UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Victoria Clayton

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

N.P.

Female

Assignment Date: 01/26/2016

Agency: FHT

Age: 79

Admission Date: 01/14/16

Marital Status: Married

Primary Medical Diagnosis

Primary Language: English

Acute respiratory distress

Level of Education: 10th Grade

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Hair dresser for 27 years

Acute dyspnea
Hypoxia
MRSA

Number/ages children/siblings: Male son (61), male son (56),

female daughter (51)

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

Code Status: Full

Living Arrangements: Assisted living facility

Advanced Directives: Yes

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

Culture/ Ethnicity /Nationality: White

Religion: Christian

Type of Insurance: Blue Cross Blue Shield

1 CHIEF COMPLAINT:
Ive been malnourished since my thoracic surgery. If I dont get more food in me or they dont put that tube in me
Im going to waste away. And those medicines they give me, give me the shakes real bad and they make me nauseous.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
N.P. was brought to the emergency room on 01/14/16 from Angels Senior Living facility. Staff noticed that she was
complaining of shortness of breath. After it continued for 30 minutes, they decided to bring her into the ED. Upon arrival
to the ED, she was given breathing treatments and put on oxygen. She was transferred to 4N for further monitor and to
continue breathing treatments. N.P. is also severely malnourished, underweight and weak. Patient attributes most of the
weight loss and the trouble swallowing to an esophageal hernia that was removed surgical in September of 2015. Part of
her esophagus and stomach was resected in the surgery. A barium swallow test was done on 01/15/16 to confirm her
dysphagia, and she was put on a full liquid diet. On 01/18/16, she started experiencing nausea and diarrhea. Her provider
then ordered PRN Zofran, which has helped. Additionally, she started experiencing tremors in her hands and face, which
are mostly likely the side effects of the breathing treatments. She is currently waiting surgical clearance for a PEG tube
insertion.

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

Father

78

Mother

99

Brother

76

Sister

79

Brother

80

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable)
Cancer

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Benign breast tumor excised
Rotator cuff repair
Total back reconstruction
Thoracic surgery to remove hiatal hernia

Age (in years)

Date
1950
09/1988
2007
1983, 09/2015

Old age
Lung
Complicatio
n
Polycythemi
a Vera
unknown

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 (2008)
Adult Tetanus (2008) Is within 10 years? Yes
Influenza (flu) (2014) Is within 1 years? No
Pneumococcal (pneumonia) (2014) Is within 5 years? Yes
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)

NKDA
Medications

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)
Typically, the esophagus is anchored to the diaphragm so that the stomach cannot be displaced. The phrenoesophageal
membrane helps maintain this fixation. A hiatal hernia is when the esophagus, part of the stomach or other organs in the
abdominal cavity protrude through the membrane to the mediastinum and chest cavity. There are four types. Type I, also
referred to as sliding, accounts for 95% of hiatal hernias. This is when the gastroesophageal junction is herniated through
the mediastinum. Type II, a paraesophageal hiatal hernia is very rare, but can cause a great deal of complications. This
occurs when the stomach herniates through the diaphragmatic esophageal hiatus alongside the esophagus. Type III, is
when the gastroesophageal junction is herniated superficially to the diaphragm and the stomach herniated along the
esophagus. Lastly, type IV occurs when other organs like the intestines or colon, herniate into the chest (Kahrilas, Kim &
Pandolfino, 2008).
While the exact etiology of hiatal hernias is unknown, loss of elasticity or an increase in laxity in the phrenoesophageal
membrane can lead to a hiatal hernia. Age, obesity and smoking are all contributing factors to developing a hiatal hernia.
Coughing, vomiting, straining, or lifting heavy objects can also increase the risk for hiatal hernias. Some smaller sliding
hiatal hernias are asymptomatic. Larger sliding hernias, or type II, III and IV hernias have symptoms similar to GERD
symptoms including heartburn, chest pain, trouble swallowing and belching. Many physicians and researchers have
studied the relationship between GERD and hiatal hernias. Because hiatal hernias alter the anatomy of the esophagus and
stomach, this can decrease peristalsis and increase the esophaguss exposure to acid which can trigger regurgitation.
Individuals can have a hiatal hernia without having GERD or they can have GERD without having a hiatal hernia. There
are many instances when the two coexist, which can precipitate the symptoms. (Gordon, Kang, Neild & Maxwell, 2004).
Hiatal hernias are diagnosed through either a barium swallow radiograph, endoscopy or manometry. A barium swallow
test is helpful for hiatal hernias that are great than 3cm. The patient drinks a barium and water mixture. Barium coats the
esophageal wall and the structures will show up white on an x-ray or fluoroscopy. This reveals the structures sizes and
shapes and is helpful in detecting hernias, tumors and other malformations or abnormalities. An upper GI endoscopy may
also be performed. This uses a scope to visualize the inside of the esophageal wall. Lastly, manometry measures the
pressure inside of the esophagus. Increased pressure also contributes to weakening the muscle around the diaphragm and
esophagus which could lead to a hiatal hernia. Chest x-rays can also be used to detect hiatal hernias.
Hiatal hernias that are smaller than 2cm are often symptomatic do not require treatment. If hiatal hernias are larger than
2cm and are symptomatic they can be surgically repaired with by laparoscopy, which is less invasive, or thoracotomy
which requires going through the chest wall. Patients with a history of hiatal hernias are often prescribed proton pump
inhibitors to reduce further irritation in the esophagus or stomach (Kahrilas, Kim & Pandolfino, 2008).

