UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student:Marieta Perino

PATIENT ASSESSMENT TOOL .

Agency: TGH

1 PATIENT INFORMATION
Patient Initials:
Gender:

MJ

Female

Assignment Date: 10/03/2015

Age: 58

Admission Date: 09/19/2015

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Level of Education: Bachelors degree

Infected postoperative seroma, subsequent

encounter (V 58.89)
Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Teacher

Post-operative infection (998.59)

Number/ages children/siblings: 1 daughter age 27; no siblings

Served/Veteran: N/A

Code Status:

Living Arrangements: Lives in a house in South Tampa with her

husband

Advanced Directives: Yes, she has it.

If no, do they want to fill them out?
Surgery Date: 09/24/2015

Culture/ Ethnicity /Nationality: American/ white

Procedure: Subcutaneous wash-out procedure

Religion: Catholic

Type of Insurance: Medicare

1 CHIEF COMPLAINT: Severe abdominal wall pain and persistently high output from her JP drains.
Redness of the incision along the right breast.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
MJ is a 58 years old female who was seen on 9/21/15 for a post-op check from bilateral TRAM in June 2015. Her postoperative course was complicated by Pyoderma Gangrenosumand a seroma of her abdomen where IR placed a pigtail
drain placed one month ago. She has a PICC from home IV Abx 2/2 positive culture for atypical mycobacterium. She
remains on IV abx per ID recs. She had a recent CT abd/pelvis which demonstrates stranding but no evidence of residual
fluid. She presents today with complains of severe abdominal wall pain and persistently high output from her JP drains.
She has also noticed reddening of the incisions along the right breast and increased redness of her DIEP flap on the right
concerning for recurrent PJ flare. She was admitted through the ER on the 9/21/15.
The pain started on 9/19/2015. It is located in the abdominal wall and along the incisions on her right breast. The pain is
sharp and severe. It hurts more when she moves. The pain level was 10 out of 10 when she was admitted. Currently the
pain level is #4 out of 10; controlled with Hydrocodone and Hydromorphone.
Patient is being treated with IV antibiotics every 12 hours; she has JP drain placed in her abdomen. She is going to
surgery for wash out in 2 days.

University of South Florida College of Nursing Revision August 2013

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation

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
)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Cancer of breast: anastazole (Arimidex) tablet 1nm oral daily
Cellulitis of breast
GERD: pantoprazole (Protonix) EC tablet 40 mg; oral; 2 times daily before meals
Hepatitis A
Hyperlipidemia: simvastatin (Zocor) tablet 2omg oral daily
Migraine: Ibuprofen
Vitamin D deficiency: cholecalciferol (Vitamin D3) 3000 units oral daily

Age (in years)

Date
6/18/2015
6/27/2015
5/26/2015
5/26/2015
5/26/2015
5/26/2015
5/26/2015

Father
Mother

Brother
Sister
Grandmother

relationship
relationship

Comments: Include date of onset

Mothers breast cancer onset was when she was 48 years old.

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)
Adult Tetanus (Date)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

NO

X
X
X
01/15/2015
09/20/2015

University of South Florida College of Nursing Revision August 2013

X
X

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

No known allergies
Medications

Other (food, tape,

latex, dye, etc.)

No known allergies

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)
Post-surgical infections related to breast and axillary surgeries have a low rate of severe complications. Because it is a
peripheral soft tissue organ, many wound complications related to breast procedures are relatively minor and frequently
are managed on an outpatient bases (Ochsner, Mills, Woolverton, 1971, p.395). Studies show that surgical morbidity from
postoperative wound infections, seromas, and hematomas occur in up to 30% of cases. Fewer than half of those cases
require prolonged hospital stay (Sanfelippo, Danielson, 1972, p.421).
Staphylococcal organisms introduced by means of skin flora usually are implicated in those infections. It is proven that
patients undergoing definitive surgery for cancer had a lower risk of wound infections if the diagnosis has been
established prior to needle biopsy rather than an open surgical biopsy (Chen, Gutkin, Bawnik, 1991. p.61). No consistent
correlation between the risk of wound infection and mastectomy.
Use of preoperative antibiotic coverage can minimize the infection rate by 40% or more. A minority of breast wound
infections progress into a fully developed abscess. The pointing, fluctuant, and extremely tender masses of a breast
abscess usually become apparent 1 to 2 weeks postoperatively and occur at the incision site. When there is uncertainty
regarding the diagnosis, ultrasound imaging is helpful. Definitive management of an abscess requires incision and
drainage (Vinton, Traverso, Jolly, 1991, p.584). It can be accomplished by reopening the original surgical wound. When
recurrent cancer is a concern, biopsy of the abscess cavity wall is prudential.

