UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kristine Martin

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

H.P.
M

Assignment Date: 9/25/15

Agency: TGH UD

Age: 82

Admission Date:7/22/15

Marital Status: Married (52 yrs)

Primary Medical Diagnosis: Hemorrhagic lesion to

the right frontal lobe

Primary Language: English

Level of Education: Some college

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Entrepreneur

Number/ages children/siblings: 1 son (47yrs)

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

Code Status: Full

Living Arrangements: Lives with his wife; wife states their house is
arranged for him to move around safely including hand rails and
devices to help him lift out of bed.

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: 7/23/15 Procedure: tracheostomy

Culture/ Ethnicity /Nationality: German/Irish

Religion: Catholic

Type of Insurance: Private

1 CHIEF COMPLAINT: Left sided weakness as a result of a hemorrhagic lesion to the right frontal lobe

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient began feeling excessively lethargic and experiencing left sided facial droop and difficultly looking left. Patient was
taken to Florida Hospital of Tampa where he was treated for stroke and discharged. Patients wife claimed her husband
was not himself the following day and decided to bring him to TGH where he was admitted on 7/22/15. CT of patients
head revealed a right frontal lobe hemorrhagic lesion. Patient has tracheostomy in place and was producing thick white
secretions upon coughing, after which he or his wife would suction the tube. Patient has no complaints of pain. History of
DM2, HTN, atrial fibrillation, CHF, respiratory failure and anemia.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
N/A
N/A
6/5/12, 7/23/15
2012
12/4/12
12/4/12
4/23/12
7/6/15

Father
Mother
Brother

~8
0
~7
5
77

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

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Appendectomy
Tonsillectomy
Tracheostomy
Biopsy of skin on scalp (benign)
Cervical fusion
Cervical Laminectomy
Laminectomy
Panendoscopy

Unsure
MI

Sister
relationship
relationship
relationship

Comments: Brother had asthma since he was young, Mother had DM/HTN as long as he can remember, Father was diagnosed with
skin cancer ~50 y.o.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U
Adult Tetanus (Date) Is within 10 years? Yes
Influenza (flu) (Date) Is within 1 years? Yes
Pneumococcal (pneumonia) (Date) Is within 5 years? Yes
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

No known
allergies
Medications

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
After presenting to the hospital with stroke-like symptoms, Mr. P was diagnosed with a hemorrhagic lesion to the right
frontal lobe following a CT scan revealing a mass. Although he and his wife are uncertain of the cause, they believe it
may be attributed to a recent fall. A subdural hematoma is defined as bleeding between the dura and arachnoid layer of the
meninges and is the most common type of intracranial lesion, most commonly caused by tearing of the bridging veins
across the surface of the brain (Osborn, 2014). This subdural hematoma is classified as chronic, as it took several weeks
for the symptoms to appear. Subdural hematomas result from a venous source of blood, thus the blood is slowly building
up and does not cause symptoms until the mass is large enough to exert pressure on an area of the brain. In older adults
this may take longer, as their intracranial space is larger due to their atrophied brain tissue. A CT scan is the most accurate
diagnostic tool. Treatment depends on the size of the hemorrhage as well as degree of neurologic impairment. Small
lesions causing no impairment may be left for the body to reabsorb with close medical management. Larger SDH with
significant neurologic impairment require surgical evacuation. In both cases the use antiepileptic drugs may be warranted
as seizures are a common occurrence in SDH. With proper, timely treatment patients are expected to make a full recovery.

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

Concentration: tablet

Route: oral

Dosage Amount: 81 mg
Frequency: once daily

Pharmaceutical class: salicylates

Home

Hospital

or

Both

Indication: prophylaxis
Adverse/ Side effects: GI bleeding, dyspepsia, epigastric distress, nausea, abdominal pain, anorexia, hepatotoxicity, vomiting, anemia, hemolysis, and allergic
reaction
Nursing considerations/ Patient Teaching: take with a full glass of water and remain in an upright position for 1530 min after administration.
report tinnitus; unusual bleeding of gums; bruising; black, tarry stools; or fever lasting longer than 3 days, avoid concurrent use of alcohol,
Name: folic acid