University of South Florida College of Nursing Revision September 2014

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

Concentration

Dosage Amount 2.5 mg

Route IV Push
Frequency Q6H
Pharmaceutical class Beta-blocker
Home
Hospital
or
Both
Indication To treat hypertension, angina, and heart failure
Adverse/ Side effects Blurred vision, dizziness, fatigue, sweating, irregular heartbeat, cardiac failure, hypotension, cough, decreased
urine output, and headache
Nursing considerations/ Patient Teaching If you have diabetes, check blood glucose regular and report symptoms of high blood sugar;
do not drive, use machinery or do any activity that requires alertness until you are sure you can perform such activities safely; limit
alcoholic beverages; check apical pulse before administering and hold the drug if HR is below 60; do not abruptly stop drug; teach
patient how to check apical pulse
Name Piperacillin and tazobactam (Zosyn)

Concentration

Dosage Amount 4.5 GM

Route IV Pump at 200 ml/hr

Frequency Q6H
Pharmaceutical class Penicillin
Home
Hospital
or
Both
Indication To treat infections
Adverse/ Side effects diarrhea, rapid heart rate, easy bruising, unusual bleeding, fever, chills, body aches, mouth ulcers, swollen gums,
seizures, nausea, vomiting, constipation, headache, dizziness, runny nose, anxiety, and insomnia
Nursing considerations/ Patient Teaching Use antibiotic for full prescribed length; do not skip doses even if symptoms have
improved; this drug may interact with blood thinning agents;
Name Albuterol (DuoNeb)

Concentration

Dosage Amount 3 mL

Route Nebulizer treatment

Frequency TID
Pharmaceutical class Bronchodilator
Home
Hospital
or
Both
Indication Relaxes the muscles in the airways to increase air flow to the lungs
Adverse/ Side effects tachycardia, trembling, agitation, cough, difficulty breathing, confusion, fainting, hallucinations, light
headedness, sweating, restlessness, headache, vomiting
Nursing considerations/ Patient Teaching take missed dose as soon as remembered, skip the missed dose if it is almost time for the
next scheduled dose; overdose symptoms include dry mouth, tremors, chest pain, fast heartbeats, seizures, light-headedness, or fainting;
monitor pulse rate and BP before administration
Name Budesonide (Pulmicort)

Concentration

Dosage Amount 0.5 mg

Route Nebulizer treatment

Frequency BID
Pharmaceutical class corticosteroid
Home
Hospital
or
Both
Indication Reduces workload of the lungs by reducing inflammation of the airways
Adverse/ Side effects dry irritated throat, hoarseness, voice changes, runny nose, nosebleeds, severe or sudden worsening of breathing
problems, thrush, muscle weakness, slow wound healing, increased thirst/urination, increase blood glucose
Nursing considerations/ Patient Teaching Must be used regularly to be effective; make sure to provide good oral hygiene in order to
prevent infections and prevent thrush; rinse mouth with water after each use; do not use with an ultrasonic nebulizer; report new or
worsening cough, shortness of breath, wheezing, increased sputum, worsening peak flow meter readings; stop using other
corticosteroids unless directed by physicians; do not abruptly stop as the drug must be tapered off gradually; may take 4-6 weeks of
regular use before the full benefit of this drug takes effect; be aware of signs and symptoms of infection as this drug weakens the

