UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: David Lepin

MSI & MSII PATIENT ASSESSMENT TOOL . Assignment Date:

1 PATIENT INFORMATION

Agency: Tampa General Hospital

Patient Initials: DK

Age: 59 years old

Admission Date: 02/06/2016

Gender: male

Marital Status: divorced

Primary Medical Diagnosis: Melena

Primary Language: English

Level of Education: High school diploma

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): unemployed

Tachycardia, Anion gap metabolic acidosis

Number/ages children/siblings: 3 children (38, 35, & 35) no

elevated liver enzymes , systemic inflammatory

siblings

response syndrome, thrombocytopenia

Served/Veteran: yes
If yes: Ever deployed? Yes (Vietnam)

Code Status: Full

Living Arrangements: Patient is homeless and occasionally stays at Advanced Directives: No

his daughters house in Tampa, FL when he is feeling ill.
If no, do they want to fill them out? No
Surgery Date: N/A
Procedure: N/A
Culture/ Ethnicity /Nationality: American
Religion: Baptist

Type of Insurance: none

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

 1 CHIEF COMPLAINT:
I have been vomiting really bad.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course
of stay)

59 year old male presented to Tampa General Hospital Emergency Department on 02/06/2016 with complaints of
nausea and vomiting for 2 days, and on/off melena for 1 week. Nausea and vomiting started around 7 in the morning on
the day prior to admission. The patient then began experiencing 3/10 sharp pain in upper quadrants of abdomen. The
pain was intermittent, following each episode of emesis, and lasted about 15-20 minutes when present. The patient
indicates that Tylenol was the only intervention attempted, and did not help with pain. The patient states I had
Mexican food the night before, but I felt fine after I ate. Melena started about 1 week ago. The patient also experienced
one episode of diarrhea, which was the deciding factor in admission to ED. The patient denied any pain or difficulty
with bowel movements. No fever. According to the patient, other than color, bowel movements have remained normal.
Upon admission in the ED the patient was hypertensive and tachycardic. Intravenous fluids and Zosyn were
administered. Blood pressure improved, but the patient remained tachycardic. A computerized tomography scan of
abdomen and chest revealed esophagitis, duodenitis, and thickening of descending and sigmoid colon. The patient does
drink alcohol (4 packs of beer for 30 years) and has history of Hepatitis C. He denied any history of tobacco use. He
reported heroin use, but quit 20 years ago.The patient was then admitted to the Medical Intensive Care Unit for risk for
Systemic Inflammatory Response Syndrome (SIRS). In the ICU Cipro and Flagyl were given IV. Also continuous
proton pump inhibitor therapy was started for melena. Urinalysis revealed ketones in urine. An electrocardiogram test
was ordered and troponin levels were negative. The patient was then admitted to Trauma Surgery Unit this morning
(02/09/2016) to await esophagogastroduodenoscopy (EGD). The EGD was reordered for tomorrow because of positive
trace of cocaine in urine. The patient is currently ambulatory and awaiting EGD for tomorrow. No emesis or melena
since admission. Patient denied any history of blood in emesis. The patient is still nauseous and experiencing 7/10 pain
in abdomen and from chronic lower back pain from 20 years ago when he fell from a two-story building. Zofran and
Norco help with nausea and pain. Fecal Occult Blood test was accomplished today, and the results are still pending.

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

Operation or Illness

2014

Hypertension (The patient is not taking any medications or following up regularly with a provider
to manage blood pressure. Blood pressure remains above recommended levels.)

2014

Hepatitis C (The patient does not see a provider for this medical condition, or take any
medication.)

2014

Right elbow repair (The patient received surgery to repair inflamed tendon in right elbow.)