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

Concentration : 650mg

Route: Oral

Dosage Amount: 650mg

Frequency: every 6 hours PRN

Pharmaceutical class: antipyretic

Both

Indication: treatment of mild pain or fever

Side effects/Nursing considerations: agitation, anxiety, headache, fatigue, insomnia, atelectasis, dyspnea, HEPATOTOXICITY, hypokalemia
Name: anastrozole (Arimidex)

Concentration: 1mg

Route: oral

Dosage Amount: 1mg

Frequency: daily

Pharmaceutical class: aromatase inhibitor

Both

Indication: adjuvant treatment for postmenopausal hormone receptor positive early breast cancer
Side effects/Nursing considerations: Myocardial infarction, angina, hypercalcemia, cough, dyspnea, nausea, abdominal pain, rash, sweating
Name: calcium Vitamin D

Concentration: 250 units per tablet

Route: oral

Dosage Amount: 1 tablet

Frequency: daily

Pharmaceutical class: mineral and electrolyte replacement

Both

University of South Florida College of Nursing Revision August 2013

Indication: binds to dietary phosphate to form an insoluble calcium phosphate complex

Side effects/Nursing considerations: headache, arrhythmias, bradycardia
Name: cholecalciferol (Vitamin D3)

Concentration: 3000 units

Route: oral

Dosage Amount: 3000 units

Frequency: daily

Pharmaceutical class: fat soluble vitamins

Both

Indication: prevention of Vitamin D deficiency

Side effects/Nursing considerations: Pancreatitis, vomiting, headache, photophobia, bone pain, muscle pain
Name: clarithromycin (Biaxin)

Concentration: 500mg

Route: oral

Dosage Amount: 500 mg

Frequency: every 12 hours

Pharmaceutical class: macrolides

Hospital

Indication: respiratory tract infections, treatment and prevention of disseminated MAC, treatment of ulcer disease due to Helicobacter pylori
Side effects/Nursing considerations: Torsades De Pointes, Steven-Johnson syndrome, rash, hepatotoxicity, pseudomembranous colitis
Name: dextrose 50%

Concentration: 50 ml

Route: IV

Dosage Amount: 50 ml
Frequency: PRN

Pharmaceutical class: carbohydrates

Hospital

Indication: provides hydration and calories

Side effects/Nursing considerations: inappropriate insulin secretions, glycosuria, hyperglacymia
Name: Hydrocodone acetaminophen

Concentration: 5 325mg per tablet

Route: oral

Dosage Amount: 1 tablet

Frequency: every 6 hours PRN

Pharmaceutical class: opioid agonist nonopioid analgesic combination

Hospital

Indication: management of pain that is severe enough to warrant daily, around the clock, long term opioid treatment
Side effects/Nursing considerations: confusion, dizziness, sedation, headache, blurred vision, urinary retention, sweating
Name: Hydromorphone (Dilaudid)

Concentration: 0.5 mg

Route: IV

Dosage Amount: 0.5 mg

Frequency: every 4 hours PRN

Pharmaceutical class: opioid agonist

Hospital

Indication: antitussive; management of moderate to severe pain

Side effects/Nursing considerations: : confusion, dizziness, sedation, headache, blurred vision, urinary retention, sweating
Name: Lorazepam (Ativan)