University of South Florida College of Nursing Revision September 2014

immune system
Name Diltiazem (Cardizem)

Concentration

Dosage Amount 60 mg

Route PO
Frequency BID
Pharmaceutical class Calcium channel blocker
Home
Hospital
or
Both
Indication Dilates coronary arteries
Adverse/ Side effects arrhythmia, bradycardia, CHF, palpitations, amnesia, anorexia, dry mouth, dyspnea, epistaxis, impotence,
tinnitus, nocturia, hyperglycemia, alopecia, angioedema, asystole, vasculitis
Nursing considerations/ Patient Teaching Check BP before administration; monitor and report signs and symptoms of CHF; monitor
for headache, make position changes slowly and in stages; do not drive or engage in other potentially hazardous activities until reaction
to drug is known
Name Levetiracetam (Keppra)

Concentration

Dosage Amount 500 mg

Route IV pump at 400 ml/hr

Frequency BID
Pharmaceutical class Anticonvulsant
Home
Hospital
or
Both
Indication To treat seizures and decreasing neuronal excitement in the brain
Adverse/ Side effects drowsiness, weakness, unsteady walking, coordination problems, headache, pain, anxiety, agitation, dizziness,
nervousness, numbness, anorexia, vomiting, diarrhea, constipation, changes in skin color, depression, hallucinations, suicidal ideations,
fever, double vision, itching
Nursing considerations/ Patient Teaching Take at the same time every day; be aware of symptoms of overdose like drowsiness,
agitation, aggression, decreased consciousness and difficulty breathing; report any suicidal ideations; take exactly as prescribed
Name Vancomycin hydrochloride

Concentration

Dosage Amount 500 mg

Route IV pump at 100 ml/hr

Frequency Daily
Pharmaceutical class Antibiotic
Home
Hospital
or
Both
Indication To treat infections especially serious or severe infections caused by susceptible strains of methicillin-resistant staphylococci
Adverse/ Side effects Red man syndrome, wheezing, dyspnea, hypotension, vertigo, tinnitus, neutropenia, Stevens-Johnson syndrome,
chills, nausea, fever, anaphylaxis, nephrotoxicity, ototoxicity
Nursing considerations/ Patient Teaching If an injection, inject slowly as medication may cause a burning sensation; Provide oral care
to prevent thrush; may develop vaginal yeast infection; monitor hearing and renal function
Name Levothyroxine (Synthroid)

Concentration

Dosage Amount 50 mcg

Route Injection
Frequency Daily
Pharmaceutical class Thyroid preparations
Home
Hospital
or
Both
Indication Hypothyroidism
Adverse/ Side effects hyperthyroidism, transient alopecia, seizures, fast or irregular heart rate, fever, hot flashes, sweating, insomnia,
changes in menstruation, vomiting, diarrhea, anorexia, weight changes
Nursing considerations/ Patient Teaching May interact with oral hypoglycemic; take a single dose 1 hour before or 2 hours after
breakfast; monitor pulse before each dose during dose adjustment if rate is above 100 consult a physician; monitor baseline and periodic
tests of thyroid function; thyroid replacement therapy is usually lifelong; notify prescriber signs and symptoms of toxicity (chest pain,
palpitations, nervousness); avoid OTC medications
Name Pantoprazole sodium (Protonix)

Concentration

Dosage Amount 40 mg

Route Injection
Frequency Daily
Pharmaceutical class Proton pump inhibitor
Home
Hospital
or
Both
Indication Suppresses gastric acid secretion by inhibiting the acid pump in the parietal cells
Adverse/ Side effects Diarrhea, flatulence, abdominal pain, headache, insomnia, rash
Nursing considerations/ Patient Teaching Monitor for and immediately report signs and symptoms of angioedema or severe skin
reaction (peeling, blistering or loosening of skin, skin rash, hives, itching, swelling of the face, tongue or lips)

University of South Florida College of Nursing Revision September 2014

Name Tiotropium bromide (Spiriva)

