UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kristine Martin

MSI & MSII PATIENT ASSESSMENT TOOL .

Agency: TGH UD 4F

1 PATIENT INFORMATION
Patient Initials:

J.C.

Gender:

Assignment Date: 10/09/15

Age: 46

Admission Date: 7/31/15

Marital Status: Married

Primary Medical Diagnosis: Hemorrhagic Stroke

Primary Language: English

Level of Education: College

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Veterinarian

Number/ages children/siblings: Son (5 y.o.)

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

Code Status: Full

Living Arrangements: Lives with wife and son; wife is aware that
they will have to make different arrangements to accommodate her
husbands disability

Advanced Directives: Yes

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

Procedure:

Culture/ Ethnicity /Nationality: English

Religion: Christian

Type of Insurance: Medicaid

1 CHIEF COMPLAINT: Patient presents with left sided paralysis related to a hemorrhagic stroke

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
46 year old M admitted on 7/31/15 after waking up at approximately 7:45am with a severe headache for which he took 4
aspirin and proceeded to experience an onset of left-sided weakness around 8am and called EMS. EMS noted left facial
droop, left HB weakness, neglect and sensory deficit. CT revealed right basal ganglia hemorrhage, effacement on right
lateral ventricle, surrounding edema and 4mm of right to left subfalcine. Patient has a history of diabetes type 1 and
hypertension.

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
Unknown

Father

71

Mother

70

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

Wisdom tooth extraction

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness

Brother
Sister

44

relationship
relationship
relationship

Comments: Mother and father were diagnosed with arthritis less than 10 years ago. Mother also has type one diabetes, diagnosed as a
child.

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)
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
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
Heparin

Type of Reaction (describe explicitly)

Nausea/vomiting

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 with symptoms of a stroke, Mr. C was diagnosed with an intraparenchymal hemorrhage of the right basal
ganglia following a CT scan of the head. The CT also revealed surrounding edema and 4mm of right to left subfalcine. An
intraparenchymal hemorrhage results from a broken blood vessel in the brain itself, which differs from subarachnoid/dural
and epidural hemorrhages that are caused by a vessel rupture outside of the brain (Osborn, 2014). The most common
cause of this type of hemorrhage is uncontrolled hypertension. Mr. C has a PMH of hypertension, which, depending on
how well he controlled it, could have been the cause. The patient also has a history of diabetes, which can cause vessel
damage when not well controlled. A CT scan is the most reliable form of diagnosis and treatment depends on the size of
the hemorrhage, its location as well as the degree of neurologic impairment (Osborn, 2014). Management for a
hemorrhage of this depth is usually limited to correction of coagulopathy, blood pressure control, platelet replacement if
necessary and supportive nursing care to avoid secondary injury (Osborn, 2014). Prognosis is dependent on location and
size of the hemorrhage. For Mr. C, he will have left sided paralysis for the remainder of his life but will retain his
cognitive function.

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

Concentration: 650/20.3 mLs

Route: Oral (peg tube)

Dosage Amount: 650mg

Frequency: Q4 hrs PRN

Pharmaceutical class: antipyretic/ nonopioid analgesic

Home

Hospital

or

Both

Indication: fever
Adverse/ Side effects: hepatotoxicity, increased liver enzymes, neutropenia, pancytopenia, acute generalized exanthematous pustulosis, stevens-johnson, rash
Nursing considerations/ Patient Teaching: Take medication exactly as directed and not to take more than the recommended amount. Chronic excessive use of >4
g/day may lead to hepatotoxicity, renal or cardiac damage. Adults should not take acetaminophen longer than 10 days, avoid alcohol (3 or more glasses per day
increase the risk of liver damage) if taking more than an occasional 12 doses and to avoid taking concurrently with salicylates or NSAIDs for more than a few
days, discontinue acetaminophen and notify health care professional if rash occurs, acetaminophen may alter results of blood glucose monitoring, check labels
on all OTC products: avoid taking more than one product containing acetaminophen at a time to prevent toxicity.
Name: Norvasc (amlodipine)

Concentration: Tablet

Route: oral (peg tube)