Concentration: tablet

Route: oral

Dosage Amount: 400 mg

Frequency: once daily

Pharmaceutical class: water soluble vitamins

Home

Hospital

or

Both

Indication: treatment of anemia

Adverse/ Side effects: irritability, difficulty sleeping, malaise, confusion
Nursing considerations/ Patient Teaching: comply with diet recommendations of health care professional, Explain that the best source of vitamins is a wellbalanced diet with foods from the 4 basic food groups, folic acid may make urine more intensely yellow,
Name: novolog (insulin aspart)

Concentration

Dosage Amount: sliding scale

University of South Florida College of Nursing Revision September 2014

Route: subcutaneous

Frequency: before meals

Pharmaceutical class: pancreatics

Home

Hospital

or

Both

Indication: control of hyperglycemia

Adverse/ Side effects: Hypoglycemia, lipodystrophy, pruritis, erythema, swelling
Nursing considerations/ Patient Teaching: Instruct patient on proper technique for administration, in proper testing of serum glucose and ketones, Emphasize
the importance of compliance with nutritional guidelines and regular exercise as directed by health care professional, notify health care professional if nausea,
vomiting, or fever develops, if unable to eat regular diet, or if blood sugar levels are not controlled, instruct patient on signs and symptoms of hypoglycemia and
hyperglycemia and what to do if they occur, carry a source of sugar (candy, glucose gel) and identification describing their disease and treatment regimen at all
times
Name: lantus (insulin glargine)

Concentration

Dosage Amount: 15 units

Route: Subcutaneous

Frequency: nightly

Pharmaceutical class:

Home

Hospital

or

Both

Indication: treatment of hyperglycemia pancreatics

Adverse/ Side effects: hypoglycemia, lipodystrophy, pruritus, erythema, swelling
Nursing considerations/ Patient Teaching: Instruct patient on proper technique for administration, in proper testing of serum glucose and ketones, Emphasize
the importance of compliance with nutritional guidelines and regular exercise as directed by health care professional, notify health care professional if nausea,
vomiting, or fever develops, if unable to eat regular diet, or if blood sugar levels are not controlled, instruct patient on signs and symptoms of hypoglycemia and
hyperglycemia and what to do if they occur, carry a source of sugar (candy, glucose gel) and identification describing their disease and treatment regimen at all
times
Name: metoprolol

Concentration: tablet

Route: oral

Dosage Amount:
Frequency: 2 times daily

Pharmaceutical class: beta blocker

Home

Hospital

or

Both

Indication: antihypertensive
Adverse/ Side effects: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares,
blurred vision, stuffy nose, bronchospasm, wheezing, bradycardia, heart failure, pulmonary edema, onstipation, diarrhea, drug-induced hepatitis, dry mouth,
flatulence, gastric pain, heartburn, liver enzymes, nausea, vomiting, hyperglycemia, hypoglycemia, arthralgia, back pain, joint pain
Nursing considerations/ Patient Teaching:
Name: Warfarin

Concentration

Dosage Amount: 2mg

Route: oral

Frequency: nightly

Pharmaceutical class: coumarins

Home

Hospital

or

Both

Indication: Prophylaxis
Adverse/ Side effects: cramps, nausea, bleeding, fever
Nursing considerations/ Patient Teaching: Limit intake of vitamin K, avoid IM injections and activities leading to injury, use a soft toothbrush, not to floss, and
to shave with an electric razor, eport any symptoms of unusual bleeding or bruising, do not drink alcohol or take other Rx, OTC, or herbal products, especially
those containing aspirin or NSAIDs, or to start or stop any new medications during warfarin therapy without advice of health care professional, Emphasize the
importance of frequent lab tests to monitor coagulation factors
Name: Nystatin (mycostatin)

Concentration

Dosage Amount

Route: topical

Frequency

Pharmaceutical class: antifungal

Home

Hospital

or

Both

Indication: treatment of candidiasis

Adverse/ Side effects: diarrhea, nausea, stomach pain (large doses), vomiting
Nursing considerations/ Patient Teaching: report increased irritation of mucous membranes or lack of therapeutic response to health care professional
Name: Peridex (chlorhexidine)

Concentration

Dosage Amount:

Route: oral

Frequency: 2x daily

Pharmaceutical class:antimicrobial

Home

Hospital

or

Both

Indication:oral care, prevent infection

Adverse/ Side effects: staining of the teeth, tooth-colored restorations, and the tongue; bitter taste, transient loss of taste, and soft tissue ulceration
Nursing considerations/ Patient Teaching: warn patient of staining of the teeth, tooth-colored restorations, and the tongue; bitter taste, transient loss of taste,
and soft tissue ulceration

University of South Florida College of Nursing Revision September 2014

Name: Flomax (tamsulosin)

Concentration

Dosage Amount:

Route:oral

Frequency:

Pharmaceutical class: peripherally acting antiadrenergics

Home

Hospital

or

Both

Indication: management of outflow obstruction

Adverse/ Side effects: dizziness, headache, orthostatic hypotension, priapism, retrograde/diminished ejaculation
Nursing considerations/ Patient Teaching: take medication at the same time each day, May cause dizziness, hange positions slowly to minimize orthostatic
hypotension,
Name: Zantac (ranitidine)

Concentration

Dosage Amount:

Route: oral

Frequency:

Pharmaceutical class: histamine h2 antagonists

Home

Hospital

or

Both

Indication: treatment of duodenal and gastric ulcers

Adverse/ Side effects: confusion, dizziness, drowsiness, hallucinations, headache, arrhythmias, constipation, diarrhea, nausea, gynecomastia, agranulocytosis,
anemia, neutropenia, thrombocytopenia
Nursing considerations/ Patient Teaching: take medication as directed for the full course of therapy, May cause drowsiness or dizziness, avoid alcohol, products
containing aspirin or NSAIDs, excessive amounts of caffeine, and foods that may cause an increase in GI irritation, increased fluid and fiber intake and exercise
may minimize constipation
Name: dilitiazem (Cardizem)

Concentration

Dosage Amount:

Route: oral

Frequency: once daily

Pharmaceutical class: calcium channel blockers

Home

Hospital

or

Both

Indication: supraventricular tachyarrhythmias and rapid ventricular rates in atrial flutter or fibrillation
Adverse/ Side effects: abnormal dreams, anxiety, confusion, dizziness, drowsiness, headache, nervousness, psychiatric disturbances, weakness, blurred vision,
disturbed equilibrium, epistaxis, tinnitus, blurred vision, disturbed equilibrium, epistaxis, tinnitus, cough, dyspnea, arrhythmias, HF, peripheral edema,
bradycardia, chest pain, hypotension, palpitations, syncope, tachycardia, increased liver enzymes, anorexia, constipation, diarrhea, dry mouth, dysgeusia,
dyspepsia, nausea, vomiting, dysuria, nocturia, polyuria, sexual dysfunction, urinary frequency, flushing, sweating, photosensitivity, pruritus/urticarial,
gynecomastia, hyperglycemia, anemia, leukopenia, thrombocytopenia, joint stiffness, muscle cramps, paresthesia, tremor
Nursing considerations/ Patient Teaching: avoid large amounts (68 glasses of grapefruit juice/day) during therapy, change positions slowly, May cause
drowsiness or dizziness, notify health care professional if rash, irregular heartbeats, dyspnea, swelling of hands and feet, pronounced dizziness, nausea,
constipation, or hypotension occurs or if headache is severe or persistent.,
Name: levetiracetam (keppra)
Route:

Concentration: tablet

Dosage Amount:
Frequency: once daily

oral

Pharmaceutical class: pyrrolidines

Home

Hospital

or

Both

Indication: Partial onset seizures

Adverse/ Side effects: suicidal thoughts, aggression, agitation, anger, anxiety, apathy, depersonalization, depression, dizziness, hostility, irritability, personality
disorder, weakness, drowsiness, dyskinesia, fatigue, coordination difficulties
Nursing considerations/ Patient Teaching: May cause dizziness and somnolence, notify health care professional if thoughts about suicide or dying, attempts to
commit suicide; new or worse depression; new or worse anxiety; feeling very agitated or restless; panic attacks; trouble sleeping; new or worse irritability;
acting aggressive; being angry or violent; acting on dangerous impulses; an extreme increase in activity and talking
Name: losartan (cozaar)