Concentration

Dosage Amount 18 mcg

Route Inhalant
Frequency daily
Pharmaceutical class Anticholinergic
Home
Hospital
or
Both
Indication Antispasmodic agent for bronchodilation especially in COPD
Adverse/ Side effects chest pain, dry mouth, depression, abdominal pain, hypercholesterolemia, sinusitis, upper respiratory tract
infection, urinary tract infection, hyperglycemia, constipation
Nursing considerations/ Patient Teaching Withhold drug if signs and symptoms of angioedema occurs, monitor for anticholinergic
effects (tachycardia, urinary retention); do not allow powdered medication to contact the eyes; report constipation, increased heart rate,
blurred vision, urinary difficulty

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?
Full liquid
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular diet, soft foods
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Two biscuits with gravy and a cup of coffee
Lunch: One serving of chicken and dumplings with fresh
peas and one slice of homemade corn bread
Dinner: One slice of country ham with half a cup of fried
okra and a glass of sweet tea
Snacks: Mixed fruit salad (bananas, oranges, strawberries,
grapes, and apples)
Liquids (include alcohol): Sweet tea and coffee
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.
N.P. provided me with her typical diet before her esophageal
surgery in September of 2015. Now, she can only eat soft pureed
foods, so she no longer eats the above diet. However, that was her
typical diet before the surgery.
Her recommended caloric intake is 1600 calories. After analyzing
all of her meals, N.P. is deficient in fiber, calcium, potassium,
magnesium, and most vitamins. Her sodium intake and saturated
fat levels are over the recommended target goal. The
recommended sodium intake for someone of N.P.s age is 1500
mg, while N.Ps average sodium intake was 4546. If N.P. could
eat regularly, I would suggest she consume more fresh fruits and
vegetables to improve her nutrient and vitamin intake. I would
also advise that she reduces sodium intake by teaching her how to
read labels. She would also need to cut back on her saturated fat
intakes by taking many of the fried foods out of her diet.
Additionally, choosing less canned meats and vegetables would
help reduce sodium intake. Many of her food choices also have a
lot of acid content. I would also encourage N.P. to choose bland
foods to help with her GERD.
(USDA, 2016)
(these are prompts designed to help guide your discussion)

1 COPING ASSESSMENT/SUPPORT SYSTEM:

Who helps you when you are ill?
My prayers.
How do you generally cope with stress? or What do you do when you are upset?
I pray and give it to the Lord.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
When there seems to be difficulties I just say Lord I give this to you, because this job is too big for me to handle on
my own.

University of South Florida College of Nursing Revision September 2014

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? Yes with my second husband.
Have you ever been talked down to? Yes. Have you ever been hit punched or slapped? Yes.
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Yes, my second husband was terrible. Just as mean as can be. I stayed faithful when he was not, but after his boys moved
out of the house I got right out of there. If yes, have you sought help for this? I got a lot of family help and Jesus
protected me from a lot through all of that.
Are you currently in a safe relationship?
Yes, I love my husband.

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 is the result of the positive resolution of the final life crisis. Ego integrity is viewed as the key to harmonious
personality development; the individual views their whole of life with satisfaction and contentment. The ego quality that emerges from
a positive resolution is wisdom. Erikson (1982) defines wisdom as a kind of informed and detached concern with life itself in the face
of death itself. Conversely, despair is the result of the negative resolution or lack of resolution of the final life crisis. This negative
resolution manifests itself as a fear of death, a sense that life is too short, and depression. Despair is the last dystonic element in
Erikson's (1959, 1982) theory (Eriksons Integrity vs. Despair, 2016).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

N.P. is in the Integrity versus Despair stage of life. She is 79 years old and has been experiencing chronic medical issues
for a long time before this hospitalization. She is very comfortable with her identity and the fact that she is closer to death.
When she reflected on her past life, she regarded it in a positive light. The few regrets shes had, she stated that they were
all a part of her life for a purpose. She seemed positively content with who she is, who is a part of her life, and where she
is going after her hospitalization, whether it be back at an assisted living facility or hospice. She does not fear death, and
she never complained about her conditions.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

Since N.P. has had numerous hospitalizations, this hospital stay has not seemed to impact her significantly. This
hospitalization is distinct from other visits in the fact that if she does not pass surgical clearance for the PEG tube and she
she will continue to be progressively malnourished. She states that she was ready to go if it was her time. Through her
statements and attitude, she seemed to view this hospitalization as yet another opportunity and another challenge. She is
confidently resolved in that whatever happens she will remain content.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Well definitely the esophageal hernias caused problems with my swallowing.

