UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Renee Dabydeen

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 9/22/2015

Agency: BMC UD

Patient Initials: BAB

Age: 60

Admission Date: 8/27/2015

Gender: Female

Marital Status: Engaged

Primary Medical Diagnosis: Shortness of Breath;

Primary Language: English

Chronic obstructive pulmonary disease (COPD)

Level of Education: 9th grade

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): None

Genital warts, Tobacco use, cerebrovascular

Number/ages children/siblings: None

Accident (CVA) , hypertension (HTN), Deep vein

thrombosis (DVT); EF < 10%

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

Code Status: Full code

Living Arrangements: Live with Father and Fianc

Advanced Directives: none

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

Culture/ Ethnicity /Nationality: Caucasian

Radiology- chest (8/27/2015)

Intubation (8/27/2015) Extubation (8/29/2015)
Type of Insurance: None

Religion: non-religious

1 CHIEF COMPLAINT:
The patient stated that I felt like I couldnt catch a breath and started to feel really dizzy and weak

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
This 60-year-old female patient was admitted to Bayfront medical center on 8/27/2015 via EMS due to the results of her
shortness of breathe (SOB). The patient stated that she has had SOB in her past due to her previous diagnosis of COPD
however, in the last three days the SOB has become increasingly worse. Pt describes SOB as constant and
states that she feels like I couldnt catch a breath. Aggregating factors include any moderate activity such as walking or
washing dishes. Relieving factors include rest and using pillows while in bed to elevate her head when she sleeps. Without
elevation pt states she has a coughing fit which leads to her SOB. PT treatment includes sitting up in the up- right
position or putting head between knees. Pt states that the inhaler was helping with SOB however, on admission
the inhaler was not helping to treat her SOB. PT has not complaints of pain, only complains of weakness and dizziness.

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

85

Mother

56

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Cause
of
Death
(if
applicable
)
N/A
Colon
Cancer

Glaucoma

2
FAMILY
MEDICAL
HISTORY

Age (in years)

09/27/2015

Diabetes

08/29/2015

Cancer

08/27/2015

Bleeds Easily

12/22/2005

Asthma

01/05/2006

Arthritis

03/03/2008

Anemia

12/08/2008

Environmental
Allergies

5/28/2009

Operation or Illness
AICD (automatic cardioverter defibrillator) placed
Treatment/management of disease: Follow-up appointments
Debridement, skin, subcutaneous
Treatment/management of disease: Unknown
Interruption vena cava
Treatment/management of disease: Follow- up appointments
Coronary arteriography catheter
Treatment/management of disease: Unknown
Thorancentesis
Treatment/management of disease: Unknown
Continuous mechanical ventilation 96 consecutive hours
Treatment/management of disease: Unknown
Intubation
Treatment/management of disease: Monitor respiratory status of pt
Extubation
Treatment/management of disease: Monitor respiratory status of pt
Radiology- chest
Treatment/management of disease: Ruled out punctured lungs, supported COPD- monitor respiratory
status and educate pt about COPD.

Alcoholism

Date
01/12/2006

N/
A
N/
Sister
A
relationship
N/
A
relationship
N/
A
relationship
N/
A
Father: Pt lives with father, no longer a alcoholic stopped at the age of 70. Heart problem began in his 40s.
Mother: Died at age 56 diagnosed with colon cancer at age 56- stage four.
No known siblings.
Brother

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U

YES

University of South Florida College of Nursing Revision September 2014

NO

Adult Tetanus (Date) Is within 10 years? Year and a half ago

Influenza (flu) (Date) Is within 1 years? (did not get last year)
Pneumococcal (pneumonia) (Date) Is within 5 years? Year ago
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
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Sulfa Drugs

Type of Reaction (describe explicitly)

I feel itchy and get hives all over and my throat is itchy

Medications

Other (food, tape,

latex, dye, etc.)

