UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Nicole Braweml

MSI & MSII PATIENT ASSESSMENT TOOL .

Assignment Date: 11/10/15

Agency:VA

1 PATIENT INFORMATION
Patient Initials: H.S.

Age: 66

Admission Date: 10/12/15

Gender:

Marital Status: Married

Primary Medical Diagnosis: Respiratory Failure

Male

Primary Language: English

Level of Education: Bachelors Degree

Other Medical Diagnoses: N/A

Occupation (if retired, what from?): Retired Teacher

Number/ages children/siblings: No children, One sibling 71

Served/Veteran: Yes
If yes: Ever deployed? Yes or No

Code Status: Full Code

Living Arrangements: Lives at Haleys Cove Nurisng Home

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: N/A
Procedure: N/A

Culture/ Ethnicity /Nationality: African American

Religion: Christian

Type of Insurance: Medicare

1 CHIEF COMPLAINT: Its been harder to breathe this week

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
H.S. is a 66yo male with a past medical history of chronic respiratory failure s/p for 7 years, CMO, arterial
Fibrillation, CVA, seizure, hypothyroidism, COPD, HTN, and lymphedema presented from the VA nursing home with
Worsening dyspnea for the last week. He was also having worsening cough that was productive of more sputum from
trach and by mouth. The symptoms began on 10/05/15 and have persisted for a week. The location of illnesss is in the
Lungs. Patient tried to suction and reposition in bed, but difficulty in breathing was not relieved. Patient was placed on
Ventilator with subjective improvement in respiratory status.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date

Operation or Illness

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

71

Diabetes

Brother

Cancer

Stroke

Bleeds Easily

80

Asthma

Mother

Arthritis

62

Anemia

Father

Cause
of
Death
(if
applicable
)
MI

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Alcoholism

CMO
CVA
AFib
COPD/HTN

Age (in years)

2013
2014
2008
2000

Sister
relationship
relationship
relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? 2007
Influenza (flu) (Date) Is within 1 years? 2015
Pneumococcal (pneumonia) (Date) Is within 5 years? 2009
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

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKA
Medications

NKA
Other (food, tape,
latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Respiratory failure is characterized by a failure of the lungs to oxygenate the blood and/or remove carbon
dioxide from the blood. The respiratory systems failure to ventilate produces hypercapnia. Hypercapnia is a
concentration of carbon dioxide in the blood above the normal range, 35-45 mmHg. To classify as hypercapnic
respiratory failure a pH less than 7.35 is needed in addition to the abnormal carbon dioxide level. Hypercapnic
respiratory failure is caused by medications causing respiratory depression, pulmonary diseases like COPD and
asthma, neuromuscular, Guillan- Barre syndrome,acute myasthenia gravis, spinal cord tumors, kyphoscoliosis,
and obesity. In order to diagnose hypercapnic respiratory failure an ABG is needed. The ABG has to show PCO2,
above 45 mmHg, a pH of 7.35, patients history physical assessment, and additional diagnostic tests (Osborn, 2014,
p. 792-794). The prognosis is positive for patients with COPD and respiratory failure, the overall mortality has
declined from approximately 26% to 10% (Kaynar, 2014).

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

Concentration (mg/ml)

Route G tube

Dosage Amount (mg) 25mg

FrequencyBID

Pharmaceutical class: Beta Blocker

Home

Hospital

or

Both

Indication: Treats hypertension

Side effects/Nursing considerations: Bradycardia, HF, Pulmonary Edema. Monitor BP, HR, and pulmonary edema since patient has history of respiratory
failure.
Nursing considerations/ Patient Teaching
Name: Pravastatin

Concentration

Dosage Amount: 10mg

Route: G tube

Frequency: HS

Pharmaceutical class: HMG-CoA reductase inhibitors

Home

Hospital

or

Both

Indication: Hypercolesterolemia
Adverse/ Side effects Headaches, flatulence, abdominal pain, constipation, cramps, muscle pain.
Nursing considerations/ Patient Teaching: Monitor for symptoms of adverse effects. Tell pt to
take at bedtime
Name: Cholecalciferol
Route: G tube