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

2
FAMILY
MEDICA
L
HISTOR
Y

Ag
e
(in
ye
ars
)

Cause
of
Death
(if
applicable
)

Father

78

Myocardia
l
infarction

Mother

78

Myocardia
l
infarction

Al
co
hol
is
m

Env
iron
men
tal
Alle
rgie
s

A
ne Art As
m hri th
ia tis ma

Bl
ee
ds
Ea
sil
y

Ca
nc
er

Di
ab
ete
s

Hea
rt
H
Tro
yp
Gl
G
uble
er
au
ou
(angi
te
co
t
na,
ns
ma
MI,
io
DVT
n

Kid
ney
Pro
ble
ms

etc.)

Me
nta
l
Sto
He
ma
alt Sei ch Stro
zur Ul ke
h
Pr es cer
obl
s
em
s

Tu
mor

Brother
Sister
relationship
relationship
relationship

Comments: Include age of onset

The patient is unaware of the age of onset for his parents medical conditions.

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

NO
U

Adult Diphtheria (Date)

Adult Tetanus (Date) Is within 10 years?

Influenza (flu) (Date) Is within 1 years?

Pneumococcal (pneumonia) (Date) Is within 5 years?

Have you had any other vaccines given for international travel or
occupational purposes? Please List U (The patient joined the Army in
1973 and got discharged in 1977. He indicates that he received
routine immunizations, but he does not know specifically which
ones.
If yes: give date, can state U for the patient not knowing date received
!3
University of South Florida College of Nursing Revision September 2014

 1 ALLERGIES

OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKDA

Medications

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

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)
Gastrointestinal bleeding is bleeding that occurs anywhere in the gastrointestinal tract. The gastrointestinal tract
includes the esophagus, stomach, small intestine, colon, and anus. There are multiple factors that can cause bleeding in
the gastrointestinal tract like esophageal varices, ulcers, cancer, hemorrhoids, etc. Gastrointestinal bleeding is divided
into upper and lower bleeding. Upper gastrointestinal bleeding is bleeding in the esophagus, stomach, or duodenum,
and is characterized by frank, bright red bleeding or dark, grainy digested blood (coffee ground) that has been affected
by stomach acids (Huether & McCance, 2012, p. 896). Lower gastrointestinal bleeding occurs anywhere from the
jejunum of small intestine to the anus. Symptoms of a gastrointestinal bleed include bloody stools, diarrhea, nausea,
vomiting, blood in emesis, and abdominal pain. An EGD is the most accurate mechanism of locating and diagnosing a
bleed in the gastrointestinal tract. A fecal occult blood test can also help identify undetected traces of blood in the
patients stool. Depending on the nature of the bleed gastrointestinal bleeding can be treated with surgery or
medications that help treat the cause of the bleed, like Proton Pump Inhibitors for peptic ulcers. The nature of the bleed
and the extent of blood loss determine the prognosis. Sometimes patients can visit their provider and receive
medications that they can take home with them, while others may have to be admitted to the hospital to receive fluid
resuscitation.
This patient in particular was experiencing melena, or dark tarry stools. He was also tachycardic and hypertensive upon
admission, which may have been a result of compensatory measures the body initiates for blood loss. An EGD has not
been done yet, and the fecal occult blood test is still pending. The patient reports that stool is now dark brown. The
patient has a history of alcohol abuse, and uses non steroidal anti-inflammatory drugs for chronic lower back pain that
started 20 years ago. Prolonged use of these drugs limit the mucosal barrier that protects the lining of the stomach, and
increased alcohol consumption erodes the stomach resulting in an ulcer. This ulcer can extend through the muscle layer
of the stomach and damage blood vessels to cause bleeding and a perforation (p. 904). As the blood is digested and
moves along the gastrointestinal tract, it is excreted bound to the patients stool.