N/A

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)
Chronic obstructive pulmonary disease (COPD) is a disease state characterized by chronic airflow obstruction; thus
pulmonary function testing is central to its diagnosis. The presence of airflow obstruction is determined by reduced ratio
of the forced expiratory volume in to force vital capacity. Individuals with airway hyperresponsiveness and certain
occupational exposures are likely also at increased risk for COPD.COPD is a progressive disorder; however the rate of
loss of lung function often slow markedly if smoking cessation occurs. Patient with COPD usually have smoke > or equal
to 20 pack-years of cigarettes. Common symptoms include cough and phlegm production; individuals with chronic
productive cough for 3 months per year for the preceding 2 years have chronic bronchitis. However, chronic bronchitis
without airflow obstruction is not included within COPD. Exertional dyspnea is a common and potentially disabling
symptom in COPD. Exercise involving upper-body activity is especially difficult for severe COPD. Treatment include
smoking cessation, non-pharmacologic treatment such as pulmonary rehabilitation, bronchodilators , corticosteroids and
long term supplemental oxygen.

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

Concentration: N/A

Dosage Amount: 5mg

Frequency: Daily

Pharmaceutical class: ACE inhibitors

Home

Hospital

or

Both

Indication: Alone or with agents in the management of hypertension, management of heart failure. Reduction of risk of death or development of heart failure after
myocardial infraction
Adverse/ Side effects: CNS: dizziness, fatigue, headache, weakness; RESP: cough; CV: hypotension, chest pain; DERM: rashes; F and E: hyperkalemia; Misc:
Angioedema
Nursing considerations/ Patient Teaching: Monitor BP and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care
professional of significant changes, assess pt for signs of angioedema (dyspnea, facial swelling). Monitor weight and assess pt routinely for resolution of fluid overload;
Monitor renal function and electrolytes (especially potassium). Instruct pt to take medication as directed at the same time each day, even if feeling well. Take missed doses
as soon as remember but not if almost time for next dose. Do not double doses. Warn pt not to discontinue ACE inhibitor therapy unless directed by health care
professional. Caution pt to avoid salt substitutes contain potassium or foods contain high levels of potassium or sodium unless directed to by physician. Caution pt to
change positions slowly pt minimize orthostatic hypotension. Advise pt to notify health care professional of all medication, vitamins, or herbal products being taken. May
cause dizziness- caution pt to avoid driving and other activates requiring alertness until response to medication is known. Instruct pt to notify heal care professional if
rash; mouth sores, sore throat, fever, swelling of hands or feet, irregular heart beat, chest pain, dry cough, hoarseness, swelling of face, eyes, lips, or tongue; or if difficult
swallowing or breathing occurs.

University of South Florida College of Nursing Revision September 2014

Name: Piperacillin/ tazobactam

Trade: Tazocin, Zosyn
Route: Intravenous

Concentration: N/A

Dosage Amount: 3.375 g

Frequency: Q6hr

Pharmaceutical class: extended spectrum penicillins

Home

Hospital

or

Both

Indication: Appendicitis and peritonitis, skin and skin structure infection, gynecologic infections, community acquired and nosocomial pneumonia caused by pipercillinresistance, beta lactamase producing bacteria
Adverse/ Side effects: CNS: seizures, confusion, dizziness, headache, insomnia, lethargy; GI: pseudomembranous colitis, diarrhea, drug-induced hepatitis, nausea,
vomiting; GU: interstitial nephritis; DERM: Steven Johnson syndrome, toxic epidermal necrolysis, rashes, uticaria; Hemat: bleeding, leukopenia, neutropenia,
thrombocytopenia; Local: pain, phlebitis at IV site; Misc: hypersensitivity reactions, including anaphylaxis and serum sickness, fever, superinfection
Nursing considerations/ Patient Teaching: Assess pt for infection at beginning of and during therapy, obtain history to see reaction to penicillin and cephalosporin;
obtain specimens for culture and sensitivity prior to initiating therapy. First dose may be given before receiving results; observe pt for s/s of anaphylaxis; monitor bowl
function, assess for skin reactions; advise pt to report rash and signs of superinfection (black furry overgrowth on tongue, vaginal itching or discharge, loose or four
smelling stools) and allergies. Caution pt to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus or mucus.
Name: Carvedilol
Trade: Coreg, Coreg CR
Route: PO