Dosage Amount: 10mg

Frequency: daily

Pharmaceutical class: calcium channel blockers

Home

Hospital

or

Both

Indication: management of hypertension

Adverse/ Side effects: dizziness, fatigue, peripheral edema, angina, bradycardia, hypotension, palpitations, gingival hyperplasia, nausea, flushing
Nursing considerations/ Patient Teaching: avoid large amounts (68 glasses of grapefruit juice/day) during therapy, change positions slowly to minimize
orthostatic hypotension, May cause drowsiness or dizziness, notify health care professional if irregular heartbeats, dyspnea, swelling of hands and feet,
pronounced dizziness, nausea, constipation, or hypotension occurs or if headache is severe or persistent, comply with other interventions for hypertension
(weight reduction, low-sodium diet, smoking cessation, moderation of alcohol consumption, regular exercise, and stress management), Instruct patient and
family in proper technique for monitoring BP: Advise patient to take BP weekly and to report significant changes to health care professional.

University of South Florida College of Nursing Revision September 2014

Name: Klonopin (clonazepam)

Concentration: tablet

Route: oral (peg tube)

Dosage Amount: .5mg

Frequency: 3x daily

Pharmaceutical class: benzodiazepines

Home

Hospital

or

Both

Indication: anticonvulsant
Adverse/ Side effects: suicidal thoughts, behavioral changes, drowsiness, fatigue, slurred speech, ataxia, sedation, abnormal eye movements, diplopia,
nystagmus, increased secretions, palpitations, rash, constipation, diarrhea, hepatitis, weight gain, dysuria, nocturia, urinary retention, anemia, eosinophilia,
leukopenia, thrombocytopenia, ataxia, hypotonia
Nursing considerations/ Patient Teaching: Abrupt withdrawal of clonazepam may cause status epilepticus, tremors, nausea, vomiting, and abdominal and
muscle cramps, does not cure underlying problems, May cause drowsiness or dizziness, notify health care professional of unusual tiredness, bleeding, sore
throat, fever, clay-colored stools, yellowing of skin, or behavioral changes, 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; other unusual changes in behavior or mood occur,
carry identification at all times describing disease process and medication regimen, Emphasize the importance of follow-up exams to determine effectiveness of
the medication.
Name: Benadryl (diphenhydramine)

Concentration: solution

Route: IV

Dosage Amount: 25mg

Frequency: Q6 hours PRN with itching

Pharmaceutical class: antihistamine

Home

Hospital

or

Both

Indication: relief of itching

Adverse/ Side effects: drowsiness, dizziness, headache, blurred vision, tinnitus, hypotension, palpitations, anorexia, dry mouth, constipation, nausea, dysuria,
frequency, urinary retention, photosensitivity, chest tightness, thickened bronchial secretions, wheezing
Nursing considerations/ Patient Teaching: May cause drowsiness, do not use oral OTC diphenhydramine products with any other product containing
diphenhydramine, including products used topically, May cause dry mouth, avoid use of alcohol and other CNS depressants concurrently with this medication.
Name: Duragesic (Fentanyl)

Concentration: 12mcg/hr patch

Route: transdermal

Dosage Amount: 1 patch/12mcg

Frequency: Q72 hours

Pharmaceutical class: opioid agonists

Home

Hospital

or

Both

Indication: moderate to severe chronic pain

Adverse/ Side effects: confusion, sedation, weakness, dizziness, restlessness, apnea, bronchoconstriction, laryngospasm, respiratory depression, bradycardia,
anorexia, constipation, dry mouth, nausea, vomiting, sweating, erythema, application site reactions, skeletal and thoracic muscle rigidity, physical dependence,
psychological dependence
Nursing considerations/ Patient Teaching: avoid grapefruit juice during therapy, Instruct patient in correct method for application and disposal, May cause
drowsiness or dizziness, change positions slowly to minimize dizziness, avoid concurrent use of alcohol or other CNS depressants, advise pt that fever, electric
blankets, heating pads, saunas, hot tubs, and heated water beds increase the release of fentanyl from the patch.
Name: Folvite (folic acid )

Concentration: 1mg/1mL oral suspension

Route: oral (peg tube)

Dosage Amount: 1 mg

Frequency: daily

Pharmaceutical class: water soluble vitamins

Home

Hospital

or

Both

Indication: Prevention of megaloblastic and macrocytic anemias

Adverse/ Side effects: rash, irritability, difficulty sleeping, malaise, confusion, fever
Nursing considerations/ Patient Teaching: may make urine more intensely yellow, notify health care professional if rash occurs,
Name: Lasix (furosemide)