!4
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 lorazepam (Ativan)

Concentration 0.5mg/tablet

Route Oral

Dosage Amount 1mg

Frequency twice daily

Pharmaceutical class benzodiazepine

Home

Hospital

or

(X)Both

Indication manage anxiety

Adverse/ Side effects agranulocytosis, diarrhea, bradycardia, dizziness, libido decrease, nausea, seizures, thrombocytopenia, dependence
Nursing considerations/ Patient Teaching Do not discontinue abruptly, pre-existing depression may emerge, do not drive or operate heavy machinery

Name ondansetron (Zofran)

Concentration 2mg/mL

Route IV

Dosage Amount 4mg

Frequency every 4 hours PRN

Pharmaceutical class serotonin-receptor antagonist

Home

(X)Hospital

or

Both

Indication to prevent and treat nausea

Adverse/ Side effects agitation, drowsiness, dizziness, diarrhea, constipation, urinary retention
Nursing considerations/ Patient Teaching should be used in caution because of Hepatitis C

Name Hydrocodone-acetaminophen (Norco)

Concentration 5mg hydrocodone, 325

acetaminophen/tablet

Route oral

Dosage Amount 5mg hydrocodone-325mg

acetaminophen

Frequency every 6 hours PRN

Pharmaceutical class analgesic

Home

(X)Hospital

or

Both

Indication moderate to severe pain

Adverse/ Side effects constipation, respiratory depression, physiological dependence
Nursing considerations/ Patient Teaching abrupt discontinuation can result in withdrawal symptoms, use cautiously with GI disease

Name pantoprazole (Protonix)

Concentration 4mg/mL

Route IV

Dosage Amount 40 mg

Frequency twice daily

Pharmaceutical class laxative

Home

(X)Hospital

or

Both

Indication gastric hypersecretion

Adverse/ Side effects C difficile diarrhea, abdominal pain, diarrhea, stevens-johnson syndrome
Nursing considerations/ Patient Teaching advise patient to report signs/symptoms of hypomagnesemia, may cause fever, rash , and diarrhea

!5
University of South Florida College of Nursing Revision September 2014

Name folic acid

Concentration 1mg/tablet

Route Oral

Dosage Amount 1mg

Frequency once daily

Pharmaceutical class water-soluble vitamin

Home

Hospital

or

(X)Both

Indication nutritional supplementation

Adverse/ Side effects bad taste in mouth, nausea, confusion, irritability
Nursing considerations/ Patient Teaching: this drug may cause loss of appetite, and sleep pattern disturbances. Do not take with alcohol

Name thiamine (vitamin B1)

Concentration 100mg/tablet

Route oral

Dosage Amount 100mg

Frequency once daily

Pharmaceutical class water-soluble vitamin

Home

Hospital

or

(X) Both

Indication thiamine deficiency related to alcohol consumption

Adverse/ Side effects:
Nursing considerations/ Patient Teaching: take with meal

Name

Concentration

Route

Dosage Amount
Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name

Concentration

Route

Dosage Amount
Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name

Concentration

Route

Dosage Amount
Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

!6
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? soft diet

Analysis of home diet (Compare to My Plate and

Diet patient follows at home? regular diet

Consider co-morbidities and cultural considerations):

24 HR average home diet: regular diet

According to choosemyplate.gov, this patient does not

consume the daily recommended amount of calories. This
patient does not consume enough vegetables, fruits, or
protein. choosemyplate.gov recommends two and a half
cups of vegetables and two cups of fruit a day. This patient
rarely eats fruit, and is missing about another cup of
vegetables a day. He exceeds the recommended daily
amount of grains. A large portion of his diet consists of
added sugars, saturated fats, and sodium. This patient has
already been diagnosed with hypertension, and the large
amount of sodium he consumes is only going to increase
his blood pressure. Prolonged consumption of a generous
amount of added sugars in a persons diet can lead to over
stimulation of pancreas, and in turn, Type II Diabetes. The
patient has been diagnosed with Hepatitis C, and alcohol
abuse will exacerbate the unhealthy condition of his liver.
The patient may even develop cirrhosis in the near future.
The patient states I eat whatever I can get my hands on.
Given the state of his living conditions it is not easy to
choose what he wants to eat. He does not follow up with a
primary care provider, and does not take any medications.
His daily exercise consists of walking 3-4 miles a day.