Concentration

Dosage Amount: 400 units

Frequency BID

University of South Florida College of Nursing Revision September 2014

Pharmaceutical class: Fat solube vitamins

Home

Hospital

or

Both

Indication: Promotes the intestinal absorption of dietary calcium

Side effects/Nursing considerations: Hypercalcemia. Monitor electrolytes primarily calcium and side effects of hypercalcemia like headache, irritability,
arrhythmias, hypertension, bone pain, and muscle pain.
Nursing considerations/ Patient Teaching
Name: Aspirin EC

Concentration

Dosage Amount 81mg

Route G tube

Frequency QD

Pharmaceutical class Salicylates

Home

Hospital

or

Both

Indication: Prophylaxis o
Adverse/ Side effects: GI bleeding, upset stomach, heartburn, dark urine, tinnitus, yellowing of
the eyes or skin
Nursing considerations/ Patient Teaching: Monitor for changes in urine color and blood in stool.
Name: Levothyroxine

Concentration

Dosage Amount 0.1mg

Route G tube

Frequency QD

Pharmaceutical class Thyroid replacement

Home

Hospital

or

Both

Indication Hypothyroidism
Adverse/ Side effects: insomnia, hyperthyroidism, palpitations, dysrhythmias, anxiety, and
weight lost
Nursing considerations/ Patient Teaching: Monitor for signs of hyperthyroidism and monitor
TSH levels.
Name Hydrazaline

Concentration

Dosage Amount 75mg

Route Gtube

FrequencyTID

Pharmaceutical class Vasodilator

Home

Hospital

or

Both

Indication Hypertension
Adverse/ Side effects: Dizziness, headache, tachycardia, orthostatic hypotension
Nursing considerations/ Patient Teaching: Get up slowly from bed and report any adverse side effects.
Name Ipratropium

Concentration: 0.06%

Route Nebulizer

Dosage Amount
Frequency QID

Pharmaceutical class Anticholinergics

Home

Hospital

or

Both

Indication: Maintenance therapy for airwary obstruction due to COPoD

Adverse/ Side effects: dizziness, headache, palpitations, hypotension
Nursing considerations/ Patient Teaching: Instruct how to use nebulizer, rinise mouth after using inhaler report signs of adverse reactions
Name Warfarin

Concentration

Dosage Amount 50mg

Route Gtube

Frequency QHS

Pharmaceutical class Anticoagulant

Home

Hospital

or

Both

Indication: Prophylaxin of AFib

Adverse/ Side effects: Bleeding
Nursing considerations/ Patient Teaching: Monitor for signs of excessive bleeding like bleeding gums, dark tary stooks, bruising, and eat a low vitamin K diet
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? NPO
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? NPO
Consider co-morbidities and cultural considerations):
Comparing the patients daily diet to the servings based
on Choose My Plate the patient eats the daily
requirements. The patient is NPO, but Jevity is a liquid
blend that provides the necessary nutrients to maintain
a healthy weight while being tube fed. Ingesting 3 to 5
cans a day provides the patient with his daily
carbohydrate, protein, fats, and vitamins and minerals
that the patient would receive by eating fruits,
vegetables, dairy, and protein. However, the patient has
multiple wounds and ingesting more protein is needed
to promote new cell growth and is a structural
component of cells.
24 HR average home diet: Jevity
Breakfast:Jevity
Lunch: Jevity
Dinner: Jevity
Snacks:
Liquids (include alcohol):
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? The nursing home staff and wife
How do you generally cope with stress? or What do you do when you are upset? I watch TV or read a book

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
NO.