University of South Florida College of Nursing Revision September 2014

What does your illness mean to you?

Its just another opportunity for Jesus to be glorified. Hes using all this for some purpose, I know it.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active? Yes.
Do you prefer women, men or both genders? Men.
Are you aware of ever having a sexually transmitted infection? No.
Have you or a partner ever had an abnormal pap smear? No.
Have you or your partner received the Gardasil (HPV) vaccination? No.
Are you currently sexually active? No.
If yes, are you in a monogamous relationship? ____________________ 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? 39 years.
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.

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 plays a big role in my life. I wouldnt be here without God.
Do your religious beliefs influence your current condition?
Absolutely, I believe and pray for the same thing every time for Gods will to be done and not mine. Im ready if he takes me.

+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?
How much?(specify daily amount)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No one smokes.

Has the patient ever tried to quit?

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

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
Not that I am aware of.
5. For Veterans: Have you had any kind of service related exposure?

University of South Florida College of Nursing Revision September 2014

10

 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:
Bathing routine: Showers daily with assist
Other:

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? U
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:
10x/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
1 x/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?
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? U
menstrual cycle
regular
irregular
menarche
age?
menopause
age? 56
Date of last Mammogram &Result: 2014.
No abnormal results.
Date of DEXA Bone Density & Result:
2014. Normal age related changes.
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

Childhood Diseases
Measles

University of South Florida College of Nursing Revision September 2014

11

Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other:

Pain
Gout
Osteomyelitis
Arthritis
Other:

Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

General Constitution
Recent weight loss or gain
How many lbs? 30 lbs
Time frame? Since 09/2015
Intentional? No
How do you view your overall health? Well Ive had over 30 surgeries in my life time. But its just been getting worse as I have
gotten older.

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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12

10 PHYSICAL EXAMINATION:
General Survey:

Height 152.4 cm
Pulse 78
Respirations 20

Temperature: 97.8 oral

SpO2 98

Weight 36.4 kg
BMI 15.6
Blood Pressure: (include location)
125/54
right brachial
Is the patient on Room Air or O2 1 L

Pain: (include rating and

location)
No pain

NC

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
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

Peripheral access device Type:

20 gauge
Fluids infusing?
no
yes - what?

Location:

left AC

Date inserted:

flat
loud

01/17/2016

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 2/2 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 (not assessed)
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 CL
LUL CL
RML CL
LLL CL
RLL CL

Chest expansion

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

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

Calf pain bilaterally negative

No JVD

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]

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Apical pulse:
Carotid:
Brachial:
Radial: 2
Femoral:
Popliteal:
DP: 2
PT:2
No temporal or carotid bruits
Edema:
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
GI
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Last BM: (date
01 /18 / 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
Other Describe:

Not assessed, patient alert, oriented, denies problems

GU
Urine output:
Clear
Cloudy
Color:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Previous 24 hour output:

without assistance

or

856

mLs N/A

with assistance x2

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ____4___ RUE __4_____ LUE __4_____ RLE & __4_____ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
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:

Biceps:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

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

Dates

CXR

01/14/2016

XR Video/Cine Swallow

01/15/2016

Trend
Loss of volume and
chronic scarring in the
left lower lobe. There is
also hyperinflation
present and
thoracolumbar fusion
with intrapedicular
screws and rods.

Swallow function is

Analysis
This finding is consistent
with the underlying
problem behind the acute
respiratory distress that
N.P. presented with. The
chronic scarring is mostly
like due to her history of
COPD. The intrapedicuar
screws and rods are from
N.P.s total back
reconstruction surgery.
The results from this

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15

Test

severely limited.

CT Head/Brain W/O
Contrast

01/15/2016

MRI Brain W/O Contrast

01/16/2016

WBC

01/14/2016
6.6
01/15/2016
9.3

White matter
hypodensities may
represent small vessel
disease revealing agerelated cerebral atrophy.
Acute worsening of
swallow function due to
age related atrophy.
There is no consistent
trend in N.P.s white
blood cell count. Her
count is within normal
limits.