Concentration: tablet

Route: oral

Dosage Amount:
Frequency: once daily

Pharmaceutical class: angiotensin II receptor antagonists

Home

Hospital

or

Both

Indication: management of hypertension

Adverse/ Side effects: dizziness, fatigue, headache, insomnia, weakness, chest pain, edema, hypotension, nasal congestion, hypoglycemia, weight gain, diarrhea,
abdominal pain, dyspepsia, nausea, impaired renal function, hyperkalemia, back pain, myalgia, angioedema, fever
Nursing considerations/ Patient Teaching: avoid salt substitutes containing potassium or foods containing high levels of potassium or sodium, avoid sudden
changes in position to decrease orthostatic hypotension, notify health care professional if swelling of face, eyes, lips, or tongue or if difficulty swallowing or
breathing occur, Instruct patient and family on proper technique for monitoring BP
Name: docusate (Colace)

Concentration: powder

Route:oral

Dosage Amount:
Frequency: once daily

Pharmaceutical class: stool softeners

Home

Hospital

or

Both

Indication: prevention of constipation

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects: throat irritation, mild cramps, diarrhea, rashes

Nursing considerations/ Patient Teaching: should be used only for short-term therapy, use other forms of bowel regulation, such as increasing bulk in the diet,
increasing fluid intake (68 full glasses/day), and increasing mobility, avoid straining during bowel movements, do not use laxatives when abdominal pain,
nausea, vomiting, or fever is present
Name: levalbutol (xopenex)

Concentration:

Route: inhalant

Dosage Amount:
Frequency: twice daily

Pharmaceutical class: adrenergics

Home

Hospital

or

Both

Indication: Bronchospasm due to reversible airway disease (short-term control agent)

Adverse/ Side effects: anxiety, dizziness, headache, nervousness, paradoxical bronchospasm, increased cough, turbinate edema, tachycardia, dyspepsia,
vomiting, hyperglycemia, hypokalemia, tremor
Nursing considerations/ Patient Teaching: proper use of metered-dose inhaler and nebulizer, contact health care professional immediately if shortness of breath
is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or chest pain, use levalbuterol first if using other inhalation medications,
and allow 5 min to elapse before administering other inhalant medications, rinse mouth with water after each inhalation dose to minimize dry mouth.
Name: ipratropin (atrovent)

Concentration

Dosage Amount:

Route: inhalant

Frequency: twice daily

Pharmaceutical class: anticholinergics

Home

Hospital

or

Both

Indication: Maintenance therapy of reversible airway obstruction

Adverse/ Side effects: dizziness, headache, nervousness, blurred vision, bronchospasm, cough, hypotension, palpitations, GI irritation, nausea
Nursing considerations/ Patient Teaching: proper use of inhaler, nebulizer, or nasal spray, notify health care professional if symptoms do not improve within 30
min after administration of medication or if condition worsens, Explain need for pulmonary function tests prior to and periodically during therapy to determine
effectiveness of medication, inform health care professional if cough, nervousness, headache, dizziness, nausea, or GI distress occurs,

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? Honey Thick
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Diabetic
Consider co-morbidities and cultural considerations):
24 HR average home diet:
After analysis of MyPlate, my patient is lacking in most
Breakfast: Eggs
food groups as well as overall calorie intake. When
Compared to the daily value, my patient eats 44% of his
whole grains, 41% of his vegetables, 4% of fruits, 64% of
the recommended intake of milk and yogurt and 66%
protein.
Lunch: Soup (1/2can/Progresso, chicken noodle)
The patients wife claims she tries to keep his diet diabetic
friendly as well as balanced. She tries not to give him fatty
foods because she knows those tend to have a lot of sugar.
I would advise the patient and his wife to try to increase his
intake of fruits, vegetables, protein as well as dairy. Protein
is an important component in muscle strength which is
especially important in old age. While I would increase the
intake of fruits I would caution the wife/patient to be
Dinner: baked pork with BBQ sauce and green beans
aware of fruits high in natural sugar. I would not
recommend increasing the patients intake of grains, as they
Snacks: 1 cup of yogurt (strawberry)
are high in carbohydrates and should be limited for diabetic
patients.
Liquids (include alcohol):
The patients wife is aware that high fluid intakes helps her
husband control and get rid of his secretions. She tries to
stay away from juices because they are high in sugar, but
she keeps them on hand in case his glucose level were to
become too low.
20-32oz of water
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? My wife
How do you generally cope with stress? or What do you do when you are upset?
Being with my wife, praying