Concentration: 1mg

Route: oral

Dosage Amount: 1mg

Frequency

Pharmaceutical class: benzodiazepine

Hospital

Indication: anxiety disorder; preoperative sedation

Side effects/Nursing considerations: apnea, cardiac arrest, blurred vision, respiratory depression, dizziness, drowsiness, lethargy, rash
Name: magnesium-sulfate in dextrose

Concentration: 1g/100ml/h

Route: IV

Dosage Amount: 1g/100ml/h

Frequency: PRN

Pharmaceutical class: minerals electrolytes

Hospital

Indication: treatment/prevention of hypomagnesaemia; treatment of hypertension;

Side effects/Nursing considerations: drowsiness, arrhythmias, bradycardia, muscle weakness, hypothermia, flushinh
Name: Multivitamin

Concentration: 1 tablet

Route: oral

Dosage Amount: 1 tablet

Frequency: daily

Pharmaceutical class: vitamins

Both

Indication: treatment and prevention of vitamin deficiency

Side effects/Nursing considerations: urine discolorations, allergic reactions

University of South Florida College of Nursing Revision August 2013

Name: Ondansetron (Zofran)

Concentration: 40mg

Route: oral

Dosage Amount: 40mg

Frequency: every 6 hours PRN

Pharmaceutical class: antiemetic five ht3 antagonist

Hospital

Indication: prevention of nausea and vomiting

Side effects/Nursing considerations: headache, dizziness, drowsiness, diarrhea, abdominal pain, Torsade De Pointes, extrapyramidal reactions
Name: tigecycline

Concentration: 50mg in sodium chloride 0.9%

Route: IV

Dosage Amount: 50mg:200ml/hour

Frequency: every 12 hours

Pharmaceutical class: glycylcyclines

Hospital

Indication: complicates skin/skin structure infections, complicated intra-abdominal infections

Side effects/Nursing considerations: Steven-Johnson syndrome, pancreatitis, pseudomembranous colitis, dry mouth, hyperglycemia
Name: timolol

Concentration: 0.5 %

Route: eyes

Dosage Amount: 1 drop in both eyes

Frequency: daily

Pharmaceutical class: beta blocker

Both

Indication: hypertension, prevention of MI

Side effects/Nursing considerations: fatigue, weakness, anxiety, arrhythmias, bradycardia, itching, paresthesia

Name: pantoprazole

Concentration: 40mg

Route: oral

Dosage Amount: 40mg

Frequency: 2 times daily before meals

Pharmaceutical class: proton pump inhibitor

Both

Indication: erosive esophagitis associated with GERD;

Side effects/Nursing considerations: headache, pseudomembranous colitis, hyperglycemia, hypomagnesaemia
Name: simvastatin (Zocor)

Concentration: 20mg

Route: oral

Dosage Amount: 20mg

Frequency: daily

Pharmaceutical class: lipid-lowering agent; hmg coa reductase

Both
inhibitor
Indication: management of primary hypercholesterolemia and mixed dyslipidemias
Side effects/Nursing considerations: amnesia, confusion, dizziness, rash, hyperglycemia, rhabdomyolysis
Name: Aspirin

Concentration: 81mg

Route: oral

Dosage Amount: 81mg

Frequency: daily

Pharmaceutical class: antipyretic; nonopioid analgestic; salicylates

Both

Indication: inflammatory disorders Rheumatoid arthritis, Osteoarthritis; mild to moderate pain, fever
Side effects/Nursing considerations: tinnitus, GI bleeding, nausea, abdominal pain, rash, laryngeal edema

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Regular diet
Analysis of home diet (Compare to My Plate and
Diet pt follows at home?
Regular diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patients total intake is about 2000 calories and that is a little
Breakfast: 3 eggs scrambled with cheese, 2 slices whole
too high for her sedentary lifestyle. The diet is too high on
wheat toast, cup berries
saturated fats and sodium. Patient needs to incorporate more
3 eggs (18g protein; 15g fats), 1 serving of cheddar cheese
green leafy vegetable and more fruit in order to increase the fiber
(7g protein, 10 g fats), 2 slices whole wheat toast (6g
in her diet. She would benefit from eating smaller portions and
protein, 5g fat, 24 carbs), cup berries (15g carbs) = 550
more often throughout the day. Her daily diet puts her at high risk
calories
for hypertensive complications.
Lunch: 5 small pork tacos (66g protein; 35g fats; 60g
carbohydrates) = 804

Patients current weight is 88 kg and based on her activity level

her total energy needs are about 1600 1700 calories.
If you are hypertensive, reduce your sodium to 1500 mg a day. In
addition, people who are age 51 and older need to reduce sodium
to 1500 mg a day. All others need to reduce sodium to less than
2300 mg a day.