Concentration: N/A

Dosage Amount: 3.125 mg

Frequency: BID

Pharmaceutical class: Beta blockers

Home

Hospital

or

Both

Indication: Hypertension, HF (ischemic or cardiomyopathy) with digoxin, diuretics, and ACE inhibitors; left ventricular dysfunction after myocardia infarction
Adverse/ Side effects: CNS: dizziness, fatigue, weakness, anxiety, depression, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares;
EENT: blurred vision, dry eyes, intraoperative floppy iris syndrome, nasal stuffiness; Resp: bronchospasm, wheezing; CV: Bradycardia, HF, pulmonary edema; GI:
diarrhea, constipation, nausea; GU: erectile dysfunction; Derm: Stevens Johnson syndrome, toxic epidermal necrolysis, itching, rashes, urticarial; ENDO: hyperglycemia,
hypoglycemia; MS: arthralgia, back pain, muscle crams; Nero: parenthesis; Misc: anaphylaxis, angioedema, drug induced lupus syndrome
Nursing considerations/ Patient Teaching: Monitor BP and pulse frequently during dose adjustment period and periodically during therapy. Assess for orthostatic
hypotension when assisting pt up from supine position. Monitor intake and output rations and daily weight. Lab test considerations: may cause increase in BUN
potassium, triglycerides, ad uric acid levels; may cause increase in blood glucose levels. Monitor pt for signs of overdose (brady, sever dizziness or fainting, sever
drowsiness, dyspnea, bluish fingernails or palm, seizures. EDUCATION: Instruct to take medication as directed, same time everyday even if feeling well, do not skip or
double up on missed doses. Take missed doses as soon as possible up to four hours before next dose. Abrupt withdraw may precipitate life threatening arrthymias,
hypertension or myocardial ischemia. Advise pt to make sure enough medication available for holidays, weekends etc. Teach pt and family how to check BP. Instruct to
check pulse daily and read BP biweekly. Caution activities that require alertness, also to change positions slowly ; advise pt to notify health care professional if slow pulse,
difficulty breathing, wheezing, cold hands and feet, dizziness, confusion, depression, rash, fever, sore throat, unusual bleeding or bruising occurs.
Name: Clotrimazole
Trade: Canesten, Clotrimaderm, Mycelex-7
Route: Vaginal

Concentration: N/A

Dosage Amount: One app. (5g)

Frequency: 2x daily

Pharmaceutical class: Anti-fungal

Home

Hospital

or

Both

Indication: Treatment of vulvovaginal candidiasis. Affects the permeability of the fungal cell wall, allowing leakage of cellular contents. Not active against bacteria.
Adverse/ Side effects: GU: itching, soreness, vulvovaginal burning
Nursing considerations/ Patient Teaching: Inspect involved areas of skin and mucous membranes before and frequently during therapy. Increased skin irritation may
indicate need to discontinue medication. Consult physican or other health care professional for proper cleansing techniques before applying medication; At home, instruct
patient to apply medication as directed for full course of therapy, even if feeling better. Therapy should be continued during menstrual cycle ; Instruct patient on proper
use of vaginal applicator. Medication should be inserted high into vagina at bedtime. Instruct patient to remain recumbent for at least 30 minuets after insertion. Advise
patient to refrain from sexual intercourse during therapy. Report to physician if increased skin irritation.
Name: Enoxaparin
Trade: Lovenox
Route: Subcutaneous

Concentration: N/A

Dosage Amount: 40mg

Frequency: Daily

Pharmaceutical class: anti-thrombotic; low molecular weight heparins

Home

Hospital

or

Both

Indication: Prevention of venous thromboembolism, deep vein thrombosis, and pulmonary embolism in surgical or medical patients; treatment of DVT with or without
PE (with warfarin); Prevention of ischemic complications from unstable angina and non-ST-segment-elevation MI; treatment of acute ST-segment elevation of MI.
Adverse/ Side effects: CNS: dizziness, headaches, insomnia CV: edema GI: constipation increased liver enzymes, nausea, vomiting GU: urinary retention DERM:
alopecia, ecchymoses, pruritus, rash, urticarial F and E: hyperkalemia MS: osteoporosis Misc: fever ; risk of bleeding may be increased by concurrent use of drugs that
affect platelet function and coagulation
Nursing considerations/ Patient Teaching: Assess for signs of bleeding and hemorrhage; Observe injection sites for hematomas, ecchymosis or inflammation; monitor
CBC, platelet count, and stools for occult blood periodically during therapy, aPTT therapy monitor in certain pt population (renal insuffiency/ obese) Monitor potassium
levels. Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to health care professional
immediately. Instruct pt not to take asprin naproxen, or ibuprofen without consulting health care professional while on therapy.

