UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Nicki Shaw
Assignment Date: 9/20/2016
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: MPM
 1 PATIENT INFORMATION
Patient Initials: XX Age: 69 Admission Date: 9/16/16
Gender: Female Marital Status: Married Primary Medical Diagnosis
Primary Language: English Pneumonia
Level of Education: High School Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Housewife COPD, asthma, arthritis, tendonitis
Number/ages children/siblings: 2 male children

Served/Veteran: No Code Status: Full Code

If yes: Ever deployed? Yes or No
Living Arrangements: Lives with husband and both sons Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: N/A Procedure: N/A
Culture/ Ethnicity /Nationality: American
Religion: Agnostic Type of Insurance: Blue Cross Blue Shield

 1 CHIEF COMPLAINT:
“Shortness of breath, couldn’t breathe”

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient presented to the emergency room with “shortness of breath”. She states she has had difficulty breathing after
activities for the last year but it has been manageable. Four days ago, she felt she was “unable to catch her breath” for an
extended period of time. Patient has a diagnosis of asthma prior to this episode and attempted to take a breathing treatment
at home. Was brought into the emergency department by her husband on 9/16/16. Upon admission, patient was diagnosed
with pneumonia as evidenced by wheezing upon auscultation, an elevated white blood cell count, and a chest x-ray.
Started on antibiotics 9/17/16.

University of South Florida College of Nursing – Revision September 2014 1

  2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
1978 Pulmonary embolism
1979 Diagnosed with asthma
1994 Endometriosis of bladder
1995 Hysterectomy
1995 Oophorectomy
2013 Colonoscopy

Pt unable to recall GERD

dates of diagnosis Diabetes Mellitus
Obstructive Sleep Apnea
Hyperlipidemia
HTN

2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause
Alcoholism

MEDICAL

Glaucoma

Problems

Problems
Allergies

of

Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father 62 CAD
Mother 73 MI
Brother 64 N/A
Sister
relationship

relationship

relationship

Comments: Include age of onset

Pt reports father died at 62 years of age due to complications from childhood Rheumatic Fever.

 1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years? 10/22/2015
Pneumococcal (pneumonia) (Date) Is within 5 years? 5/6/2014
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state “U” for the patient not knowing date received

University of South Florida College of Nursing – Revision September 2014 2

 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS

NKDA
Medications

Perfume Triggers asthma attack, dyspnea

Other (food, tape, Pollen Triggers asthma attack, dyspnea
latex, dye, etc.)
NKFA

 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
This patient’s primary diagnosis is pneumonia. Pneumonia is an “infection of the lower respiratory tract” (Huether and
McCance 2012) and leads to inflammation of the alveoli. This illness can be caused by many different factors including
aspiration of upper airway secretions, fungi, a virus, and many others. Pneumonia is usually first presented as “a viral
upper respiratory tract infection” (Huether and McCance 2012), and causes chills, fever, dyspnea, and a productive cough.
Upon auscultation, diminished lung sounds and sometimes wheezing may be heard as the sputum production and
inflammation narrows the patient’s airways. There are many factors that can increase an individual’s risk for pneumonia.
This patient was at a very high risk due to her history of smoking, sedentary lifestyle, previous diagnosis of COPD and
asthma, and also her recent rhinovirus. Her diagnosis was made based on examination of her lung sounds, sputum
collection, blood cultures, and a chest xray. Her white blood cell count was elevated which indicates an infection of some
sort. The chest xray showed opacity bilaterally in her lower lobes. Treatment for pneumonia includes “establishing
adequate ventilation and oxygenation” (Huether and McCance 2012). Other treatments include the use of antibiotics,
increased fluid intake, and breathing exercises. Although pneumonia is the “sixth leading cause of death in the United
States” (Huether and McCance 2012), prognosis is generally individualized based on age, health, lifestyle, comorbidities,
and compliance with treatment.