Breakfast: 1 cup of cereal

Lunch: 1 Hamburger with tomato and ketchup.

Dinner: 1 bologna and cheese sandwich

Snacks: 1 bag of Cheetos

Liquids (include alcohol): 1 cup of whole milk, 24 fl oz of

soft drink, 288 fl oz of beer

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

Use this link for the nutritional analysis by comparing the

patients 24 HR average home diet to the recommended portions,
and use My Plate as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
The patient reports that he goes to his daughters house here in Tampa when he is feeling ill. He does not keep in
contact with any other members of his family.
How do you generally cope with stress? or What do you do when you are upset?
The patient usually turns to alcohol when he is under stress. He stopped using heroin 20 years ago and denies any other
use of recreational drugs. The patient denies any depression or thoughts of homicide or suicide. When the patient is
under stress he also tries to find work to get his mind of off things. Sometimes he goes and visits his daughter if they are
on good terms.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The patient reports that he feels anxious. He is curious to find out what is the nature of his illness. He does not want to
stay here in the hospital anymore. The patient does not believe that he needs to form any other relationships. The patient
reports that he communicates with his daughter at least twice a month. Sometimes he feels like a burden and likes to
just manage things on his own.

!8
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?

________No_______________________________________________

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?
_______No_______________

Are you currently in a safe relationship? No

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust

Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority
Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation (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: 40 - 64 years old Generativity vs self absorption/stagnation. Generativity is the process of guiding the next
generation, or improving the whole of society. Stagnation occurs when development ceases: A stagnant middle adult cannot guide
the next generation or contribute to society (Treas, 2014, p. 190).

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

The generativity vs self absorption/stagnation stage of psychosocial development is the stage in which middle adults are
transitioning to older adulthood. In this transition stage middle adults are preparing the future generations for adulthood,
or remaining stagnant and trying to find their role in society. This is the stage where many people experience midlife
crises. This patient in particular is in the stagnation stage. He feels like he does not contribute to society, and is just a
burden for his daughter. He does not keep in contact with his two sons, or anyone else in his family. He results to
alcohol when he faces an issue. He has expressed a want to quit, but continues to struggle despite professional help.
This patient recognizes that he has been neglecting his health, but indicates that interventining right now would be
ineffective.

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

This condition and hospitalization has only contributed to the patients developmental stage in a negative way. The
patient denies any depression but is not satisfied with the current status of his life. This condition is only a reminder of
poor life choices. The patient reflects back on his past and wishes that circumstances were different. This patient feels
like his chronic back pain has kept him out of work, which has had the greatest impact on his current stage in life. He
does not feel like a role model to his daughter or grandchildren.

!9
University of South Florida College of Nursing Revision September 2014

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The patient believes that self-neglect and poor life choices are the cause of this illness.

What does your illness mean to you?

To the patient this illness is an annoyance. He is curious to see what the results will reveal, but believes that this is all a
result of decisions he has made in his past. The patient indicates that his future is in Gods hand. He does not see the
need to intervene if he has no control over the future.

+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?
___________________________women__________________________________
Are you aware of ever having a sexually transmitted
infection? ___________________________no____________________
Have you or a partner ever had an abnormal pap smear?_______________________________N/A
______________________
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? ___________No_________ When sexually active, what measures do you take to prevent acquiring a
sexually transmitted disease or an unintended pregnancy? _______The patient reports that he does not take any
measure to prevent acquiring a sexually transmitted disease or unintended pregnancy. ___________________________

How long have you been with your current partner?____________________________N/A

____________________________

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

!10
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?

___The patient is a Baptist. This patient does not avidly attend a church, but does occasionally engage in prayer. Religion is not the
most important thing in this patients life, but it does take a high priority.
___________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
___The patient reports that he is hopeful, but it is hard to stay positive. The patient reports that he has wondered if he is being tested
by God or even punished in some way.
___________________________________________________________________________________________________
______________________________________________________________________________________________________

+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)

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?