Dinner: Lasagna (40g protein; 18g fat; 40g carbohydrates)

= 482
Total caloric intake= 1974 calories
Liquids (include alcohol): 2 3 liters of water a day, no
alcohol consumption

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My husband is always here for me and so is my daughter. They are my emotional
support.
How do you generally cope with stress? or What do you do when you are upset? I pray to God and I verbalize my
feelings and emotions to my husband. I also like to meditate and apply breathing techniques to calm me down.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life). I do worry
about all the surgeries I am having and the possible complications, but I try and stay positive for the most part.
+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? __No, I have never felt unsafe._________________
Have you ever been talked down to? I dont recall. Have you ever been hit punched or slapped? : No, never. ___
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? : No, I have
not.
______________ If yes, have you sought help for this? ______________________

University of South Florida College of Nursing Revision August 2013

Are you currently in a safe relationship?

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 X 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:
My patient is 58 years old and that puts her into the Generativity versus Stagnation (40 to 65) stage seven of Eric Eriksons theory of
psychosocial development. According to Youth and Crisis. New York: Norton(1968), during this stage, adults strive to create or
nurture things that will outlast them; often by having children or contributing to positive changes that benefits other people.
Generativity refers to caring for others, creating things and accomplishing things that make the world a better place. Stagnation is the
failure to find a way to contribute. These individuals may feel disconnected or uninvolved with their community and with society as a
whole.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient is in Generativity stage. She feels like she has contributed to the society and her community by being a role model for
the young people and giving them her knowledge she is a teacher. She considers herself a successful parent and is very proud of her
daughter who is a lawyer and also happily married.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
Patient shares that she wasnt surprised when she first got diagnosed with breast cancer because it runs in her family. She has a lot of
emotional support from her family and is trying to keep her spirits up throughout these difficult times. She is anxious about the
surgical complications but she believes that everything will be ok at the end.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
- I believe it has a lot to do with my genetic predisposition to it.
What does your illness mean to you?
-I believe that what doesnt kill us makes us stronger. It means to me that everything that we can overcome in life will
make us better people tomorrow.

+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, I have.__________________________________
Do you prefer women, men or both gender? Men only._____________________________________
Are you aware of ever having a sexually transmitted infections? No, I dont have any STIs._____________________
Have you or a partner ever had an abnormal pap smear?_______ No, I have not.
____
Have you or your partner received the Gardasil (HPV) vaccination?
-_No, we have not._______________________________________
Are you currently sexually active? _No, I am not._____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? - Thirty three years._________________
Have any medical or surgical conditions changed your ability to have sexual activity?
The breast surgeries made our sex life slow down a lot.____
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No I do not.

University of South Florida College of Nursing Revision August 2013

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

What importance does religion or spirituality have in your life?
_I am a spiritual person. I do believe in God. My husband and I go to church. I also like to meditate and feel peaceful at times when
the stress accumulates.
Do your religious beliefs influence your current condition?
No they do not. But my religion helps me overcome and had handle some of the pressure related to the disease process.

+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)
Patient was a cigarette smoker..
1 pack

Yes

No

For how many years? 25 years

(age 20

thru 45

If applicable, when did the

patient quit?
When she was 45 years old.

Pack Years:1 pack daily for 25 years

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

Has the patient ever tried to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
No, patient does not drink alcohol.
What?
How much? (give specific volume)

For how many years?

(age

thru

If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?
No, patient has never used street drugs.
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 I have not.