 5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name insulin aspart (Novolog) Concentration 100 units/mL Dosage Amount Sliding scale
Route SQ Frequency 3x daily with meals
Pharmaceutical class Human insulin analogue / Antidiabetic Home Hospital or Both
Indication Control hyperglycemia, pt has Diabetes Mellitus, regulates metabolizing of glucose
Adverse/ Side effects – Hypoglycemia, pruritus, pain at injection site
Nursing considerations/ Patient Teaching – Consider other medications that may affect blood glucose level, plan insulin
administration according to meals, teach patients signs of hypoglycemia

Name atenolol (Tenormin) Concentration 50 mg/ 1 tablet Dosage Amount 100 mg (2 tablets)
Route PO Frequency 2x daily
Pharmaceutical class Beta blocker - Antihypertensive Home Hospital or Both
Indication Treat hypertension
Adverse/ Side effects Dizziness, hypotension, bradycardia, bronchospasm, heart failure
Nursing considerations/ Patient Teaching Consider interactions with other medications, monitor BP and HR before and after,
monitor EKG, teach patient dangers of abruptly stopping drug, teach patient how to take their own pulse

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

Name azithromycin (Zithromax) Concentration 500 mg/ 1 tablet Dosage Amount 500 mg (1 tablet)
Route PO Frequency 1x daily
Pharmaceutical class Macrolide - Antibiotic Home Hospital or Both
Indication Pt diagnosed with pneumonia, can slow or kill bacteria
Adverse/ Side effects GI distress, pseudomembranous colitis, angioedema, photosensitivity, hepatotoxicity
Nursing considerations/ Patient Teaching Take antibiotics as prescribed – do not stop, take antibiotics with food to avoid GI
distress, teach patient to report adverse effects

Name diltiazem (Cardizem) Concentration 180 mg/ 1 tablet Dosage Amount 180 mg (1 tablet)
Route PO Frequency 1x daily
Pharmaceutical class Calcium channel blocker – Antihypertensive Home Hospital or Both
Indication Treat hypertension, decrease contractility and oxygen demand
Adverse/ Side effects HA, arrhythmias, bradycardia, heart failure, hepatotoxicity, edema
Nursing considerations/ Patient Teaching Monitor BP and HR, do not discontinue suddenly, do not crush or chew tablets,
wouldn’t give medicine if BP <90 systolic or HR was <60

Name rosuvastatin (Crestor) Concentration 10 mg/ 1 tablet Dosage Amount 40 mg (4 tablets)

Route PO Frequency 1x daily
Pharmaceutical class HMG-CoA reductase inhibitor - Antilipidemic Home Hospital or Both
Indication Reduce LDL cholesterol, slow down atherosclerosis, rhabdomyolysis
Adverse/ Side effects Anxiety, GI distress, angina, dyspnea
Nursing considerations/ Patient Teaching Give medication at night, teach pt about proper diet and exercise in addition, report
muscle pain, do not take with antacids

Name methylprednisolone (SoluMedrol) Concentration 20 mg / 1 mL Dosage Amount 60 mg

Route IV Frequency 1x daily (Q 12 hours)
Pharmaceutical class Glucocorticoid - corticosteroid Home Hospital or Both
Indication Pt has pneumonia, COPD, and asthma, Reduces inflammation/pain
Adverse/ Side effects Arrhythmias, thromboembolism, cardiac arrest, pancreatitis, adrenal insufficiency, angioedema,
hypoglycemia
Nursing considerations/ Patient Teaching Monitor blood glucose, BP, HR, weight, Teach patient signs of adrenal insufficiency

Name aspirin (Bayer) Concentration 81 mg/ tablet Dosage Amount 81 mg

Route PO Frequency 1x daily
Pharmaceutical class Salicylate - NSAID Home Hospital or Both
Indication to prevent clotting, to lower risk of ischemia and MI
Adverse/ Side effects hepatotoxic, GI bleeding, thrombocytopenia, tinnitus/ototoxic, slow clotting, GI distress
Nursing considerations/ Patient Teaching Monitor platelet labs in long term use, take with food to decrease GI problems, watch
for bleeding and bruising, report signs of hearing loss or ringing