+2 DOMESTIC VIOLENCE ASSESSMENT

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Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? _________NO______________________________________________
Have you ever been talked down to?____NO___________ Have you ever been hit punched or slapped?
_____NO_________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
________NO__________________________________ If yes, have you sought help for this? ______________________
Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: Ego Integrity vs Despair
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is in Ego Integrity. Ego Integrity means that as we become senior citizens we reflect on lives seeing if we
Lived a full and successful life. The patient is in ego integrity by the joy in his face when the patient talked about family
And friends. Also, the patient states Im glad to be alive and enjoy what time I have left.
Erik Erikson Psychosocial Stages. (2008). Retrieved November 10, 2015, from http://www.simplypsychology.org/ErikErikson.html
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The patients development has not been impacted by the patients hospitalization because the patient is always in good
spirits and does not make any comments that suggest his condition is causing development problems.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Smoking for a long time

What does your illness mean to you?

The patient felt it was a consequence for smoking

+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?______Pt refused to answer___________________________
Do you prefer women, men or both genders? ______ Pt refused to answer_________________________________
Are you aware of ever having a sexually transmitted infection? ____ Pt refused to answer______________
Have you or a partner ever had an abnormal pap smear?____________________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? _____ Pt refused to answer______________

University of South Florida College of Nursing Revision September 2014

Are you currently sexually active? ______Pt refused to answer_________________ If yes, are you in a monogamous
relationship? ____________________ When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? __________________________________
How long have you been with your current partner?________________Pt refused to answer________________
Have any medical or surgical conditions changed your ability to have sexual activity? ______Pt refused to
answer____________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
Pt refused to answer

University of South Florida College of Nursing Revision September 2014

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

What importance does religion or spirituality have in your life?
____It doesnt play a huge role in my life_________________________________________________________________
______________________________________________________________________________________________________
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?
If so, what? Yes, Newports
How much?(specify daily amount)
2 packs a day

Yes
No
For how many years? 40years
(age

20

thru

60

If applicable, when did the

patient quit? At age 60

Pack Years: 80
Does anyone in the patients household smoke tobacco? If
so, what, and how much? NO

Has the patient ever tried to quit? Yes

If yes, what did they use to try to quit? Just stopped

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What?
How much?
Volume:
Frequency:
If applicable, when did the patient quit?

Yes

No
For how many years?
(age

thru

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
NO
5. For Veterans: Have you had any kind of service related exposure? NO

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF: 15
Bathing routine:
Other:

Be sure to answer the highlighted area

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? 2015
Other:

Chills with severe shaking

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

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: Foley Cath
235ml output
x/day
Bladder or kidney infections

Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Hematologic/Oncologic

Other:

Metabolic/Endocrine
2 x/day
1x/year

Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? (10/12/15)
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision September 2014

Last EKG screening, when? (10/12/15)

Other:

Arthritis
Other:

Chicken Pox
Other:

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health?

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

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10

10 PHYSICAL EXAMINATION:
General Survey: Patient
is a well developed 66 year
old. Alert and oriented x3.
Patient is calm and no
signs of respiratory
distress.

Height 70 inches
Pulse 56
Respirations 17

Weight 304
BMI 40.1
Blood Pressure: Right Upper Arm
101/54

Pain: 0/10

Temperature: (route
SpO2 98%
Is the patient on Room Air or O2
taken?) 98.4 (ear)
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
Unable to assess pt is on ventilator
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
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:
Fluids infusing?
no
yes - what?

Location:

flat
loud

Date inserted:

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 / 3mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
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
clear
LUL clear
RML
wheezes
LLL wheezes
RLL wheezes

Chest expansion

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

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11

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

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3
Brachial: 3
Radial: 3
Femoral: 3
Popliteal: 3
DP: 2
PT: 2
No temporal or carotid bruits
Edema:
2+
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
LE
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 10 / 14 / 15
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

GU
Urine output:
Clear
Cloudy
Color: Light yellow
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance
CVA punch without rebound tenderness
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at ____5___ RUE ___5____ LUE ___5____ RLE

Previous 24 hour output: 750

or

with assistance

& ____5___ in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: 3

Biceps3

Brachioradial:

Patellar3

Achilles:

3 Ankle clonus: positive negative Babinski: positive

negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
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12

abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
ABG
7.23 pH
60 PCO2
80 P02

Dates
10/12/15

7.34 pH
50 PCO2
88PO2

10/22/15

Trend
The trend shows that the
patients ABG at
admission was not within
normal limits, however
over the course of
treatment ABG levels
began to normalize.