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
X Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
X Skin infections
Use of sunscreen
SPF:
Bathing routine: patient is currently in
need of assistance with her bathing routine
due to surgical infection
Other:

HEENT
X 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
x/day
Routine dentist visits
x/year
Vision screening
Other: hypertensive pressure on the optic
nerve

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

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction

Appendicitis

Enlarged lymph nodes

Abdominal Abscess
Last colonoscopy?
Other:

Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
X Cancer
Blood Transfusions
Blood type if known: Not known
Other: breast cancer

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 30 ml/h
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?
Other:

Cardiovascular
Hypertension
X 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
X Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? 08/20/2015
menstrual cycle
regular
irregular
menarche
age?
X menopause
age? 53
Date of last Mammogram &Result:
05/05/2015 positive for breast cancer
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
X Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other: occasional migraines treated with
ibuprofen.

Mental Illness
Depression
Schizophrenia
X Anxiety
Bipolar
Other: anxiety related to surgery

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision August 2013

Last EKG screening, when?

Other:

Arthritis
Other:

Chicken Pox
Other:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?

Any other questions or comments that your patient would like you to know?

University of South Florida College of Nursing Revision August 2013

10

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey:

Height: 165 cm

Temperature: (route taken?)

98.1 - oral

Pulse: 74
Respirations:18

Weight: 88 kg
BMI:32.52
Blood 159/84
Pressure:

Pain: (include rating & location)

In abdominal wall current status #3 out
of #10

(include location): left

arm
Is the patient on Room Air or O2: 98% - room air

SpO2: 98% - room air

Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
X 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]
X awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
X clear, crisp diction
Mood and Affect:X pleasant Xcooperative
cheerful
X talkative
quiet
boisterous
flat
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
loud
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
X No rashes, lesions, or deformities
X Nails without clubbing
X Capillary refill < 3 seconds
X Hair evenly distributed, clean, without vermin
Bilateral breast incisions well approximated; pink; redness;
tenderness; warmth; no drainage.
Right lower abdomen collapsible closed device.

Peripheral IV site Type:

Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
X Central access device Type:
PICC line
Location: left arm
Date inserted:
Fluids infusing?
no X yes - what? tigecycline 50mg in sodium chloride 0.9% every 12 hours

09/08/2015

HEENT:X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ X Trachea midline
X Thyroid not enlarged X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge
X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
X PERRLA pupil size / mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmus
X Ears symmetric without lesions or discharge X Whisper test heard: right ear- hearing intact & left ear- hearing intact
X Nose without lesions or discharge X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

University of South Florida College of Nursing Revision August 2013

11

Pulmonary/Thorax:X Respirations regular and unlabored X Transverse to AP ratio 2:1 X Chest expansion symmetric
X Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
X Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

No unusual sputum production.

Cardiovascular: X No lifts, heaves, or thrills PMI felt at: 5th intercostal space midclavicular line
Heart sounds: S1 S2 Regular
X No murmurs, clicks, or adventitious heart sounds
X No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
Patient is not on a heart monitor. No ECG strip available. Patient has a normal sinus rhythm.

X Calf pain bilaterally negative

Apical pulse:
Carotid:
X No temporal or carotid bruits

X Pulses bilaterally equal 3-normal

Brachial:
Radial:
Femoral:
Edema 0-none

Popliteal:

DP:

PT:

X Extremities warm with capillary refill less than 3 seconds

GI/GU: X Bowel sounds active x 4 quadrants; no bruits auscultated
X No organomegaly
X Percussion dull over liver and spleen and tympanic over stomach and intestine
X Abdomen non-tender to palpation
Urine output: X Clear
Color: light yellow
Previous 24 hour output: 730
mLs
Foley Catheter
Urinal or Bedpan X Bathroom Privileges without assistance
CVA punch without rebound tenderness
Last BM: (date 9 /21/2015 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia: X Clean, moist, without discharge, lesions or odor

Other Describe:

X Not assessed, patient alert, oriented, denies problems

Musculoskeletal: X Full ROM intact in all extremities without crepitus

X Strength bilaterally equal at __5_____ RUE _____5__ LUE ____5___ RLE & ____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]