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Feeling overwhelmed but is okay if he is with his wife, no feelings of depression

+2 DOMESTIC VIOLENCE ASSESSMENT

University of South Florida College of Nursing Revision September 2014

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

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

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

Industry 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: This phase occurs during old age and is focused on reflecting back on life. Those who are unsuccessful during this
stage will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness
and despair. Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means
looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death.
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 the Integrity vs. Despair stage of development as described by Erikson occurring in old age. My patient has been
Successful in this stage, as he does not feel as though he has many regrets in life, rather he is proud of his accomplishments, his
Greatest one (as described by him) was his marriage to his wife. He says he still finds joy in life and does not let his hardships bring
Him down. He states that he is not afraid of death, as long as he is with his wife in the end.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
My patients current illness has had no impact of his developmental stage. My patient is aware that as he ages his health will decline
thus giving him to ability to prepare for such changes.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? My accident a few years ago

What does your illness mean to you? That I need to be more careful

+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?_no _______________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? _No_____________________________________
Are you currently sexually active? _No__________________________ If yes, are you in a monogamous relationship?

University of South Florida College of Nursing Revision September 2014

___Yes_________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _My wife can no longer get pregnant_________________________________
How long have you been with your current partner?_52 Years______________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? Im very weak now_cannot
move the same_________
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?
_I believe that God plays a big role in our lives______________
_________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
___Im always praying to get better______
___________________________________________________________________________________

+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)
Cigars occasionally, Cigarettes
Cigarettes/Cigars
pack per day

Yes
No
For how many years? X years
(age 20 thru ~30 ) Cigarettes
(age 30 thru ~50) Cigars

If applicable, when did the

patient quit? 30 years ago

Pack Years: 10
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? Yes

If yes, what did they use to try to quit? Gradually slowed
down until he just stopped

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? Beer/liquer
How much?
Volume: 1 Beer/8oz
Frequency: social/occasionally
If applicable, when did the patient quit?

No
For how many years? 50+ years
(age

18

thru

~ 65/70

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

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

University of South Florida College of Nursing Revision September 2014

10

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen Yes, if going
outside for long periods
SPF: 50
Bathing routine: sponge bath daily
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
Routine dentist visits
Vision screening
Other:

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor

Diverticulitis

Life threatening allergic reaction

Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

Enlarged lymph nodes

Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: A+
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 5-8 x/day
Bladder or kidney infections

Hematologic/Oncologic

Metabolic/Endocrine
1 x/day
x/year

Diabetes
Type: 2
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive thick/white
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other:

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

Central Nervous System

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

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision September 2014

11

Last EKG screening, when?

Other:

Arthritis
Other:

Chicken Pox
Other:

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

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

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

University of South Florida College of Nursing Revision September 2014

12

10 PHYSICAL EXAMINATION:
General Survey: Warm,
Height
65 in
Weight 108.8lbs
BMI 30.1
Pain: (include rating and
Dry, alert/orientated,
location) None
Pulse 60
Blood Pressure: (include location)
calm
138/59
R
arm
Respirations 14
Temperature: (route
SpO2
Is the patient on Room Air or O2
98
28% O2
taken?) 98.2 Oral
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] Using passe mare valve; raspy due to secretions
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
Skin turgor has lost elasticity, nails are slightly clubbed, skin has splotchy redness/bruising along upper extremities,
Scalp is balding
Central access device Type: Triple lumen Location: R Subclavian
Fluids infusing?
no
yes - what?