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? beer

Yes

How much? 4 6-packs a day

For how many years? 30

Volume: 288 fl oz

(age 29

thru

59

Frequency: daily
If applicable, when did the patient quit? N/A

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?

Yes

If so, what? Heroin, cocaine

Is the patient currently using these drugs?

Yes

How much?

For how many years?

(declined to answer)

(age 37
cocaine)

thru

39

) (currenlty using

If not, when did he/she quit?

Quit Heroin 20 years ago.

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

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
The patient is homeless here in Tampa and is exposed to many environmental hazards like prolonged sun exposure,
unsanitary/unsafe living conditions, etc. The patient also engages in unprotected sexual intercourse with different
women.

5. For Veterans: Have you had any kind of service related exposure?
The patient was deployed to Vietnam in 1977 and was exposed to gunfire, grenades,and mines. The patient reports that
there were also insects that posed a risk to his health. There were multiple days of increased sun exposure. The patient
was also exposed to second-hand smoke from other soldiers. The patient can recall several occurrences when he could
not shower or change his clothing/gear.

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

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea (X)

Chills with severe shaking

Integumentary

Constipation

Irritable Bowel

Night sweats

Changes in appearance of skin (X)

GERD

Cholecystitis

Fever

Problems with nails

Indigestion (X)

Dandruff (X)

Hemorrhoids

Psoriasis

Yellow jaundice Hepatitis (X)

Rheumatoid Arthritis

Hives or rashes

Pancreatitis

Sarcoidosis

Skin infections

Colitis (X)

Tumor

Diverticulitis

Life threatening allergic reaction

Bathing routine: usually bathes at his

daughters house 5-7 times a week

Appendicitis

Enlarged lymph nodes

Other:

Abdominal Abscess

Other:

Be sure to answer the highlighted area

Last colonoscopy? N/A

HEENT

Other:

Hematologic/Oncologic

Difficulty seeing

Genitourinary

Anemia

Cataracts or Glaucoma

nocturia

Bleeds easily

Difficulty hearing (X)

dysuria

Bruises easily

Ear infections

hematuria

Cancer

Sinus pain or infections

polyuria

Blood Transfusions

Nose bleeds

kidney stones

Blood type if known: O positive

Post-nasal drip

Normal frequency of urination:

day

Oral/pharyngeal infection

Bladder or kidney infections

Use of sunscreen N/A

SPF:

Gastritis / Ulcers
Blood in the stool (X)

Lupus

Other:

Metabolic/Endocrine

Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening

3-4/

HIV or AIDS

1/day

Diabetes

0/year

Type:

Hypothyroid /Hyperthyroid

unknown

Intolerance to hot or cold

Other:

Osteoporosis
Other:

Pulmonary
Central Nervous System

Difficulty Breathing
Cough - dry (X)
Asthma

WOMEN ONLY
Infection of the female genitalia

CVA
Dizziness

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

Bronchitis

Monthly self breast exam

Severe Headaches

Emphysema

Frequency of pap/pelvic exam

Migraines

Pneumonia

Date of last gyn exam?

Seizures

Tuberculosis

menstrual cycle

Environmental allergies

menarche

age?

Encephalitis

last CXR? 02/06/2016

menopause

age?