Concentration: tablet

Route: oral (peg tube)

Dosage Amount: 20mg

Frequency: daily

Pharmaceutical class: loop diuretics

Home

Hospital

or

Both

Indication: treatment of hypertension

Adverse/ Side effects: blurred vision, dizziness, headache, vertigo, hearing loss, tinnitus, hypotension, anorexia, constipation, diarrhea, dry mouth, dyspepsia,
increased liver enzymes, nausea, pancreatitis, vomiting, increased BUN, excessive urination, nephrocalcinosis, erythema multiforme, stevens-johnson,
photosensitivity, pruritis, rash, urticarial, hypercholesterolemia, hyperglycemia, hypertriglyceridemia, hyperuricemia, dehydration, hypocalcemia,
hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis, aplastic anemia, agranulocytosis, hemolytic anemia,
leukopenia, thrombocytopenia, muscle cramps, paresthesia, fever
Nursing considerations/ Patient Teaching: hange positions slowly to minimize orthostatic hypotension, caution pt that: use of alcohol, exercise during hot
weather, or standing for long periods during therapy may enhance orthostatic hypotension, contact health care professional of weight gain more than 3 lbs in 1
day, contact health care professional immediately if rash, muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs, monitor
blood glucose closely; may cause increased blood glucose levels.

University of South Florida College of Nursing Revision September 2014

Name: apresoline (hydralazine)

Concentration: solution

Route: IV

Dosage Amount: 10mg

Frequency: Q4 PRN; SBP > 160

Pharmaceutical class: vasodilators

Home

Hospital

or

Both

Indication: moderate to severe hypertension (with a diuretic)

Adverse/ Side effects: dizziness, drowsiness, headache, tachycardia, angina, arrhythmias, edema, orthostatic hypotension, diarrhea, nausea, vomiting, rash,
sodium retention, arthralgias, arthritis, peripheral neuropathy, drug-induced lupus syndrome
Nursing considerations/ Patient Teaching: take medication at the same time each day; last dose of the day should be taken at bedtime, Take missed doses as soon
as remembered; do not double doses, must be discontinued gradually to avoid sudden increase in BP, weigh yourself twice weekly and assess feet and ankles for
fluid retention, May occasionally cause drowsiness, avoid sudden changes in position to minimize orthostatic hypotension, notify health care professional
immediately if general tiredness; fever; muscle or joint aching; chest pain; skin rash; sore throat; or numbness, tingling, pain, or weakness of hands and feet
occurs.
Name: Novolog (insulin aspart)

Route: subcutaneous
Pharmaceutical class: pancreatics

Concentration: 100 units/mL; rapid acting

Onset: within 15 min
Peak: 12 hr
Duration: 3-4 hr
Frequency: Q6 hours
Home

Hospital

or

Dosage Amount: 4-16 units

Both

Indication: Control of hyperglycemia

Adverse/ Side effects: hypoglycemia, lipodystrophy, pruritis, erythema, swelling, allergic response
Nursing considerations/ Patient Teaching: Instruct patient on proper technique for administration (including correct timing of doses), Instruct patient in proper
testing of serum glucose and ketones, Emphasize the importance of compliance with nutritional guidelines and regular exercise, 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)

Route: subcutaneous
Pharmaceutical class: pancreatics

Concentration: 100 units/mL; long-acting

Onset: 34 hr
Peak: none
Duration: 24hr
Frequency: daily
Home

Hospital

or

Dosage Amount: 25 units

Both

Indication: control of hyperglycemia

Adverse/ Side effects: hypoglycemia, lipodystrophy, pruritis, erythema, swelling, allergic response
Nursing considerations/ Patient Teaching: Instruct patient on proper technique for administration (including correct timing of doses), Instruct patient in proper
testing of serum glucose and ketones, Emphasize the importance of compliance with nutritional guidelines and regular exercise, 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: Prevacid (lansoprazole)

Concentration: tablet

Route: oral (peg tube)

Dosage Amount: 30mg

Frequency: daily

Pharmaceutical class: proton pump inhibitors

Home

Hospital

or

Both

Indication: preventative antiulcer

Adverse/ Side effects: dizziness, headache, pseudomembranous colitis, diarrhea, abdominal pain, nausea, rash, hypomagnesemia
Nursing considerations/ Patient Teaching: May occasionally cause dizziness, avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an
increase in GI irritation, report onset of black, tarry stools; diarrhea; or abdominal pain to health care professional promptly, notify health care professional
immediately if rash, diarrhea, abdominal cramping, fever, or bloody stools occur and not to treat with antidiarrheals without consulting health care professional.
Name: Lopressor (metoprolol)