University of South Florida College of Nursing – Revision September 2014 4

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Consistent Carbohydrate
Diet patient follows at home? Regular
24 HR average home diet:
Breakfast: 2 large scrambled eggs, 1 link sausage, 1 piece
of toast
Lunch: Salad – 2 cups of Cobb salad – chicken, blue
cheese, avocados, tomato, Italian dressing, bacon
Dinner: 1 baked chicken breast, 1 cup spinach, 1 cup
broccoli
Snacks: 1 peach, ½ cup dried prunes
Liquids (include alcohol): 2 8 oz glasses water, 1 8 oz glass
diet iced tea
University of South Florida College of Nursing – Revision September 2014
Analysis of home diet (Compare to “My Plate” and
Consider co-morbidities and cultural considerations):
An analysis of this patient’s diet reveals that she does not
meet her daily recommended amount of dairy or grains but
exceeds in the other food groups. The patient reported to
me that she has recently changed her diet to help her
achieve a healthier lifestyle. While I’m sure this current diet
is a healthier alternative to her previous one, there are still
areas that could be improved. Overall the patient needs to
be made aware of her high sodium intake in particular and
the complications that could arise from it (Super Tracker
2016). She should be educated on ways to incorporate more
dairy and grains into her diet for better, balanced nutrition.
The addition of a glass of milk or a cup of yogurt would be
an excellent way to incorporate more dairy into her daily
diet. Her morning toast is the only grain she consumed all
day. Patient should be educated on the healthier alternative
of whole wheat bread rather than her white bread.
Suggestions regarding her lunch might be to include more
items from the food groups in which her intake is lacking.
The addition of dairy and grains is a simple fix that would
assist in the overall daily balance of her diet. Healthy
options include whole grain pasta or rice.
There is little room for improvement in this patient’s
dinner. This is a large portion of her daily protein intake
and also her vegetables. The patient reports that she bakes
the chicken and does not bread them, making this meal
even healthier. Again, the addition of a grain might be the
only suggestion offered.
This patient does have the diagnosis of Diabetes Mellitus
and controls her illness through insulin and other
antidiabetics. This should be taken into consideration when
consulting with her about her diet. She should be able to
recognize the effects of hypoglycemia and be able to
counteract it with fruits and other foods.
According to the patient, soda and other unhealthy drinks
were cut out of her diet over five years ago. She drinks
mostly water throughout the day.
5
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
“My husband and sons, my sister-in-law”
How do you generally cope with stress? or What do you do when you are upset?
“Eat food, take a Xanax” Patient reports she has been dealing with anxiety and depression for most of her life.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“Very depressed and stressed recently.” 2nd son moved in with patient and her family recently due to losing his job,
suffering a stroke, and becoming homeless in a different state. She helps support him and his multiple illnesses.
Family relying solely on husband’s income.

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? ___No____________________________________________________

Have you ever been talked down to?___Yes____________ Have you ever been hit punched or slapped? _No________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with
you? ________Yes – during childhood_______________ If yes, have you sought help for this? __No__________

Are you currently in a safe relationship? Yes

 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. Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your
patient’s age group:
Based on this patient’s age and position in life, she would fall into the developmental stage of ego integrity versus
despair. This stage in life is defined as a time to “contemplate accomplishments” (McLeod 2013). If the individual
can look back on their past and be proud, Erikson would group them in the integrity stage. If the individual looks
back with feelings of guilt or dissatisfaction, they would be considered in the despair stage.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
This patient is in the Ego Integrity stage of life. Even though I only visited with her for a short time through this
assessment, the pride she felt was evident throughout our conversation. She talks fondly of her two children and
her happy marriage. She talked about her accomplishment of being a housewife for close to fifty years and raising
her children.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
Her hospitalization has impacted her stage in life as it forces her to acknowledge her health and possibility of
death. Part of the Integrity versus Despair stage is coming to terms with death and feeling a sense of closure. She
seemed calm and composed as we discussed her health and prognosis.