X vertebral column without kyphosis or scoliosis

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

Neurological:X Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
X CN 2-12 grossly intact
X Sensation intact to touch, pain, and vibration
X Rombergs Negative
X Stereognosis, graphesthesia, and proprioception intact X 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:

+2

Biceps:

+2

Brachioradial:

+2

Patellar: +2

Achilles:

+2

Ankle clonus: negative Babinski: 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):

Lab
WBC
4.99
5.94
6.07

HGB
9.1
9
11.9

Dates
(08/18/2015)
(08/19/2015)
(09/22/2015)

(08/18/2015)
(08/19/2015)
(09/22/2015)

HCT
29
28.1
37

(08/18/2015)
(08/19/2015)
(09/22/2015)

NA
140
141
135

(08/18/2015)
(08/19/2015)
(09/22/2015)

K
3.7
4
4.1
CL
108
109
103
CO2
27
25
28

(08/18/2015)
(08/19/2015)
(09/22/2015)
(08/18/2015)
(08/19/2015)
(09/22/2015)
(08/18/2015)
(08/19/2015)
(09/22/2015)

Trend

Analysis

On the very first day the

patients WBC count is lower
than the normal range but after
that it goes up.

The low number of WBC is

indicative for disruption in the
bone marrow function. The
cancer disease is damaging the
bone marrow. The patient is
receiving treatment and the
WBC is going up.

The patients hemoglobin

levels are lower than normal
but are showing an increase.

Low hemoglobin levels may be

indicative for anemia. The
patient is receiving vitamin and
electrolyte treatment.

The patients first lab results

show very low levels of HCT.
Compared to the last reading
when the value is in the normal
range.

The low HCT is indicative for

decreased production of RBC.
The low levels are due to the
cancerous formation in the
patients breast. After the
surgical removal of the
diseased tissue the levels are is
normal range.
Normal levels of sodium
indicative for well balanced
electrolytes and adequate diet.

No indication for
hypernatremia or
hyponatremia

No indication for
hyperkalemia or hypokalemia

Normal levels of potassium are

important for normal heart and
muscle function.

Showing good electrolyte

balance

Patient maintains cellular

integrity via effective osmotic
pressure, water balance, and
acid base balance.

CO2 is in normal range, which

is indicative for normal
respiration and pH balance.

Steady levels of CO2 are

indicative successful
postoperative recovery.

BUN
5
11
14.3
GLU
151
117
110
Creatinine
0.6
0.6
0.7

(08/18/2015)
(08/19/2015)
(09/22/2015)
(08/18/2015)
(08/19/2015)
(09/22/2015)

(08/18/2015)
(08/19/2015)
(09/22/2015)

BUN is low upon initial

admission. On the second
reading its already in normal
range, showing and increase
and stability at the last lab test.
The patients fasting glucose
levels are very high on the first
lab test. The last test is
showing normal values.

Createnin levels are in normal

range

Low BUN is indicative for

liver dysfunction or damage.
Upon assessment liver is
slightly enlarged measuring up
to 23 cm in craniocandial
dimension.
The reason for the high
glucose levels in the patients
blood on the first test may be
medications and stress
induced. The patient is not
diabetic and is not receiving
insulin treatment.
Normal createnin levels are
indicative for normal kidney
function.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
CT abdomen and Pelvis with contrast.
Lab values check prior to surgery.
Monitoring JP drains output from abdomen. Output documented per shift. Trend shows decreased output.

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

1. Infection of abdominal wall and breast incisions related to surgery, as evidenced by high output from JP drain.
2. Acute pain in breast and abdominal wall related to infection of surgical incision.
3. Impaired skin integrity related to surgical incisions.