Meningitis

Other:

Date of last Mammogram &Result:

regular

irregular

Ticks or Tremors

Other:

Date of DEXA Bone Density & Result:

Cardiovascular

MEN ONLY

Mental Illness

Hypertension (X) diagnosed 2014

Infection of male genitalia/prostate? none

Depression

Hyperlipidemia

Frequency of prostate exam? N/A

Schizophrenia

Chest pain / Angina

Date of last prostate exam? N/A

Anxiety (X) not diagnosed

Myocardial Infarction

BPH N/A

Bipolar

CAD/PVD

Urinary Retention N/A

Other:

CHF

Musculoskeletal

Murmur

Injuries or Fractures Lower back

herniated disk 1986, Right elbow 2014

Childhood Diseases

Thrombus

Weakness

Measles

Rheumatic Fever

Pain (X) lower back, constant dull ache

Mumps

Myocarditis

Gout

Polio

Arrhythmias

Osteomyelitis

Scarlet Fever

Last EKG screening, when? 02/06/2016

Arthritis

Chicken Pox

Other:

Other:

Other:

General Constitution
Recent weight loss or gain: gain
How many lbs? 5 lbs
Time frame?2 days
Intentional? yes (As a result of medical interventions. The patient does not know what his weight was before admission, but has
gained 5 lbs since.)
How do you view your overall health? could be better

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No

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

Any other questions or comments that your patient would like you to know?
No

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

10 PHYSICAL EXAMINATION:
General Survey:Height 167.6 cm Weight 60.6 kg BMI 22% Pain: (7/10 in upper quadrants of abdomen and lower back)
Pulse 87
Blood Pressure: (133/91 right arm)
Respirations 18
Temperature: (oral) 98.5
SpO2 98% Is the patient on Room Air or O2 room air
Overall Appearance:
hair is sweaty and matted, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps,
no facial hair

Overall Behavior:
awake, interacts well with others, judgment intact, anxious

Speech:
clear, crisp diction

Mood and Affect:

cooperative,

quiet,

flat,

anxious

Other:
Integumentary
(X)Skin is warm, dry, and intact
(X)Nails without clubbing

(X)Skin turgor elastic

(X)No rashes, lesions, or deformities

(X)Capillary refill < 3 seconds

Hair evenly distributed, clean, without vermin

(Hair appears sweaty and matted. Skin is very dry)

Central access device N/A Type:

Location:

Date inserted:

Fluids infusing? yes 0.9 NaCL 75 mL/hr , peripheral IV left metacarpal vein, 20 gauge

HEENT: (X)Facial features symmetric

midline
(X)Thyroid not enlarged

(X)No pain in sinus region (X)No pain, clicking of TMJ

(X) No palpable lymph nodes

(X)Trachea

(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 3mm bilateral (X)Peripheral vision intact (X)EOM intact through 6 cardinal fields without
nystagmus
(X)Ears symmetric without lesions or discharge
(X)Nose without lesions or discharge
lesions

(X)Whisper test heard: right ear-

24

inches & left ear-

24

inches

(X)Lips, buccal mucosa, floor of mouth, & tongue pink & moist without

Dentition: normal, teeth in tact with slight decay/erosion

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

Comments:
Pulmonary/Thorax: (X)Respirations regular and unlabored
symmetric

(X)Transverse to AP ratio 2:1 (X)Chest expansion

(X)Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: N/A
Color: white

pale yellow

Amount: scant small

yellow dark yellow green

moderate large
gray

light tan brown

red

Lung sounds:
RUL

CL

RML

CL

RLL

CL

LUL CL
LLL CL

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

!17
University of South Florida College of Nursing Revision September 2014

Cardiovascular: (X)No lifts, heaves, or thrills

Heart sounds: (X) S1 S2 audible (X)Regular Irregular (X)No murmurs, clicks, or adventitious heart sounds (X)No
JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
(X)Calf pain bilaterally negative
(X)Pulses bilaterally equal [3-normal]
Apical pulse: 2+ (normal) Carotid: 2+ (normal) Brachial: 2+ (normal) Radial: 2+ (normal) Femoral: 2+ (normal)
Popliteal: 2+ (normal) DP: 2+ (normal) PT: 2+ (normal)
(X)No temporal or carotid bruits
Edema: 0 none
Location of edema: N/A
(X)Extremities warm with capillary refill less than 3 seconds
GI
(X) Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion tender over liver and spleen and tympanic over stomach and intestine
Abdomen tender to palpation on
bilateral upper quadrants
Last BM: (date 02 / 09
/ 16
)
Formed
Color: Dark Brown
Nausea emesis Describe if present: N/A
Genitalia: Clean, moist, without discharge, lesions or odor
(X)Not assessed, patient alert, oriented, denies problems
Other Describe:
GU