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

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“Not taking care of myself, poor diet and lifestyle”

What does your illness mean to you?

“I can’t help take care of my family”

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

Have you ever been sexually active?_________Yes______________________________________________________

Do you prefer women, men or both genders? ____Men____________________________________________________
Are you aware of ever having a sexually transmitted infection? ___No________________________________________
Have you or a partner ever had an abnormal pap smear?___Yes______________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? _____No__________________________________

Are you currently sexually active? ______No_____________________ If yes, are you in a monogamous relationship?
_______N/A___________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? __________N/A_____________________

How long have you been with your current partner?_____46 years__________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? ___Menopause_______________

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

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

±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
_____None – raised Catholic, identifies as Agnostic but does not actively practice anymore________
______________________________________________________________________________________________________
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? 12 years
Cigarettes Half a pack per day (age 14 thru 26 )

If applicable, when did the

Pack Years: 6 pack years
patient quit? 1973

Has the patient ever tried to quit? Yes

Does anyone in the patient’s household smoke tobacco? If
If yes, what did they use to try to quit? Pt quit when she
so, what, and how much?
got pregnant – no medication
No

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years? 24 years
Wine Volume: Half a glass (age 45 thru 69 )
Frequency: Twice a week
If applicable, when did the patient quit?
N/A

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
No How much? N/A For how many years? N/A
(age thru )

Is the patient currently using these drugs?

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

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No, stay at home wife

5. For Veterans: Have you had any kind of service related exposure?
N/A

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: 30 Diverticulitis Life threatening allergic reaction
Bathing routine: Daily showers Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy? 2013
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:
Post-nasal drip Normal frequency of urination: 2-3x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2x/day Diabetes Type: DM 2
Routine dentist visits 2x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam 1x/yr Migraines
Pneumonia Date of last gyn exam? Unknown Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? 13 yo Encephalitis
last CXR? 9/16/16 menopause age? 48 yo (following
Meningitis
hysterectomy/oophorectomy)
Other: Pt reports sputum production but it Date of last Mammogram &Result:
Other:
could not be examined at time of exam Unknown
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
University of South Florida College of Nursing – Revision September 2014 9
 Last EKG screening, when? 9/16/16 Arthritis Chicken Pox
Other: Other: Other:

General Constitution
Recent weight loss or gain
How many lbs? N/A
Time frame?
Intentional?
How do you view your overall health? “I know I am overweight and unhealthy, but I’m trying to be better about it.”

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: Height 5’ 6” Weight 134.8 kg BMI 47.9 Pain: (include rating and
Symmetrical, A&O x3, Pulse 57 bpm Blood Pressure: (include location) location) 0/10
appropriate, pleasant Respirations 20 rpm 175/80 upper RA
Temperature: (route SpO2 97% Is the patient on Room Air or O2?
taken?) 97.5 oral 3 L 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

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?

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge N/A 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
Dentition: N/A - unknown
Comments:

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
N/A Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large unable to be examined at this time
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: wheezing auscultated

Cardiovascular: No lifts, heaves, or thrills

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

University of South Florida College of Nursing – Revision September 2014 11

Rhythm

Sinus rhythm with premature ventricular complexes and T wave abnormalities

EKG strip unable to be attached

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: +2 Femoral: Popliteal: DP: 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: N/A pitting non-pitting
Extremities warm with capillary refill less than 3 seconds

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

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 09 / 19 / 2016 ) Formed (normal for pt) 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: Pt alert, denies problems Previous 24 hour output: mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

Musculoskeletal:  Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __5/5__ RUE __5/5_____ LUE __5/5_____ RLE & _5/5__ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration N/A Romberg’s Negative
N/A Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: N/A [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

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

±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):