Analysis
Upon admission the ABG
shows the patient was
experiencing respiratory
acidosis. Indicated by the
decreased pH and
increased PCO2 level.
However, with the course
of treatment with
ventilator placement the
patient is recovering and
ABGs are beginning to
fall within normal ranges.

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

multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
Pt is NPO diet. He has vitals assessed every hour and a full assessment every 4 hours. Pt has labs and ABG
draws .
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Impaired gas exchange related to ventilation-perfusion imbalance as evidence by hypercapnia.
2. Ineffective airway clearance related to increased production of secretions as evidence by changes in pulse oximetry.
3. Imbalanced nutrition more than body requirements related to caloric intake exceeding energy expenditure as evidence by
BMI over 40.
4. Risk for ineffective peripheral tissue perfusion related to sedentary life style
5. Risk for infection related to ventilator placement
6. Risk for skin breakdown related to sedentary lifestyle
7. Risk for activity intolerance related to fatigue and weakness.

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University of South Florida College of Nursing Revision September 2014

14

 15 CARE PLAN
Nursing Diagnosis: Impaired gas exchange related to ventilation-perfusion imbalance as evidence by hypercapnia.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Demonstrate improved patient gas Assess respiration, rate, depth,
Thichk, tenacious, copious
Patient was suctioned four times
exchange and adequate
pulse oximetry and suction as
secretions are a major sources of
before the end of my shift.
oxygenation as evidenced by
needed.
impaired gas exchange in small
respiration rate and pulse oximetry
airways. Deep suctioning may be
within normal range within 8
required when cough is ineffective
hours.
for expectoration of secretions
(Doenges & Moorhouse, 2010,
p.128)
During my shift I will maintain the Position the client in a
The patients head of bed
head of the patients bed between
semirecumbent position with head maintained between 30 to 45
30-45 degrees.
of the bed at 30- to 45- degreedegrees.
angle to decrease the aspiration of
gastric, oral, and nasal secretions.
Evidence shows tha mechanically
ventilated clients have a decreased
incisdence of VAP if the client is
paced in a 30- to 45- degree
semirecumbent position as opposed
to supine position (Ackley
&Ladwig, 2014, p. 375).
Monitor oxygen saturation
Pulse oximetry is useful for
Patients oxygen saturation was
continuously using pulse oximetry. tracking and /or adjusting
monitored continuously throughout
supplemental oxygen therapy for
my shift.
clients with COPD (Ackley
&Ladwig, 2014, p. 375)
Patient will be weaned of ventilator Monitor patient airway for signs
A study demonstrated that when
Patient monitored for signs of
in two weeks and able to maintain
and symptoms of respiratory
the respiratory rate exceeds 30
respiratory distress and will notify
airway patency.
distress such as respiratory rate,
breaths/min, along with
physician with any respiratory
depth, and use of accessory
physiological measures, a
changes as needed.
muscles. Keep oxygen saturation
significant cardiovascular or
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15

greater than 92%.

respiratory alteration exists. An

oxygen saturation of less than 90%
or a partial pressure of oxygen less
than 80 mm Hg indicates
significant oxygenation problems.
(Ackley &Ladwig, 2014, p. 375)
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