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? Regular
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Based on the information supplied by My Plate the pt
Breakfast:
should be informed about excessive amount of calories
Cup of regular coffee with milk and sugar
taken in on a daily basis. Based off of My Plate the pt
Lunch:
takes in over 2453 calories and the total limit is 2000.
Cheese burger, fries and a glass of coke
In addition the based on the information that the pt gave
Dinner:
she eats approximately 815 empty calories. These are
Bowel of chicken alfredo pasta, garlic bread and a coke
unnecessary calories that provide no nutrition to the pt.
Snacks:
Also the pt should be informed about the importance of
Bag of chips, bagel bites (6 pieces), crackers and cheese
including more fruits in her diet. Based on the information
Liquids (include alcohol):
provided the pt does not receive an adequate and balanced
Beer (at night), Coke, Coffee, Milk
diet.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
Me, Rick works and Dads to old
How do you generally cope with stress? or What do you do when you are upset?
I try to talk to Rick but hes always so busy, so I usually stay to myself
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Well, I have been having anxiety about not being able to breathe, I just want to get home

+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_______________________________________________
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_________________________ If yes, have you sought help for this? Yes, I got a restraining order on my
ex-boyfriend
Are you currently in a safe relationship? Yes

University of South Florida College of Nursing Revision September 2014

 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: According to Medical surgical Nursing text book generativity is transmitting something positive to the next
generation such as roles of parenting, teaching, or social activism. Furthermore, Stagnation is the feeling of having done nothing to
help the next generation or failure to leave a legacy.
Resource: Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical-surgical nursing: preparation for practice. Upper

Saddle River, NJ: Pearson Prentice Hall.

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

During the initial interview with the pt after asking her if she had children she stated No, I never wanted one when I was
younger, but now I wish I had one- Maybe they could have helped me through this, but at least I have Rick. Also the
body language of the pt after talking about children seem more distant and flat- until moved on to a different subject.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

With the presence of her illness, she has had time to reflect on what she had missed out on in her past. Through this
Hospitalization the pt has come to the realization of not having a legacy and has brought her into stagnation. This may
Influence her next stage in life integrity vs despair.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I think its because of my COPD, I just have a lot of problems with my breathing
What does your illness mean to you?
Its annoying, I feel like I cant get anything done because I cant breath whenever I move around to much

+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?
Yes, I have genital warts
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? ___Yes_______________ If yes, are you in a monogamous relationship?
_____Yes________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease
or an unintended pregnancy? ___None_______________________
How long have you been with your current partner? __2 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?
__God watches out for me ________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
__ I think God is looking out for me right now and making sure I make it through this, so I can get back home
____
______________________________________________________________________________________________________

+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)
I smoke Marlboro
About half a pack a day

Yes
No
For how many years? 44years
(age 16

thru

60

If applicable, when did the

patient quit? N/A

Pack Years: 22
Does anyone in the patients household smoke tobacco? If
so, what, and how much? Yes (Fianc) , Marlboro, pack a day

Has the patient ever tried to quit? Yes

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

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? Beer
How much? One
Volume: 12 oz
Frequency: Daily
If applicable, when did the patient quit? N/A

Yes

No
For how many years?
(age

16 thru

60

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

Is the patient currently using these drugs?

Yes No
N/A

thru

If not, when did he/she quit?