Urine output: 300 mL Clear

assistance
(X)CVA punch

Color: yellow Previous 24 hour output: N/A Bathroom Privileges without

without rebound tenderness

Musculoskeletal: (X) Full ROM intact in all extremities without crepitus

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 paresthesia

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
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:

Biceps: 3

Brachioradial:

Patellar:

Achilles: 3

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):
!18
University of South Florida College of Nursing Revision September 2014

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

Trend

Analysis

lipase

02/06, 02/07

107, 36

Lipase levels were 107 upon

admission, and have decreased to 36
presumably because of decreased
alcohol consumption.
.
Anion gap results were 29, 13, and
9 respectively. Metabolic acidosis
was diagnosed upon admission,
and now results are within normal
limits. Normal limits are 5-13 at
TGH.
Potassium levels are within
normal limits.
Ketones in urine were greater than
79 due to in metabolic acidosis.

anion gap

02/06, 02/07, 02/08

29, 13, 9

potassium

02/06, 02/07, 02/08

3.9,3.8.3.9

urine

02/06

>79

hemoglobin

02/06, 02/07, 02/08

13.8,10.3,12.0

platelets

02/06,02/07,02/08

137,79,80

white blood cell

02/06,02/07,02/08

Stool culture

11.78,5.78,5.58

(I would expect)

EGD
chest/abdomen CT

Fecal Occult Blood Test

scheduled for 02/10/16

02/06

02/09 (pending)

Hemoglobin is decreasing due to

possible GI bleed. 12.0 is low.
Platelets are elevated, but were
higher upon admission due to
GI bleed.
WBC were initially presumably
because SIRS or infection.
Patient had complaints of nausea
vomiting, and high WBC count.
Stool culture could help identify the
pathogen.
.
.
Esophagitis, duodenitis, and
thickening of descending and
sigmoid colon.
This will help determine if there is
still blood located in stool.
.

!19
University of South Florida College of Nursing Revision September 2014

+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.)
GI consult. EGD is scheduled for 02/10/2016 dependent on negative U/A for cocaine. Patient is currently on
soft diet, NPO after midnight. Fecal Occult blood test was sent this morning and pending. Patient is
independent with bathroom privileges. Pain and nausea are being managed with PRN medications. Vitals are
checked every 4 hours for withdrawal symptoms. Ativan taper is ordered for withdrawal symptoms and
anxiety.

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

1. Self neglect r/t effects of alcohol abuse as evidenced by poor self-care management.
2. Fear r/t presence of blood in feces as evidenced by melena.
3. Risk for imbalanced fluid volume: Risk factors: decreased intake, loss of fluids with vomiting.
4.
5.

!20
University of South Florida College of Nursing Revision September 2014

 15 CARE PLAN
Nursing Diagnosis: Fear r/t presence of blood in feces as evidenced by melena
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal

Rationale for
Interventions
Provide References

Evaluation of Goal on
Day Care is Provided

1. Establishing trust will

help patient confide in
nurse and reduce
anxiety.
2. Expressing fear in
narrative form will
help make sense of
illness.
3. Addressing underlying
feelings may help with
unresolved conflicts.

1. Patient verbalized that

being in a hospital
makes him uneasy. He
is also anxious about
his health.
2. Patient verbalized that
he feels like he is
alone, and has no one
outside the hospital
that will help him.

Patient will verbalize

known fears.

1. Establish trust with

patient so fears can be
stated.
2. Encourage patient to
express fear in
narrative form.
3. Encourage patient to
explore underlying
feelings that may be
contributing to fear.