15 CARE PLAN
Nursing Diagnosis: Ineffective airway clearance related to increased production of secretions as evidence by changes in pulse oximetry.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Demonstrate effective coughing
Auscultate breath sounds q 1 to 4
Breath sounds are normally clear or Patient demonstrated clear breath
and clear breath sounds and
hours
a few scattered fine crackles at
sounds and patent airway
maintain a patent airway
bases, which clear with deep
throughout shift.
throughout 12 hour shift.
breathing. The presence of crackles
during inspiration indicates fluid
and wheezing indicates airway
obstruction. (Ackley &Ladwig,
2014, p. 130).
Monitor blood gas values and pulse An oxygen saturation of less than
oxygen saturation levels as
90% or partial presence of oxygen
available.
less than 80 indicates insignificant
University of South Florida College of Nursing Revision September 2014
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Administer medications such as

bronchodilators or inhaled steroids
as ordered. Watch for side effects
such as tachycardia or anxiety with
bronchodilators, or inflamed
pharynx with inhaled steroids.
Hyperoxygenate before and
between endotracheal suction
sessions.
Suction for less than 15 seconds.

Observe sputum, noting color,

odor, and volume.

Patient will be weaned of ventilator

in two weeks with the ability to
maintain own airway bring patient
back to baseline.

Monitor patient airway for signs

and symptoms of respiratory
distress such as respiratory rate,
depth, and use of accessory
muscles. Keep oxygen saturation

oxygenation problems. (Ackley

&Ladwig, 2014, p. 130).
Bronchodilators decrease airway
resistance, improve the efficiency
of respiratory movements,
improve exercise tolerance, and
can reduce symptoms of dyspnea
on exertion. (Ackley &Ladwig,
2014, p. 130).
Studies have demonstrated that
hyperexygenation may help
prevent oxygen desaturation in a
suctioned client. (Ackley
&Ladwig, 2014, p. 131).
Studies demonstrated that because
of a drop in partial pressure of
oxygen with suctioning, that
preferably no more than 10 seconds
be used actually suctioning, with
the entire procedure taking 15
seconds. (Ackley &Ladwig, 2014,
p. 131).
Normal sputum is clear or gray
and minimal. Abnormal sputum is
green, yellow, or bloody;
malodorous; and often copious.
The presence of purulent sputum
during COPD exacerbation can be
sufficient indication for staring
empirical antibiotic treatment.
(Ackley &Ladwig, 2014, p. 130).
A study demonstrated that when
the respiratory rate exceeds 30
breaths/min, along with
physiological measures, a
significant cardiovascular or

University of South Florida College of Nursing Revision September 2014

Patient monitored for signs of

respiratory distress and will notify
physician with any respiratory
changes as needed.
17

greater than 92%.

Schedule weaning periods for the

time of day when the patient is
most rested. Cluster care activities
to promote successful weaning.
Avoid other procedures during
weaning; keep the environment
quiet and promote restful activities
between periods.
During weaning, monitor clients
physiological and psychological
responses; acknowledge and
respond to the fears and subjective
complaints.

respiratory alteration exists. An

oxygen saturation of less than 90%
or a partial pressure of oxygen less
than 80 mm Hg indicates
significant oxygenation problems.
(Ackley &Ladwig, 2014, p. 375)
It is important that the client
receives adequate rest between
weanning periods. (Ackley
&Ladwig, 2014, p. 848)

Weaning is a stressful experience

that requires active participation by
the client. The clients work needs
to understand and supported by
clinical to facilitate recovery from
mechanical ventilation and
weaning. (Ackley &Ladwig, 2014,
p. 848)

Include a minimum of one

Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
University of South Florida College of Nursing Revision September 2014

18

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

University of South Florida College of Nursing Revision September 2014

19

References

Erik Erikson Psychosocial Stages. (2008). Retrieved November 10, 2015, from
http://www.simplypsychology.org/Erik-Erikson.html

Nursing Central. (2013-2014).Unbound Medicine (2.3.16m) [Mobile application software]. Retrieved from
http://www.uboundmedicine.com

Osborn, K. (2014). Nursing Management of Patient's with Respiratory Disorders. In Medical-surgical nursing:
Preparation for practice (2nd ed., pp. 792-794). Boston: Pearson.

SuperTracker Detect Time Zone. (n.d.). Retrieved November 6, 2014, from https://www.supertracker.usda.gov

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