01/16/2016
6.2
01/17/2016
6.6

Hemoglobin/Hematocrit

01/14/2016
15.5
48.2 H
01/15/2016
11.4 L
35.9 L
01/16/2016
6.2 L
34 L
01/17/2016
9.9 L
32.3 L

Since N.P. was admitted

to the hospital, her
hemoglobin and
hematocrit levels have
been consistently
trending low.

infers the needs to consult

a nutritionist to better
meet N.P.s nutritional
needs. She will also need
a full liquid or soft foods
diet. This finding is
consistent with her
history of hiatal hernias.
These results reveal that
the decrease in
swallowing function is
not only a problem from
the thinning of the GI
tract, but also stems from
cerebral atrophy.

N.P. came to FHT from

acute respiratory distress,
thus her WBCs need to
be monitored since she is
at risk for developing an
infection. Her WBCs
also help indicate whether
or not the corticosteroid
treatment is effective.
Because her white count
is within normal limits,
there is no current
concern for infection or
inflammation. Otherwise,
her WBC would be
trending high.
These are important labs
to monitor for several
reasons. Ulceration and
damage to the lining of
the stomach can cause
anemia. N.P. is at an
increased risk of
developing anemia due to
her history of GERD and
hiatal hernias. The low
trend of hemoglobin and
hematocrit levels are also
consistent with N.P.s
nutritional deficiency.

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16

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

N.P. is currently waiting for surgical clearance for a PEG tube insertion. A pulmonologist and nutritionist
collaborate for her current care. She is on a full liquid diet. She is continent of stool and urine and has bathroom
privileges with two assists. She receives physical therapy every day. She has several nebulizer treatments by
respiratory therapists every day. Vitals are performed Q6H and she is also on telemetry monitoring. Lastly, she is
on contact precaution due to MRSA of the nares.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Impaired swallowing r/t aging and complications of thoracic surgery aeb barium swallow test
2. Ineffective airway clearance r/t history of COPD and respiratory distress
3. Imbalanced nutrition: less than body requirements r/t inability to effectively swallow foods aeb loss of body weight
4. Risk for aspiration r/t ineffective swallowing aeb barium swallow test
5. Diarrhea r/t adverse effects of medications, gastric irritation and malabsorption
6. Risk for falls r/t extreme weakness aeb PT evaluation and trembling
7. Risk for electrolyte imbalance r/t diarrhea and imbalanced nutrition
8. Nausea r/t gastric irritation and pharmaceuticals aeb patient stating I feel so nauseous.
9. Readiness for enhanced hope r/t to positivity aeb by patient stating Whatever happens, I am content, because I know itll
be Gods will.

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17

 15 CARE PLAN
Nursing Diagnosis: Impaired swallowing r/t aging and complications of thoracic surgery aeb barium swallow test
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will swallow and digest
Before initiating oral feeding,
A client can aspirate even with an Patient did not aspirate during the
oral, nasogastric, or gastric feeding check clients gag reflex and ability intact gag reflex.
shift. For lunch, she sat in the chair
without aspiration for each meal
to swallow by feeling the laryngeal
at 90 degrees and ate jello with no
given during shift.
prominence as the client attempts
complications.
to swallow.

Patient will progressively gain

Have suction machine available

when feeding high-risk clients. If
aspiration does occur, suction
immediately.

A client with aspiration needs

immediate suctioning and may
need further lifesaving
interventions such as intubation.

Keep the head of bed elevated 30

to 45 degrees, preferably sitting up
in a chair at 90 degrees when
feeding. Keep head elevated for an
hour afterward.

Maintaining a sitting position with

and after meals can help decrease
aspiration pneumonia.

Check the oral cavity for proper

emptying after the client swallows
and after the client finishes the
meal. Provide oral care at the end
of the meal. It may be necessary to
manually remove food from the
clients mouth. If this is the case,
use gloves and keep the clients
teeth apart with a padded tongue
blade.
Evaluate nutritional status daily.

Food may become pocketed and

cause stomatitis, tooth decay and
possible later aspiration.

Dysphagic stroke clients who

University of South Florida College of Nursing Revision September 2014

Patient experienced diarrhea almost

18

weight toward desired goal during

hospital stay and after discharge.