Patient will state accurate

information bout the
situation.

1. Discuss the situation

1. Distinguishing between 1. Patient confirmed that
with the patient and
real and imagined
he is aware that fear
help distinguish
threats to well-being
has sprouted from
between real and
will help reduce
worry.
imagined threats to
extraneous fear.
well-being.
2. Fear may be a result of
disorientation or
2. Monitor for dementia
and use appropriate
impaired reality.
interventions.
3. Highlighting the
importance of the
3. If irrational thoughts or
fears are present, offer
meaning of events to
the client accurate
the patient is an
information and
important factor in
encourage him or her
helping the patient
to talk about the
identify what makes
meaning of the events
him anxious.
contributing to anxiety.

!21
University of South Florida College of Nursing Revision September 2014

Patient will identify,

1. Explore coping skills
verbalize, and
previously used by the
demonstrate those coping
patient to deal with
behaviors that reduce own
fear.
fear.
2. Suggest yoga to the
patient.
3. Provide client with a
means to listen to
music of their choice.

1. This will help reinforce 1. Patient was given

past successful coping
headphones to listen to
mechanisms.
music, and confirmed
that it helps keep him
2. Studies have supported
the benefits of yoga as
distracted.
an effective modality
2. Patient indicated that
for reducing anxiety.
medication has helped
lower heart rate and
3. Music listening
reduces anxiety and
anxiety levels.
pain.

Nursing Diagnosis: Risk for imbalanced fluid volumes: Risk factors: decreased, loss of fluids with vomiting

Patient Goals/Outcomes Nursing Interventions to

Achieve Goal

Rationale for
Interventions
Provide References

1. Monitor intake and

Patient will maintain
elastic skin turgor; moist
output every shift.
2. Check skin turgor over
tongue and mucous
membranes; orientation to
boney prominences.
person, place, and time.

1. Checking intake and

output will help assess
fluid volume
maintenance.
2. Tenting of skin
indicates dehydration.

Evaluation of Goal on
Day Care is Provided
1. Patient is oriented to
person, time, and
place.
2. Mucous membranes
are pink and moist.
3. No tenting in skin
turgor.

1. Maintenance of oral
1. NPO diet has been
Explain measures that can 1. Provide oral
be taken to treat or
replacement therapy as
intake aides absorption
discontinued and
prevent fluid volume loss.
ordered and tolerated
of nutrients in
patient is eating and
with hypotonic
intestines.
drinking again.
2.
2.
glucose-electrolyte
Antidiarrheals and
Patient confirmed that
solution when the
antiemetics will help
he has not vomited in 1
patient has acute
avoid fluid loss.
day.
diarrhea or nausea/
vomiting.
2. Administer
antidiarrheals and
antiemetics as ordered.

!22
University of South Florida College of Nursing Revision September 2014

Describe symptoms that

indicate the need to
consult with the health
care provider.

1. Assess for early signs

of hypovolemia,
including thirst,
restlessness,
headaches, and
difficulty
concentrating.
2. Note the color of urine
and specific gravity.

1. Thirst, restlessness,
1. Patient denied any
headaches, and
headache or dizziness.
difficulty concentrating 2. Urine is pale and
may indicate
yellow.
deficiency in fluid
volume.
2. Dark-colored urine and
increased specific
gravity may indicate
fluid deficit.

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

!23
University of South Florida College of Nursing Revision September 2014

References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care. Maryland Heights, MO: Elsevier.
Clinical Pharmacology. (2016). retrieved February 18, 2016, from
http://www.clinicalpharmacology-ip.com.ezproxy.hsc.edu/default.aspx

Food Tracker. (2016). Retrieved February 18, 2016, from https://www.supertracker.usda.gov/foodtracker.aspx

Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (5th ed.). St. Louis, Mo:
Elsevier
Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning. Philadelphia, PA: F.A.
Davis Company.

!24
University of South Florida College of Nursing Revision September 2014