Lab Dates Trend Analysis

WBC – 15.8 (09/16/16) Although WBC count is High WBC count can be
still high as of today, it is indicative of an infection as the
trending downward. body produces more WBC’s to
13.5 (09/18/16) fight it off. These lab values
are consistent with the dx of
9.6 (09/20/16) pneumonia upon admission
and the downward trend could
be associated with antibiotic
and corticosteroid therapy.
BG - 122 (09/16/16) Upon admission, blood Patient has dx of DM 2 and has
glucose was high and has insulin 3x daily with meals.
continued to trend upward. Upward trending BG may be a
198 (09/18/16) side effect of patient’s
corticosteroid prescription.
265 (09/20/16)

9/16 EKG - sinus rhythm with PVC’s

9/16 CXR – showed lung consolidation lower lobes bilaterally

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

Consistent carbohydrate diet – related to DM diagnosis
Accuchecks – 3x daily – around mealtimes/ insulin sliding scale
Continuous telemetry monitoring
Vitals – Q6 – monitoring effects of medication
Labs – monitoring WBC to track infection
Fall Risk – up with assistance – due to dyspnea and generalized weakness

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

1. Activity intolerance r/t generalized weakness, obesity, aeb dyspnea, patient verbal report, unsteady gait

2. Ineffective airway clearance r/t sputum production, inflammation aeb productive cough, wheezing, dyspnea, patient
report

3. Deficient knowledge r/t new diagnosis aeb patient verbal report

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

± 15 CARE PLAN
Nursing Diagnosis: Activity intolerance r/t generalized weakness, sedentary lifestyle aeb exertional dyspnea, unsteady gait, patient report
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
1. Patient will use incentive Educate patient on how to use IS. Incentive spirometer will increase Goal was met. Patient
spirometer 10x an hour during Have patient demonstrate use back. pulmonary function. It will teach demonstrated use of IS and
shift. Remind patient. Explain benefits of patient proper breathing techniques reported compliance with
use. which will in turn assist with recommended usage per hour.
dyspnea upon exertion (Ackley and
Ladwig 2014)
2. Patient will call for nurse before Make sure call light is within Patients with activity intolerance Goal met. Client contacted nurse
ambulating during shift. reach. Have patient demonstrate are at an increased risk for fall due before attempting to get out of bed.
back where the call button is. to their difficulty ambulating on Patient did not fall.
Check in on patient. Make sure bed their own (Ackley and Ladwig
alarm is armed. 2014)

Nursing Diagnosis: Ineffective airway clearance r/t sputum production, inflammation aeb productive cough, wheezing, dyspnea, patient report
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
1. Patient will adjust position every Nurse will turn patient. Client will Changing the client’s position can Goal was met. Patient position was
2 hours during shift. assist as much as they can tolerate. help to break up and move out shifted every two hours and
Prop pillows under patient to keep secretions that may be causing procedure was documented.
them supported. dyspnea (Ackley and Ladwig
2014)
2. Client will drink at least 2000 Patient input and output will be Increased fluid intake helps cilia Goal was met. Patient drank over
mL of fluid over the course of a monitored. Encourage patient to move secretions up and out of 2000 mL of fluid by end of day.
day. drink water. Keep a pitcher and respiratory tract (Ackley and Input was tracked and documented.
cups available and within reach of Ladwig 2014)
patient.

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

±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
□SS Consult
X Dietary Consult
X PT/ OT
□Pastoral Care
□Durable Medical Needs
X F/U appointments
X Med Instruction/Prescription
 □ are any of the patient’s medications available at a discount pharmacy? X Yes □ No
□Rehab/ HH
□Palliative Care

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

 References

Ackley, B. J. & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide

to planning care (10th ed.). St. Louis, MO: Mosby Elsevier.

Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St. Louis, Mo:

Elsevier.

McLeod, S. A. (2013). Erik Erikson. Retrieved from www.simplypsychology.org/Erik-Erikson.html

SuperTracker: My Foods. My Fitness. My Health. (n.d.). Retrieved Oct 16, 2016, from

https://supertracker.usda.gov/

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