Patient will consume adequate

nourishment on shift and during
hospital stay.

Weigh the client weekly to help

evaluate nutritional status. If the
client is not adequately nourished,
work with the dysphagia team to
determine whether the client needs
therapeutic feeding only or need
enteral feeding until the client can
swallow adequately.

received thickened fluid dysphagia

diets failed to meet their needs for
fluids, whereas a group receiving
enteral feeding and IV fluid did
meet fluid requirements.

Prior to giving oral feedings,

determine the clients readiness to
eat (alertness, able to hold head
erect, follow instructions, move
tongue in mouth and manage oral
secretions).

If one of these elements is

missing, it may be advisable to
withhold oral feeding and use
enteral feeding for nourishment.

To manage impaired swallowing

use a dysphagia team composed of
a rehabilitation nurse, speech
pathologist, dietician, physician
and a radiologist.

The dysphagia team can help the

client learn to swallow safely and
maintain a good nutritional status.

Work with the client on

swallowing exercises prescribed by
the dysphagia team.

Clients who received a highintensity swallowing intervention

versus usual care of a low-intensity
swallowing intervention were more
likely to return to a normal diet and
recover swallowing ability by 6
months.

Watch for signs of malnutrition

and dehydration and keep a record
of food intake.

Malnutrition is common in
dysphagic clients. Clients with
dysphagia are at serious risk for
malnutrition and dehydration,

University of South Florida College of Nursing Revision September 2014

immediately after eating.

Patient was able to eat, however

she had diarrhea shortly after.

19

Patient will identify nutritional

requirements by the end of the
week through short intervals of
education given during each shift.

Patient will maintain patent airway

and clear lung sounds after eating.

Teach the client and family

exercises prescribed by the
dysphagia team. Teach the client a
systematic method of swallowing
effectively as prescribed by the
dysphagia team.*
Educate the client, family, and all
caregivers about rationales for food
consistency and choices.*
Auscultate lung sounds frequently
and before and after feedings; note
any new onset of crackles or
wheezing.
Monitor respiratory rate, depth,
and effort. Note any signs of
aspiration such as dyspnea, cough,
cyanosis, wheezing, hoarseness,
foul-smelling sputum, or fever. If
new onset of symptoms, perform
oral suction and notify provider
immediately.

which can lead to aspiration

pneumonia resulting from
depressed immune function and
weakness, lethargy, and decreased
cough.
It is common for family members
to disregard necessary dietary
restrictions and give the client
inappropriate foods that predispose
to aspiration.

Auscultation of lung sounds was

shown to be specific in identifying
clients at risk for aspiration.

Patient demonstrated understanding

of education by explaining to me
her need to consume more calories.

Patients lung sounds were

auscultated after each meal, and all
lobes were clear.

Signs of aspiration should be

detected as soon as possible to
prevent further aspiration and to
initiate treatment that can be
lifesaving. Because of laryngeal
pooling and residue in clients with
dysphagia, silent aspiration may
occur.

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20

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 & Respiratory therapy
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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21

Nursing Diagnosis: Ineffective airway clearance r/t history of COPD and respiratory distress
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will demonstrate effective
Monitor respiratory patterns,
A normal respiratory rate for an
All lobes were clear throughout the
coughing and clear breath sounds
including rate, depth, and effort.
adult without dyspnea is 10 to 20. day and patient successfully turned,
during shift.
coughed, and practiced breathing
Position the client to optimize
An upright position allows for
deeply.
respiration (head of bed elevated
maximal lung expansion; lying flat
30-45 degrees and repositioned at
causes abdominal organs to shift
least every 2 hours).
toward the chest, which crowds the
lungs and makes it more difficult to
breathe.
Administer mediations 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.*

Patient will maintain a patent

airway at all times during hospital
stay.

Auscultate breath sounds q 1 to 4

hours.

Encourage the client to use an

incentive spirometer if ordered.

Bronchodilators decrease airway

resistance, improve the efficiency
of respiratory movements, improve
exercise tolerance, and can reduce
the symptoms of dyspnea on
exertion. Pharmacologic therapy in
COPD is used to reduce symptoms,
reduce the frequency and severity
of exacerbation and improve health
strategies and exercise tolerance.
Breath sounds are normally clear
or a few scattered fine crackles or
bases, which clear with deep
breathing. The presence of coarse
crackles during inspiration
indicates fluid in the airway;
wheezing indicates an airway
obstruction.