Date inserted:

flat
loud

8/25/15

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 / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 5 inches & left ear- 5 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Some false teeth but has many of his own teeth remaining, those of which are discolored (yellow/brown)
Commens: unable to assess thyroid and trachea due to tracheostomy, sclera were errythemic, eyelashes had remants of
drainage stuck to them, orbital area was puffy but not edematous.
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
Coarse
LUL Coarse
RML
Coarse
LLL Crackles
RLL Crackles

Chest expansion

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

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

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3
Femoral: 3
Popliteal: 3
DP: 3
PT: 3
No temporal or carotid bruits
Edema:
1
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
Lower extremities
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 / 11 / 15 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe: Small lesion on tip of urethra r/t catheter placement
GU
Urine output:
Clear
Cloudy
Color: yellow
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Previous 24 hour output:

without assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ___4____ RUE ___4____ LUE ___4____ RLE

or

mLs N/A

with assistance

& ___4____ in LLE

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

vertebral column without kyphosis or scoliosis

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

Biceps:

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
CT of Head

Dates
8/13/15, 8/27/15

Hemoglobin
7.9 (low)
8.7 (low)
8.6 (low)

8/25/15
9/10/15
9/11/15

Normal 14 to 18 g/100

RBC count
3.06 (low)

9/11/2015

Normal: 3.8-5.1
WBC count
11.33 (high)
10.91 (high)

9/10/15
9/11/15

Normal: 4.5-11

INR
1.6
2.0

9/10/15
9/11/15

These values are normal

for a patient receiving
anticoagulant treatment
(1.5-2)

Trend
Stable/unchanged.

Analysis
CT shows R frontal lobe
acute infarction with
small amount of
hemorrhagic
transformation. It is
important monitor
patients with a brain mass
to monitor for changes in
size.
Hemoglobin levels are
Hemoglobin is the
increasing.
component in RBCs that
carries oxygen throughout
the body. Without
adequate hemoglobin
levels the tissues become
under-oxygenated. The
patient has a history of
anemia and these results
confirm his anemic status.
Unable to assess trend as A low RBC count is
only one lab value was
indicative of a loss of
recorded.
blood. For this patient,
this indicates a large loss
of blood from his brain
lesion.
WBC count is decreasing. WBC count represents the
number of infection
fighting cells. A high
WBC count indicates
possible infection. The
patients WBC count is
decreasing indicating the
infection is resolving.
INR is increasing.
INR is the time it takes
for blood to coagulate. In
this patients case, he is
on anticoagulant therapy
due to his history of atrial
fibrillation with
placement of DVT stent.
However, this is a

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negative factor as he is
also experiencing an
intracranial hemorrhage,
With an increased INR
the patient is taking
longer to coagulate and
stop the hemorrhage in
his brain.

+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.)
The patient is currently receiving pulmonary consults as well as daily respiratory therapy treatments. A
neurosurgeon has been consulted as well however the patient will not be having his hematoma drained, rather he
will be monitored until reabsorption occurs. Nursing tasks include monitoring the patients LOC and neuro status
to watch for increasing ICP or respiratory failure as well as routine suctioning of the patients trach tube. The
patients diet is honey thick liquids but had his dobhoff tube removed today (9/11) and is expecting to advance his
diet. Patient is looking forward to being able to walk as soon as he gets the proper equipment to help stabilize him
while he walks.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Ineffective airway clearance r/t increased secretions as evidenced by frequent need for suctioning of tracheostomy tube
2. Risk for increased intracranial pressure r/t cerebral hemorrhage
3. Risk for ineffective cerebral tissue perfusion r/t cerebral hemorrhage
4. Risk for aspiration r/t presence of tracheostomy tube
5. Ineffective breathing pattern r/t compromised pulmonary function as evidenced by placement of tracheostomy
6. Risk for deficient fluid volume r/t hemorrhage