N/A

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?
N/A

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- Pt does not sue
Bathing routine: Once a day
Other:

Be sure to answer the highlighted area

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
1x/day
Routine dentist visit- Pt states that she
has not been to the dentist in over 5 years
Vision screening- Unknown
Other:

Gastrointestinal

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? Unknown
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: Unknown
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 5x/day
Bladder or kidney infections

Hematologic/Oncologic

Metabolic/Endocrine
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? 9/1/2015
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? 2 years ago
menstrual cycle
regular
irregular
menarche
age?
menopause
age? 50 years old
Date of last Mammogram &Result:
Unknown
Date of DEXA Bone Density & Result: U
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?

Other: On this visit

Arthritis
Other:

Chicken Pox
Other:

General Constitution
Recent weight loss or gain- N/A
How many lbs?
Time frame?
Intentional?
How do you view your overall health? Not the best it could be

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? None

University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:
General Survey:
Height: 5 6
Weight: 195
BMI: 31.5
Pain: (include rating and
Unkempt, flat affect, lack Pulse: 75
location)- No pain
Blood Pressure: (include location)
of good hygiene,
Systolic: 142
Respirations: 23
unpleasant odor (tobacco
Diastolic: 56
smoke)
Left arm- radial pulse used
Temperature: (route
SpO2
Is the patient on Room Air or O2
taken?): 97.1
100%
2 liters
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Pt dressed appropriate for setting and temperature, maintains eye contact and had no obvious handicap. However pt is not
well kept/ groomed
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Pt demonstrated a flat affect
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Slurred speech
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
Pt has present of genital warts and small lesions on upper and lower extremities. Small lesion in healing process- no needed
Nursing intervention. Genital warts- medication and perri care (nursing intervention)
Central access device Type: PICC
Location: Right Upper Arm
Fluids infusing?
no
yes - what? Piperacillin, NS

Date inserted: 08/29/2015

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 mm
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: N/A
Comments: N/A
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: D
RLL: D
Labored breathing and demonstrates SOB

Chest expansion

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

University of South Florida College of Nursing Revision September 2014

10

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): Unable to access

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 2+ Carotid: 2+ Brachial: 2+ Radial:2+ Femoral: 2+ Popliteal: 2+ DP: 1 PT: 1 (used Doppler )
No temporal or carotid bruits
Edema: none
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: none
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 / 01 / 2015 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe: Pt has presence of genital warts- Perri area was cleaned and need medication applied
GU
Urine output:
Clear
Cloudy
Color: yellow
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Previous 24 hour output: mLs N/A

without assistance

Musculoskeletal: X Full ROM intact in all extremities without crepitus

Strength bilaterally equal at _4___ RUE ___4___ LUE ___3__ RLE

or

with assistance

& __3___ 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
(unable to walk)
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

2+

Biceps: 2+

Brachioradial: 2+

Patellar: 2+ Achilles: 2+

Ankle clonus: positive negative Babinski: positive negative

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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
WBC:
(Normal: 4.5-11)

Dates
12.8 (09/01/2015)
10.6 (08/31/2015
9.7 (08/30/2015)

Trend
WBC has gradually
increased within the last
week

BUN: 21
(Normal: 825mg/100mL)

21 (09/01/2015)
18 (08/31/2015)
16 (08/30/2015)

BUN has gradually

increased in the last three
labs

Chest X-Ray

08/27/2015

Chest x-ray WNL, beside

mild basal effusions

Analysis
Pt may have an infection,
need to continue to
monitor and keep
physician informed. Also
important to monitor
temperature and look for
signs of infection.
This can be an indication
of the decrease in PTs
renal function- continue
to monitor and inform the
physician if becomes
outside of normal range.
Results demonstrate the
signs of pts COPD
however ruled punctured
or injured lungs.

+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 prescribed piperacillin this will help with any infection that pt has. Pt was on a NPO except medication diet
however was changed to a normal diet today (09/01) passed swallow test., continue to monitor all vitals for
change
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Ineffective breathing pattern related to shortness of breath as evidence by repertory rate of 23 and pallor complexion.
2. Risk for falls related to weakness as evidence by decreased strength in lower and upper extremities.
3. Risk for skin break down related to immobility as evidence by overall weakness and refusal to turn on side.
4. Ineffective individual coping related to decreased social support as evidence by verbalization from patient on coping
mechanisms