 15 CARE PLAN
Nursing Diagnosis: Acute pain in breast and abdominal wall related to infection of surgical incision.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Regains integrity of skin surface

1.Individualize plan according to

client's skin condition, needs, and
preferences.
2. Assess site of skin impairment and
determine etiology

Reports any altered sensation or pain

at site of skin impairment

1. Monitor site of skin impairment at

least once a day for color changes,
redness, swelling, warmth, pain, or
other signs of infection. Determine
whether client is experiencing changes
in sensation or pain
2. Monitor client's continence status,
and minimize exposure of skin
impairment and other areas to
moisture from incontinence,
perspiration, or wound drainage.
1.For clients with limited mobility, use
a risk-assessment tool to
systematically assess immobilityrelated risk factors
2. Select a topical treatment that will
maintain a moist wound-healing
environment and that is balanced with
the need to absorb exudate

Demonstrates understanding of plan to

heal skin and prevent reinjury

Describes measures to protect and heal

the skin and to care for any skin lesion

1. Evaluate for use of specialty

mattresses, beds, or devices as
appropriate
2. Implement a written treatment plan

1. Avoid harsh cleansing agents, hot

water, extreme friction or force, or
cleansing too frequently (Panel for the
Prediction and Prevention of Pressure
Ulcers in Adults, 1992).
2. Prior assessment of wound etiology
is critical for proper identification of
nursing interventions (van Rijswijk,
2001).
1. Systematic inspection can identify
impending problems early (Bryant,
1999).

Area with skin integrity issue is

cleansed gently with p h balanced
cleanser. Maintaining adequate skin
hydration. Apply topical skin moisture
barrier.

1. A validated risk-assessment tool

such as the Norton or Braden scale
should be used to identify clients at
risk for immobility-related skin
breakdown (Panel for the Prediction
and Prevention of Pressure Ulcers in
Adults, 1992).
2. Caution should always be taken not
to dry out the wound (Bergstrom et al,
1994).
1. If the goal of care is to keep a client
(e.g., a terminally ill client)
comfortable, turning and repositioning
may not be appropriate. Maintain the

Patient was able to reposition herself

in bed, which eliminates the risk of
developing pressure ulcers.

Protect periwound skin during removal

of dressing. Note exudate or changes
in wound characteristics. Utilize
aseptic technique with dressing
changes. Implement appropriate
transmission precautions. Avoid
unnecessary taping. Inspect all
vulnerable areas when changing
positions.

Dew to intact sensitivity, patient is in

no need of special mattress, bed or
devices. Client is comfortable turning
on her own.

for topical treatment of the site of skin

impairment. A written plan ensures
consistency in care and documentation
(Maklebust, Sieggreen, 1996).
3. Avoid massaging around the site of
skin impairment and over bony
prominences.

head of the bed at the lowest possible

degree of elevation to reduce shear
and friction, and use lift devices,
pillows, foam wedges, and pressurereducing devices in the bed. Evaluate
for the use of specialty mattresses or
beds as appropriate (Krasner,
Rodeheaver, Sibbald, 2001; Panel for
the Prediction and Prevention of
Pressure Ulcers in Adults, 1992;
Wilson, 1994).
2. Topical treatments must be matched
to the client, wound, and setting
(Krasner, Sibbald 1999).
3. Research suggests that massage
may lead to deep-tissue trauma (Panel
for the Prediction and Prevention of
Pressure Ulcers in Adults, 1992).

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 - patient consulted with pastoral care and requested another appointment post-operatively.
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes X No
Rehab/ HH
Palliative Care :
Patient is going to be discharged home as soon as she is stable enough. Her husband is going to take care of her needs.

 15 CARE PLAN
Nursing Diagnosis: Infection of abdominal wall and breast incisions related to surgery, as evidenced by high output from JP drain.
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions
Evaluation of
Achieve Goal
Provide References
Interventions on Day
care is Provided
1. Identify related risk factors and signs
and symptoms.

Screen and restrict visitors with

observed/ reported infections.
Monitor skin integrity. Promote
personal
hygiene.
Promote
pulmonary hygiene.