Concentration: 10mg/mL

Route: Oral (peg tube)

Dosage Amount: 10mg

Frequency: 2x daily

Pharmaceutical class: beta blockers

Home

Hospital

or

Both

Indication: hypertension
Adverse/ Side effects: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares,
blurred vision, stuffy nose, bronchospasm, wheezing, bradycardia, HF, pulmonary edema, hypotension, peripheral vasoconstriction, constipation, diarrhea,
drug-induced hepatitis, dry mouth, flatulence, gastric pain, heartburn, increased liver enzymes, nausea, vomiting, urinary frequency, erectile dysfunction,
rashes, hyperglycemia, hypoglycemia, arthralgia, back pain, joint pain
Nursing considerations/ Patient Teaching: Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia, check pulse
daily and BP biweekly and to report significant changes to health care professional, May cause drowsiness, change positions slowly to minimize orthostatic
hypotension, closely monitor blood glucose, especially if weakness, malaise, irritability, or fatigue occurs, notify health care professional if slow pulse, difficulty

University of South Florida College of Nursing Revision September 2014

breathing, wheezing, cold hands and feet, dizziness, light-headedness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occurs.
Name: Morphine

Concentration: solution

Route: IV

Dosage Amount: 10mg

Frequency: q4 hours with pain

Pharmaceutical class: opioid agonists

Home

Hospital

or

Both

Indication: pain relief

Adverse/ Side effects: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred vision, diplopia,
miosis, Respiratory depression, hypotension, bradycardia, constipation, nausea, vomiting, urinary retention, flushing, itching, sweating, physical dependence,
psychological dependence, tolerance
Nursing considerations/ Patient Teaching: Instruct patient how and when to ask for pain medication, May cause drowsiness or dizziness, change positions slowly
to minimize orthostatic hypotension, avoid concurrent use of alcohol or other CNS depressants with this medication, Encourage patients who are immobilized or
on prolonged bedrest to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.
Name: Potassium chloride

Concentration: 10mEq/100mL

Route: IVPB

Dosage Amount: 10mEq

Frequency: q4 hours PRN; K+ < 3.4

Pharmaceutical class: electrolyte replacement

Home

Hospital

or

Both

Indication: low potassium

Adverse/ Side effects: confusion, restlessness, weakness, arrhythmias, ECG changes, abdominal pain, diarrhea, flatulence, nausea, vomiting, paralysis,
paresthesia, burning at infusion site
Nursing considerations/ Patient Teaching: avoid salt substitutes or low-salt milk or food unless approved by health care professional, report dark, tarry, or
bloody stools; weakness; unusual fatigue; or tingling of extremities. Notify health care professional if nausea, vomiting, diarrhea, or stomach discomfort persists
Name: Zofran (ondansetron)

Concentration: tablet

Route: oral (peg tube)

Dosage Amount: 4mg

Frequency:Q6 PRN with nausea

Pharmaceutical class: f ive ht3 antagonists

Home

Hospital

or

Both

Indication: prevention of N/V

Adverse/ Side effects: headache, dizziness, drowsiness, fatigue, weakness, QT interval prolongation, onstipation, diarrhea, abdominal pain, dry mouth,
extrapyramidal reactions.
Nursing considerations/ Patient Teaching: notify health care professional immediately if symptoms of irregular heart beat or involuntary movement of eyes,
face, or limbs occur.