Patients breath sounds were

routinely auscultated. Patient was
educated on incentive spirometry
and used it twice every hour.

A study on care of clients in a

medical unit found that use of

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22

Recognize that controlled coughing respiratory bundle that include use

and deep breathing may be just as
of spirometer and good oral care
effective.*
for ambulatory clients, and oral
care, turning, and elevation of the
head of the bed for dependent
clients was effective in decreasing
the incidence of transfer to critical
care for respiratory problems.

Patient will explain methods useful

to enhance secretion removal by
end of the shift.

Patient will explain the

significance of changes in sputum
to include color, character, amount
and odor by the end of hospital
stay.

Encourage activity and

ambulation as tolerated. If unable
to ambulate client, turn patient
from side to side at least every 2
hours.
If the client has obstructive lung
disease, such as COPD, cystic
fibrosis, or bronchiectasis, consider
helping the client use the forced
expiratory technique the huff
cough. The client does a series of
coughs while saying the word
huff.

Body movement helps mobilize

secretions.

Help the client deep breathe and

perform controlled coughing. Have
the client inhale deeply, hold breath
for several seconds and cough two
or three times with mouth open
while tightening the upper
abdominal muscles.
Educate patient to observe sputum,
noting color, odor and volume.

Controlled coughing uses the

diaphragmatic muscles, making the
cough more forceful and effective.

This technique prevents the glottis

from closing during the cough and
is effective in clearing secretions.

Normal sputum is clear or gray

and minimal; abnormal sputum is
green, yellow, or bloody;
malodorous; and often copious.
The presence of purulent sputum

University of South Florida College of Nursing Revision September 2014

Patient successfully turned,

coughed, and practiced deep
breathing before the end of the
shift.

Patient was educated on how

sputum and mucus can collect in
the lungs and cause breathing
problems. Patient demonstrated
understanding and concern by
23

during a COPD exacerbation can

be sufficient indication for starting
empirical antibiotic treatment.
Notify provider of purulent
sputum.
Teach the client how to deep
breathe and cough effectively.*
Patient will identify and avoid
specific factors that inhibit
effective airway clearance before
discharge.

Assess home environment for

factors that exacerbate airway
clearance problems (presence of
allergens, lack of adequate
humidity in air, poor air flow, and
stressful family relationships).

Controlled coughing uses the

diaphragmatic muscles, making the
cough more forceful and effective.
Success in avoiding emergency or
institutional care may rest solely on
medication compliance or
availability.

diligently using the incentive

spirometer and turning and
coughing.

Patient was asked about living

situation at assisted living facility.
Patient has not yet identified
factors and triggers that inhibit
effective airway clearance.

Teach the client when and how to

use inhalant or nebulizer treatments
at home. Teach the client/family
importance of maintain regimen
and having PRN drugs accessible
at all times.*
Teach the client/family to identify
and avoid specific factors that
exacerbate ineffective airway
clearance, including known
allergens and smoking.*

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
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24

Durable Medical Needs

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

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25

References
Ackley, Betty J. & Ladwig, Gail B..(2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. Maryland Heights, Mo:
Mosby.
Erikson's Integrity vs. Despair. (2016). Webster University. Retrieved from http://faculty.webster.edu/woolflm/lrerikson.html
Gordon, C., Kang, J.Y., Neild, P.J., & Maxwell, J.D. (2004). The role of the hiatus hernia in gastro-oesophageal reflux disease. Aliment Pharmacol
Ther. 1;20(7):719-32.
Kahrilas, P. J., Kim, H. C., & Pandolfino, J. E. (2008). Approaches to the Diagnosis and Grading of Hiatal Hernia. Best Practice & Research. Clinical
Gastroenterology, 22(4), 601616. http://doi.org/10.1016/j.bpg.2007.12.007
USDA. (2015). SuperTracker Home. Retrieved from https://supertracker.usda.gov/
Valerand, A. H., & Sanoski, C. A. (2013). Daviss drug guide for nurses (13th ed.). Philadelphia, PA: FA Davis Company.

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