
Rationale for Interventions
Leaning forward can help decrease
dyspnea because there is a
decrease in pressure on the
diaphragm.
Evaluation of Goal on Day Care
Patient verbalized understanding
of how tripods can increase
oxygenation, and used the
positioning when dyspneic.

*Teach the patient to deep breath Controlled coughs are more Patient verbalized understanding
and perform controlled coughing effective at clearing mucus of purpose of controlled cough,
at least every 2 hours when awake. secretions because they use but only participated in it every 4
diaphragmatic muscles. hours when awake.

Patient will demonstrate adequate
oxygenation as evidenced by pulse
oximetry and absence of signs of
distress during this shift.
University of South Florida College of Nursing – Revision September 2014
*Educate the patient on the Aspiration of secretions or food
importance of increasing the head products can lead to a respiratory
of the bed at a 30 to 45 degree infection, further decreasing gas
angle to decrease chance of exchange. An increased head of
aspiration. the bed also allows for increased
expansion because there is a
decrease in pressure.
Monitor oxygen saturation An oxygen saturation less than
continuously using pulse oximetry. 90% indicates poor oxygenation
and a need for supplemental
oxygen therapy.
Patient verbalized understanding
of the importance of an increased
head of bed. The head of the bed
was maintained at 40 degrees the
entire shift.
A continuous pulse oximetry
monitor was placed, with provider
order, and trends were monitored
this shift. She maintained SpO2
above 90 with supplemental
therapy.
17

Patient will maintain clear lung
fields without need for
supplemental oxygenation therapy
by discharge.
University of South Florida College of Nursing – Revision September 2014
Monitor the patient for new onset
restlessness, agitation, confusion
and/or lethargy.
Monitor respiratory rate, depth,
work of breathing, and assess for
use of accessory muscles or nasal
flaring.
Auscultate breath sounds every
one to two hours, listening for
normal or adventitious breath
sounds.
Collaborate with respiratory
therapy and health care providers
to titrate level of supplemental
oxygenation.
Early signs and symptoms of poor
gas exchange are a change in
behavior or mental status.
An increase in respiratory rate
(greater than 20), with use of
accessory muscles or nasal flaring,
indicates that there is poor gas
exchange and the body is fighting
to compensate.
Adventitious sounds can indicate
there is an acute respiratory
disease process occurring.
Oxygen should be titrated down to
the lowest possible amount the
patient can tolerate prior to
discharge.
Patient behavior and mental status
was assessed at each hourly
rounding session. Patient did not
exhibit signs or symptoms of
decreased oxygenation when
receiving supplemental therapy.
The characteristics and quality of
respirations were noted to be
unlabored when the patient was
not ambulating or performing
ADLs. Her respirations were
assessed at each hourly rounding
session, and as indicated.
Breath sounds were noted to be
diminished at each time
auscultated.
The patient’s oxygen was
decreased from 4 liters nasal
cannula, to 2 liters during
admission. Physician and nurse are
continuing to assess patient’s need
for supplemental therapy daily.
18
Nursing Diagnosis: Activity intolerance related to potential infection as evidenced by dyspnea on exertion, weakness when ambulating, and inability
to perform activities of daily living (ADLs) without assistance and supplemental oxygen.
Patient Goals/Outcomes
Patient will verbalize an
understanding of the need to
gradually increase activity based
on tolerance and symptom by end
of shift.
Patient will independently perform
two activities of daily living by
end of next day.
Patient will ambulate to nurses’
station, with assistance, by the end
of the shift.
University of South Florida College of Nursing – Revision September 2014
Nursing Interventions to
Achieve Goal
Determine the contributing factors
to activity intolerance, including
physical, psychological, and
motivational factors.
*Teach the patient the benefits that
activity can have for hospitalized
patients, with attention to
prevention of complications (i.e.
prevent deep vein thrombosis).
Help the patient to set up an
activity log to record exercise and
exercise intolerance.
Obtain any assistive devices or
equipment needed before
ambulating or performing ADLs
with the patient.
Provide emotional support and
encouragement as the patient is
increasing activity and working to
reach her goals.
Use a gait walking belt when
ambulating the patient.
Rationale for Interventions
Identifying the factors contributing
to activity tolerance will allow the
nurse and patient to collaborate on
formulating a plan to address each
factor.
If the patient is aware of the
benefits of activity, they will be
more likely to engage in their plan
of care.
An activity log encourages patient
participation in plan of care, and
will allow the health care
providers to adjust the plan with
accurate information, as needed.
The appropriate assistive devices
may decrease pain and frustration,
increasing the patient’s motivation
to participate.
Fear of breathlessness, pain, and
falling often decrease willingness
to increase activity. Ensuring the
nurse is there for support can
counteract this.
Gait belts improve the caregiver’s
grasp, reducing incidence of
injuries of clients and nurses.
Evaluation of Goal on Day Care
The main factors contributing to
her activity intolerance were
identified as exertional dyspnea
and fear.
The patient stated she was aware
of why she should increase her
activity, but that she was “scared”.
She agreed to be evaluated by
physical therapy.
The white board in the patient’s
room was utilized to keep track of
her goals for ambulation.
The patient was able to perform
oral care independently at the sink.
A shower chair was obtained for
her to take a shower.
Nurse, patient care technician, or
physical therapist remained with
patient during activities of daily
living and provided
encouragement as needed.
The patient ambulated one time to
the nurses’ station with assistance
from physical therapist. Later in
the day, the patient agreed to
19
 ambulate to the chair with
assistance from the nurse.

Monitor the patient’s response to
activity by observing for signs of
respiratory intolerance (i.e. pallor,
nasal flaring, facial distress).
Monitoring the patient’s response
will allow the nurse to adjust the
plan of care to meet the patient’s
individual needs.
When ambulating, the SpO2 and
heart rate was still monitored.
With supplemental therapy,
patient could ambulate short
distance, with assistance, without
exhibiting symptoms of distress.

±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 is still dyspneic on exertion. Evaluation and follow up care from physical therapy and occupational therapy will give the patient skills to
independently perform ADLs.
Pastoral Care
Durable Medical Needs
F/U appointments: The patient should follow up with a primary care physician to assess for any residual symptoms or concerns relating to this visit.
Med Instruction/Prescription: Every patient should be provided education on the medications prescribed, as this will increase understanding and compliance
once discharged from the hospital.
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 20

 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.

Centers for Disease Control and Prevention (CDC). (2016). Mycoplasma pneumoniae infection.

Retrieved from https://www.cdc.gov/pneumonia/atypical/mycoplasma/index.html

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 21