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?
Novasource
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 reaches 75% of his
daily recommended intake of all food groups besides
vegatables at 65% of his intake. When compared to the
Breakfast: Banana, coffee with sugarfree cream
daily value, my patient eats 78% of his whole grains, 93%
of fruits, 82% of dairy, and 109% of his recommended
Lunch: Sandwich: wheat bread, ham, lettuce, swiss cheese, protein intake.
light mayo
Dinner: baked chicken, salad (iceburg lettuce, tomatoes,
light ranch dressing, cheddar cheese), small portion of
whole wheat pasta with light alfredo sauce.
Snacks: grapes, nutri-grain bar
Liquids (include alcohol): Water (16oz), coffee (8oz),
Gatorade (12oz)

My patient states he is aware of foods that are not

recommended for diabetic patients and avoids them for the
most part. I would advise my patient to be careful with his
fruit choices, as many are high in natural sugars. I would
also recommend limiting his bread and pasta intake,
although the patient states he only occasionally eats these
items. I would also inform the patient that Gatorade has
added sugar and to monitor his intake and maybe replace
this drink with more water. According the MyPlate the
patient also needs to monitor the sodium content of his
food, as he is receiving about 300mg more of sodium than
the recommended amount.
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 family
How do you generally cope with stress? or What do you do when you are upset?
Talk to my family

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Feeling depressed, anxious, and overwhelmed with his health status and his disability; r/t his ability to care for himself
and his family/becoming a burden.
+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

University of South Florida College of Nursing Revision September 2014

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: During adulthood, we continue to build our lives, focusing on our career and family. Those who are successful
during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail to
attain this skill will feel unproductive and uninvolved in the world. Care is the virtue achieved when this stage is handled successfully.
Being proud of your accomplishments, watching your children grow into adults, and developing a sense of unity with your life partner
are important accomplishments of this stage
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 Generativity vs. Stagnation stage of development described by Erikson. It is very difficult to determine if my
patient has been successful in this stage as he has a complex case. Prior to his stroke, my patient described himself as feeling
accomplished in his life as he was doing what he loved and had a wife and child. However, now that he is disabled, he feels as though
he is a burden to his wife because he is no longer being productive and she now has to care for him. I would say that my patient was
successful in this stage up until this point as he has had many accomplishments in his life that he is proud of. His disability, however,
has caused him to believe he is no longer contributing to the world, which is a characteristic of someone who is failing this stage of
development. In my opinion, with the proper treatment for his recent feelings of depression, my patient can still be successful in this
stage if he is able to recall all that he has done thus far in life, and that he can overcome his disability and be productive again.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
My patients hospitalization and resulting disability has had a major impact on his developmental stage of life, as mentioned above.
Rather than feeling successful, as he once did, he now feels like a burden. If the patient continues this way of thinking, he will be
failing this stage of development.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? They [the doctors] say it is related to be high blood pressure and
diabetes

What does your illness mean to you? It means my life will be completely different from now on

+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_________________________________________________________

University of South Florida College of Nursing Revision September 2014

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? __Yes_________________________ If yes, are you in a monogamous relationship?
____Yes_____________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? __Condoms________________________________
How long have you been with your current partner?____15 years______________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _Yes_______________________
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?
__We are not too religious________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
__Not really, but I appreciate my family and friends who pray for me ____________________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

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

Has the patient ever tried to quit?

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

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What?
How much?
Volume:
Frequency:
If applicable, when did the patient quit?

Yes

No
For how many years?
(age

thru

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks

5. For Veterans: Have you had any kind of service related exposure?

University of South Florida College of Nursing Revision September 2014

10

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF: 20
Bathing routine: once a day/morning
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:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

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

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 4/5 x/day
Bladder or kidney infections

Hematologic/Oncologic

Metabolic/Endocrine
2 x/day
x/year

Diabetes
Type: 1
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive Small/white
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 9/25/15
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 9/11

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- r/t stroke
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other: anxiety/depression recent w/illness

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox

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Other:

Other: Left-sided paralysis

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

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10 PHYSICAL EXAMINATION:
General Survey: Calm,
pleasant, clean

Height: 162.6 cm
Pulse: 96
Respirations: 25
SpO2: 97

Weight: 82.2kg
BMI: 28.2
Blood Pressure: (include location)
138/78 right arm
Is the patient on Room Air or O2: 30%

Pain: (include rating and

location): none

Temperature: (route
taken?): 98.1 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]
clear, crisp diction
Trach present, talks through passy muir valve
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
flat
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
loud
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: Double lumen
Location: right subclavian
Date inserted: 8/5/15
Fluids infusing?
no
yes - what?
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:
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: coarse throughout
RUL
LUL
RML
LLL
RLL

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:
LU/LE
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 9 / 25 / 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
Other Describe:

Not assessed, patient alert, oriented, denies problems

GU
Urine output:
Clear
Cloudy
Color:
Yellow
Previous 24 hour output:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
Bladder scan Q6 hours, straight cath if >300mls
CVA punch without rebound tenderness
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at ___4____ RUE ___0____ LUE ____4___ RLE

mLs N/A

& ___0____ in LLE

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

vertebral column without kyphosis or scoliosis

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

Biceps:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

Unable to assess rombergs and gait as patient is unable to walk r/t left sided paralysis
DTR: 0in left side, +2 in right side

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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 scan of the head

Dates
7/31/15
8/04/15
9/10/15

RBC count
3.82 (low)
3.01 (low)
2.43 (low)
2.77 (low)

7/31/15
8/06/15
9/10/15
9/25/15

Trend
Initial CT revealed
intraparenchymal
hemorrhage of the right
basal ganglia, following
CT scans deemed the
condition stable, but most
recent CT showed
resolving hemorrhage and
edema that has improved
from previous scans.
RBC count is decreasing,
except the last value
which is an increase from
the previous value.

Normal: 4.69-6.13

WBC count
5.44
6.41
9.63
10.57 (high)

7/31/15
8/06/15
9/10/15
9/25/15

WBC count is steadily

increasing.

Normal: 4.6-10.2
Platelet count
210
170
356
424

7/31/15
8/06/15
9/10/15
9/25/15

Platelet count is
increasing.

Analysis
Frequent CT scans of the
head are essential in this
patients case as we need
to monitor the size of the
hemorrhage as well as the
edema and subfalcine
shift. Changes can
indicate improvement or
worsening that will
require immediate
intervention to prevent
further damage.
A low RBC count is
indicative of a loss of
blood. For this patient, it
is related to his
intraparenchymal
hemorrhage. CT scans
coincide with this finding
as the patient was stable
until his most recent scan
where the hemorrhage
was resolving; therefore
his RBC count has started
to increase.
WBC count represents the
number of infection
fighting cells. A high
WBC count indicates
possible infection. The
patients WBC count is
increasing which is
consistent with his
diagnosis of MRSA
Platelets are important in
the clotting process. For a
patient with a hemorrhage
this value is important to
monitor because it

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INR
1
1.2

8/21/15
9/10/15

INR increased slightly

but is still WNL

determines the patients

ability to clot and stop the
hemorrhage. An
increasing value is ideal
for this patient. This
finding is consistent with
the treatment for a
intraparenchymal
hemorrhage, which is
platlet replacement.
INR is the time it takes
for blood to coagulate.
This is an important value
to monitor in a patient
with a hemorrhage
because it indicates how
long the patient takes to
clot and stop the
hemorrhage. A high INR
is dangerous as it
indicates the patient will
take longer to clot and
therefore lose more blood
and cause more damage.
This value must be
monitored closely to
ensure appropriate
clotting time.

+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 PT/OT consults and SW consults to help the
patient adjust to his new disability. Patient receives frequent (3-4 weekly) CT scans of the head to monitor
hematoma and edema. Neurosurgeon has been contacted and is monitoring the patients condition and assessing
reabsorption and hemorrhage/resolving edema. Nursing tasks include monitoring the patients LOC/neuro status
for any changes that indicate worsening hemorrhage and/or increasing ICP as well as being diligent with turning
the patient q2 hours as he cannot do so himself. Patient received NovaSource continuous feed though peg tube.
Patient and family are looking into rehab facilities that would accommodate his needs.
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

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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