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 15 CARE PLAN
Nursing Diagnosis: Ineffective breathing pattern related to shortness of breath as evidence by repertory rate of 23 and pallor complexion.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will be able to efficiently
-Educate patient and family about
-If patient knows the reasoning
- Patient successfully demonstrated
demonstrate at least one breathing
the importance of practicing
behind the breathing technique she both the turn, deep breath and
technique by end of the shift
breathing techniques
is more likely to do the techniques cough technique and the tripod
-Demonstrate the tripod position to - Showing the patient different
position
the patient and have her
types of techniques gives her
-Patient stated that while in the
demonstrate it back to you and
option to choose from
tripod position she get deeper
explain how it help her breathe
- Having the patient show the
breathes
better
techniques back, demonstrates that - Patient stated that she will
-Show patient how to turn, deep
they understand how to do the
practice these techniques as home
breath and cough routine and
technique
when needed.
practice this technique every 2
hours with patient
Patient will be able to ambulate
200 feet with assistance without
experiencing SOB and lack of
oxygen.

Long term goal: Patient will able to

return home and conduct ADLs
without experiencing SOB or
desaturation in oxygen

- Educated the patient on the

importance of ambulating
-Encourage patient to ambulate
with your assistance.
- Assist patient during ambulation
and monitor oxygen levels and
respiratory rate
- Continue to ambulate patient with
assistance
- Continue to educate patient about
importance of breathing techniques
- Monitor how patient is
responding to PT/OT

-Able to see patients base-line

- Able to encourage patient and get
rid of some of their anxiety- see
their improvements
- Mobility allows for blood flow
and peristalsis

- Patient was able to ambulate 120

feet without experiencing SOB
- Patient did not have a rapid
decrease in oxygen levels
-Patient stated that she felt like she
was doing better than before.

-Patient will have decreased

anxiety, because has had practice in
the hospital to ambulate
-Patient will feel comfortable at
home
-If patient does experience SOB,
knows techniques to solve issue

-Patient learned and demonstrated

two breathing techniques
-Patient able to ambulate with
assistance and becoming
increasingly slower to ambulating
w/o assistance and w/o SOB

Ackley, B. J., & Ladwig, G. B.

(2014). Nursing diagnosis
handbook: an evidence-based
guide to planning care. (10th ed.).
Mosby.
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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
XPT/ OT
Pastoral Care
Durable Medical Needs
XF/U appointments
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 individual coping related to decreased social support as evidence by verbalization from patient on coping
mechanisms
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Short term: Patient will be able to
Listen to patient and allow her to
This allows the patient to open up
Patient able to open up, and create
verbalize at least three healthy
tell you and issues she may have
and tell you any issues that she
a trusting relationship with nurse
coping mechanisms by the end of
may be having, which is a healthy
the shift
coping mechanism and builds trust
with the patient
Educate patient about the
Making awareness of healthy and
Patient able to recognize some
difference in healthy and unhealthy unhealthy coping mechanisms
unhealthy coping mechanisms such
coping mechanisms, and why it
allows the patient to be aware of
as smoking tobacco
matters
their actions and choose the
healthier mechanisms
Educate and talk to the family
Allows the family to notice coping Fianc and father interested and
about coping mechanisms and
mechanisms and help family
involved in education
importance of social support
member through difficult time.
Long term: Patient will be able to
Have patient list three healthy
Give the patient the ability to use
Patient able to give three healthy
efficiently cope with the help of
coping mechanisms and ways they healthy coping mechanism in
coping mechanisms and recognize
social support and learned healthy
will try to use them
future issues that they encounter
one of her own unhealthy coping
coping mechanisms
mechanism
Family able to talk with patient and Allows this to be a group
University of South Florida College of Nursing Revision September 2014
14

importance of having social

support educate as group about
the importance

discussion and work together as a

family rather than being alone

Ackley, B. J., & Ladwig, G. B.

(2014). Nursing diagnosis
handbook: an evidence-based
guide to planning care. (10th ed.).
Mosby.
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:
XSS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
XF/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

15

References
1. Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: an evidence-based guide to planning
care. (10th ed.). Mosby.

2. Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical-surgical nursing: preparation for practice. Upper Saddle River, NJ: Pearson
Prentice Hall.

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