1.Note and report laboratory values (e.g., white blood cell

count and differential, serum protein, serum albumin, and
cultures).
Laboratory values are correlated with client's history and
physical examination to provide a global view of the client's
immune function and nutritional status and develop an
appropriate plan of care for the diagnosis (Lehmann, 1991).
2.Assess skin for color, moisture, texture, and turgor
(elasticity). Keep accurate, ongoing documentation of
changes.
Preventive skin assessment protocol, including
documentation, assists in the prevention of skin breakdown.
Intact skin is nature's first line of defense against
microorganisms entering the body (Kovach, 1995).
3. Hands should be thoroughly dried with paper towels after
washing.
Bacterial transfer occurs more readily between wet surfaces
than dry ones (Marples, Towers, 1979). More microorganisms
were removed with paper towels than with linen. After use of
hot-air dryers, fecal organisms have been recovered from
hands, and bacterial counts are significantly higher than
when paper towels are used (Gould, 1994b).

1. Patients most current lab

values are within normal range
proving that the infection is
well controlled by the current
antibiotic treatment therapy.
2. Skin is still red and tender
around the incision side on the
right breast.
3. Patient is compliant and
understands hand hygiene
procedure.
4. Nurse and hospital personal
always wash and dry off hands
prior o any contact with the
patient. Always wear gloves
upon dressing change
procedures.

2. Promote/ Optimize nutrition.

Optimize nutritional intake. Avoid

unnecessary restrictions. Monitor
appetite,
intake,
tolerance/
intolerance. Monitor fluid and
electrolyte balance and bowel
elimination
pattern.
Provide
supportive environment and rest
periods as needed. Provide/
encourage oral care.

1. Encourage a balanced diet, emphasizing proteins to feed

1. Patient has no diet

restrictions. Patient has a good
appetite. Regular diet in and
outside the hospital.
2. Patient consumes 2 3 liters
of water a day.

3. Infection resolution

Patient will demonstrate the

desired outcomes by discharge/
transmission of care. Implement
transition based precautions as

the immune system.

Immune function is affected by protein intake (especially
arginine); the balance between omega-6 and omega-3 fatty
acid intake; and adequate amounts of vitamins A, C, and E
and the minerals zinc and iron. A deficiency of these nutrients
puts the client at an increased risk of infection (Lehmann,
1991).
2. Encourage fluid intake.
Fluid intake helps thin secretions and replace fluid lost
during fever (Carlianno, 1999).
1.Assess temperature of neutropenic clients every 4 hours;
report a single temperature of >38.5 C or three temperatures
of >38 C in 24 hours.
Neutropenic clients do not produce an adequate inflammatory

1. Patients temperature is
under 38 C upon last VS
reading.

indicated. Obtain cultures prior to

initiating antimicrobial when
possible. Promptly administer
ordered
antimicrobial
agent.
Provide fever reduction measures.
Identify/ manage signs of early
Sepsis. Signs include temperature
> 38 C or <36 C; HR changes; low
BP; tachypnea; changes in mental
status.

response; therefore fever is usually the first and often the only
sign of infection (Wujcik, 1993).
2. Use an electronic or mercury thermometer to assess
temperature.
When temperature values have important consequences for
treatment decisions, use mercury or electronic thermometers
with established accuracy (Erickson et al, 1996).

References:

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2. Bryant LR, Spencer FC, Trinkle JK. Treatment of median sternotomy infection by mediastinal irrigation with
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3.Chen J, Gutkin Z, Bawnik J. Postoperative infections in breast surgery. J Hosp Infect 1991;
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4. Engelman RM, Williams CD, Gouge TH, Chase RM, Jr, Falk EA, Boyd AD, Reed GE. Mediastinitis
following open-heart surgery. Review of two years' experience. Arch Surg. 1973 Nov;107(5):772778.
5. Jimnez-Martnez M, Argero-Snchez R, Prez-Alvarez JJ, Mina-Castaeda P. Anterior mediastinitis as a
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Jun;67(6):929934. 5. Jurkiewicz MJ, Arnold PG. The omentum: an account of its use in the reconstruction of
the chest wall. Ann Surg. 1977 May;185(5):548554.
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Cardiovasc Surg (Torino) 1972 Sep-Oct;13(5):394399.
Sanfelippo PM, Danielson GK. Complications associated with median sternotomy. J Thorac Cardiovasc
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