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 15 CARE PLAN
Nursing Diagnosis: Risk for increased intracranial pressure r/t cerebral hemorrhage
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 Frequent monitoring of LOC and
A change in mental status,
By end of shift, patient had no
have no change in mental status
behavior, A&O checks; perform
presenting with change in LOC and change in behavior or level of
neuro assessment q1-4 hours
behavior, can indicate an increase
consciousness
in ICP. (Ackley & Ladwig, 2011)
By end of 8 hour shift, patient will Frequent assessment of PERRLA;
A change in pupil size or reactivity By end of shift, patient maintained
have no change in pupil size or
q4 hours
is indicative of increasing ICP.
appropriate pupil size and
reactivity
(Ackley & Ladwig, 2011)
reactivity.
By end of 8 hour shift, patient will Monitor vital signs and ask patient Presence of a headache can
By end of 8 hour shift, patient did
have remained free of a headache
to rate their pain score on a scale
indicate increasing ICP. (Ackley & not report presence of headache.
from 1-10; OLDCART symptoms
Ladwig, 2011)
By end of 8 hour shift, patient will Frequent assessment of symptoms; Vomiting can cause an increase in
By end of 8 hour shift, patient
have remained free of nausea
administer an antiemetic if pt
intracranial pressure. (Ackley &
reported no nausea.
becomes nauseous; monitor tube
Ladwig, 2011)
feedings- right rate, type, amount
By discharge, patient will have
Monitor for any changes (as listed
Monitoring for any changes that
Unable to assess patient on day of
maintained an ICP between 0above) that would indicate an
would indicate an increase in ICP
discharge. By end of shift patient
15mmHg.
increase in intracranial pressure.
will allow the nurse to quickly
had no changes that would indicate
identify a problem and thus
increasing ICP.
intervene before damage occurs.
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- work with family to accommodate pts disability; help place patient in rehab facility
Dietary Consult patient currently has a peg tube; there may be a need for family teaching if patient will continue tube feeds or has an altered diet
related to his disability
PT/ OT- help patient become more independent/live with his disability
Pastoral Care
Durable Medical Needs
F/U appointments- rehab facility, neurologist, PCP
Med Instruction/Prescription- importance of medication adherence; risk for another stroke if diabetes/HTN is not controlled
are any of the patients medications available at a discount pharmacy? Yes No
Patient Goals/Outcomes

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Rehab/ HH- r/t left sided paralysis

Palliative Care
Patient Goals/Outcomes
By end of 8 hour shift, patient will
maintain clear lung sounds

By end of shift, will have adequate

respirations

By end of 8 hour shift, patient will

remain free of nausea
By end of 8 hour shift, patient will
have tracheostomy tube mostly
clear of secretions

By discharge, patient will remain

free from aspiration

Nursing Diagnosis: Risk for aspiration r/t presence of tracheostomy tube

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Auscultate lung sounds frequently; Presence of crackles indicates fluid
keep HOB elevated to 30-45
in the lungs, which can be related
degrees
to aspiration; elevating the HOB
helps decrease risk of aspiration
(Ackley & Ladwig, 2011)
Monitor respiratory rate, depth and Change in rate, depth or effort of
effort; note any dyspnea, coughing, respirations as well as dyspnea,
cyanosis, wheezing, or hoarseness
coughing, cyanosis, wheezing or
hoarseness can indicate aspiration
(Ackley & Ladwig, 2011)
Frequent assessment of symptoms; Vomiting increases the patients
administer an antiemetic if pt
risk of aspiration.
becomes nauseous; monitor tube
(Ackley & Ladwig, 2011)
feedings- right rate, type, amount
Monitor pts ability to cough/teach Secretion present in tracheostomy
proper coughing methods; suction
increases patients risk of
pts tracheostomy tube PRN/q1
aspiration of these secretions. A
hours
completely clear tracheostomy tube
is an unrealistic goal.
(Ackley & Ladwig, 2011)
Monitor/assess for any signs of
Change in lung sound and
aspiration, as mentioned above.
respiratory rate/depth/effort are
indicative of aspiration;
nausea/vomiting increases risk for
aspiration. Quick identification will
allow for quick intervention.

Evaluation of Goal on Day Care

is Provided
By end of shift, patient had coarse
lung sounds, which had been
present since admission; unrelated
to aspiration. HOB was elevated
between 30-45 degrees.
By end of 8 hour sift, patient
maintain adequate respirations with
no signs of dyspnea, cyanosis,
wheezing or hoarseness. Patient
had minimal coughing.
By end of shift, patient reported no
nausea.
By end of 8 hour shift, patients
tracheostomy tube was mostly clear
of secretions; patient was suctioned
as needed appox. Q1 hours.
Unable to assess patient on day of
discharge. By end of shift, patient
had remained free of aspiration and
had adequate respirations, no
change in lung sounds with HOB
elevated and no report of nausea.

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)
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Consider the following needs:

SS Consult
Dietary Consult
PT/ OT/RT- teaching proper coughing techniques, self-care of tracheostomy tube (suctioning)
Pastoral Care
Durable Medical Needs
F/U appointments- PCP to monitor respiratory effort/pneumonia r/t aspiration
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH- r/t disability/ineffective airway
Palliative Care
Speech pathologist- if tracheostomy tube is removed, patient will need swallow study performed

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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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