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 15 CARE PLAN
Nursing Diagnosis: Ineffective airway clearance r/t increased secretions as evidenced by frequent need for suctioning of tracheostomy tube
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
By end of 8 hour shift, patient will Help the client deep breath and
This technique can help increase
By end of shift patient was able to
demonstrate effective coughing
perform controlled coughing *
sputum clearance; controlled
cough effectively, bringing sputum
coughing uses the diaphragmatic
to beginning of trach tube to be
muscles, making the cough more
suctioned out. After coughing
forceful and effective
patient was noticeably more
comfortable in relation to breathing
as well as speaking.
By end of 8 hour shift, patient will Position the client to optimize
An upright position allows for
At end of shift, patient was able to
be able to maintain a patent airway respiration: HOB elevated 30-45
maximal lung expansion.
maintain his airway and was
at all times.
degrees*
There is a decreased risk for
positioned at a 30-45 degree angle
pneumonia if the client is
positioned at 30-45 degrees upright
By end of 8 eight hour shift patient Continue controlled coughing,
Effective coughing, self-suctioning, By end of shift, patients SpO2 was
will maintain SpO2 levels WNL
teach patient proper self-suctioning and elevated HOB will clear
WNL at 98% with supplemental o2
techniques, keep HOB elevated to
patients airway and allow for
at 28%.
30-45 degrees, deliver O2 as
proper respirations. Supplementary
needed
O2 will increase circulating oxygen
allowing for proper saturation
levels.
By discharge, patient will have
Maintain clear airway by teaching
Effective coughing will increase
Unable to assess long-term goal as
clear lung sounds
client effective coughing methods, sputum clearance form airway as
patient was not discharged on day
keeping the client in an upright
well as prevent bacteria growth and of care.
position and implementing
aspiration of secretions to prevent
prevention methods for preventing pneumonia. Upright positioning
pneumonia
helps clear secretions and prevent
pneumonia
Include a minimum of one
Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
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SS Consult
Dietary Consult
PT/ OT/RT- PT to assist patient with becoming mobile again/providing patient with equipment for safe mobility at home; RT for patient teaching on
effective breathing techniques/administration of breathing treatments
Pastoral Care
Durable Medical Needs
F/U appointments- with neurologist to monitor hematoma
Med Instruction/Prescription- patient teaching of proper medication administration and adherence
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
15 CARE PLAN
Nursing Diagnosis: Risk for ineffective cerebral tissue perfusion r/t cerebral hemorrhage
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
By end of 8 hour shift, patient will Monitor for changes in mental
Decreased mental status is
By end of shift patient remained
have remained alert and orientated status or behavior; perform neuro
suggestive of decreased cerebral
alert and orientated x4
x4
assessment q1-4 hours
perfusion
By end of 8 hour shift, patient will Monitor vital signs and ask patient Headache is indicative of
By end of shift, patient did not
remain free from headache
to rate their pain score on a scale
decreasing cerebral tissue perfusion report any pain.
from 1-10; OLDCART symptoms
By end of 8 eight hour shift, patient Monitor LOC, vital signs including Increasing intracranial pressure
By end of shift, patient had no
will not display any symptoms of
HR and BP, pupil size and
indicates an increase in
signs of increasing ICP
increasing ICP
reactivity
hemorrhaging/size of hematoma. If
blood is entering the cranial space
it is not reaching the tissues to
perfuse them.
By discharge, patient will have
Monitor for any changes (as listed
Keeping a close watch on the
Was not able to assess patient as
maintained adequate perfusion of
above) that would indicate a
patient to monitor for any changes they were not discharges on day of
cerebral tissues
change in cerebral perfusion.
indicating a decrease in cerebral
care. However, patient had no
perfusion will allow the nurse to
changes by end of shift that would
quickly identify there is a problem indicate a change in cerebral
thus allowing for quick
perfusion.
interventions to reperfuse the tissue
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before permanent danage results.

Include a minimum of one
Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT/ RT
Pastoral Care
Durable Medical Needs
F/U appointments- with neurologist to monitor hematoma
Med Instruction/Prescription- patient teaching of proper medication administration and adherence
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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References

Ackley, B., & Ladwig, G., (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care.
St. Louis, Missouri: Elsevier Inc.
Cherry, K. (n.d.). Erikson's Theory of Psychosocial Development. Retrieved from:
http://psychology.about.com/od/psychosocialtheories/a/psychosocial.htm
MyPlate. (n.d.) Supertracker. Retrieved from: https://www.supertracker.usda.gov/foodtracker.aspx
Osborn, K. S., (2014). Medical Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson
Education, Inc.
Unbound Medicine. (2014.) Nursing Central (Version 1.24 (414)) [Mobile application software]. Retrieved
from: http://nursing.unboundmedicine.com/nursingcentral

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