UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Ashley Kavumkal

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

PP

Assignment Date: 3/13/2015

Agency: SMH

Age: 68

Admission Date: 3/04/2015

Marital Status: married

Primary Medical Diagnosis: emesis:condition

stable Claudication with ulceration ICD9: 443.9

Primary Language: English

Level of Education: bachelor in accounting

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): accountant

Number/ages children/siblings: 3 children

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

Code Status: Full code

Living Arrangements: Home with wife, 30 minutes away from

SMH

Advanced Directives: yes

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

Culture/ Ethnicity /Nationality: USA

Religion: Catholic

Type of Insurance: Medicare, medicaid

1 CHIEF COMPLAINT: pain of 5 on the incisions on RLE (toe amputation, intermittent aching pain that
increases with movement and decreases with pain meds.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is a 68 year old Male who was admitted to the cardiac unit on 3/4/2015. The patient was admitted from PACU
after a Right femoral popliteal bypass surgery. The patient is hospitalized for claudication with ulceration. The patient also
had amputation of 2nd ,3rd and 4th toe on right leg on 3/11/2015.

University of South Florida College of Nursing Revision September 2014

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

Father
Mother

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Cause
of
Death
(if
applicable
)
Heart
attack
stroke

Arthritis

2
FAMILY
MEDICAL
HISTORY

Age (in years)

2009

Anemia

January 2015
April 2014
2014
2014
2010,2012
Age 15

Environmental
Allergies

Operation or Illness
Chronic anemia, MI-2014, CHF-jan 2015, Hypertension, Hypercholesterolemia, valvular
dysfunction,
L BKA
Pacemaker/defibrillator
L cataract surgery
TAVR
Stents times 2 in lower extremeties
R knee surgery
Diabtes- insulin, glucose home monitoring FBS=75-120
depression
MRSA

Alcoholism

Date

Brother
Sister

65

relationship
relationship
relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
2014
Pneumococcal (pneumonia) (Date) Is within 5 years? yes

YES

University of South Florida College of Nursing Revision September 2014

NO

Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKA
Medications

NKA
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) Claudification is refered to as the cramping pain that limits the movement of the legs or arms which
is a marker of peripheral vascular disease of the aortoiliac, femoral or popliteal arteries. In patients with
suggestive history, the blood pressure is measured in the affected limb and divided by the BP in the arm on the
same side of the body. This ratio is called the ankle-brachial index. Patient with significant peripheral vascular
disease have an ABI of less than 85%. If surgery is contemplated for the patient, angiography may be used to
define anatomical obstructions more precisely. Affected patients are encouraged to begin a program of regular
exercise, to try to maximize collateral blood flow of legs. Oral pentoxifylline improves the distance patients can
walk without pain. For severely limiting claudication, patients may require angioplasty or arterial bypass
surgery to open or bypass obstructed arteries.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: Aspirin

Concentration: 81mg/tab

Route: PO

Dosage Amount: 1tab

Frequency: once daily

Pharmaceutical class: SALICYLATES

Home

Hospital

or

Both

Indication: pain, fever, prophylaxis for TIA and MI,

Adverse/ Side effects: GI BLEEDING, ANAPHYLAXIS, LARYNGEAL EDEMA
Nursing considerations/ Patient Teaching: take with full glass of water, remain upright for 15-30 min, avoid alcohol, acetaminophen or NSAIDS unless
prescribed
Name: Bumetanide

Concentration : 1mg /tab

Route: PO

Dosage Amount: 1 tab

Frequency: Q AM

Pharmaceutical class: loop diuretec

Home

Hospital

or

Both

Indication:edema due to heart failure, hepatic disease, renal impairment

Adverse/ Side effects: dehydration, hypochloremia, hypookalemia, hyponatremia, hypovolemia, metabolic alkalosis
Nursing considerations/ Patient Teaching: asses for skin rash, discontinue with first sign of rash. Contact physician for cramps, muscle weekness, nausea,
numbness, tingling of extremities
Name: Carvedilol

Concentration 3.125mg/tab

Dosage Amount : 1 tab

University of South Florida College of Nursing Revision September 2014

Route: PO

Frequency: BID

Pharmaceutical class: Beta blocker

Home

Hospital

or

Both

Indication: hypertension,HF, MI
Adverse/ Side effects: bradycardia, HF, pulmonary edema, anaphylaxis, angioedema, dizziness, fatigue, diarrhea, erectile dysfuntion
Nursing considerations/ Patient Teaching: abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, MI
Name; Docusate sodium
Route

Concentration: 100mg/cap

PO

Dosage Amount 1tcap

Frequency BID

Pharmaceutical class: stool softner

Home

Hospital

or

Both

Indication: prevention of constipation

Adverse/ Side effects: diarrhea, mild cramps,
Nursing considerations/ Patient Teaching: short term therapy, increase fluid intake, increasing bulk diet, do not take with other laxatives within 2 hrs
Name:clopidogrel

Concentration: 75mg/tab

Route: PO

Dosage Amount 1 tab

Frequency: once daily

Pharmaceutical class: platelet aggregation inhibitor

Home

Hospital

or

Both

Indication: reduction of atherosclerotic events

Adverse/ Side effects: GI bleeding, rash with eosinophilia and systemic symptoms, neutropenia, thrombocytopenia
Nursing considerations/ Patient Teaching: notify if fever, chills, sore throat, rash, unusual bleeding or bruising.
Name: Lovenox

Concentration; 40mg/0.4mL

Route: SQ

Dosage Amount : 40mg

Frequency: Q24H

Pharmaceutical class: antithrombotic

Home

Hospital

or

Both

Indication; prevention of VTE /DVT,

Adverse/ Side effects: edema, hypertension
Nursing considerations/ Patient Teaching: monitor VS, intake and output, watch for fluid overload, edema
Name: Escitalopram

Concentration: 10mg/tab

Route: PO

Dosage Amount: 1 tab

Frequency: once daily

Pharmaceutical class: SSRI

Home

Hospital

or

Both

Indication: depression, GAD

Adverse/ Side effects: neurolyptic malignant syndrome, suicidal thoughts, serotonin syndrome, insomnia, diarrhea, nausea
Nursing considerations/ Patient Teaching: advice caregiver to look for suicidal thoughts and notify anxiety insomnia, change in mood, rash
Name: GAbapentin

Concentration: 300mg/cap

Route; PO

Dosage Amount 1 cap

Frequency: QHS

Pharmaceutical class: anticonvulsant

Home

Hospital

or

Both

Indication: neuropathic pain, anxiety, diabetetic peripheral neuropathy

Adverse/ Side effects:suicidal thought, confusion, depression, rhabdomyolysis, multiorganhypersensitivity reactions
Nursing considerations/ Patient Teaching: advice caregiver to look for suicidal thoughts and notify anxiety insomnia, change in mood, rash
Name: Losartan

Concentration: 25mg/tab

Route: PO

Dosage Amount

12.5mg, 0.5 tab

Frequency: once daily

Pharmaceutical class: angiotensin 2 receptor antagonists

Home

Hospital

or

Both

Indication: hypertension, diabetic nephropathy, stroke prevention

Adverse/ Side effects: diarrhea, angioedema
Nursing considerations/ Patient Teaching: notify swelling of face, eyes, lips, or toungue, difficulty swallowing or breathing

University of South Florida College of Nursing Revision September 2014

Name: Omaprazole

Concentration 20mg/cap

Route: PO

Dosage Amount 40mg , 2cap

Frequency: once daily

Pharmaceutical class: proton pump inhibitor

Home

Hospital

or

Both

Indication: GERD , duodenal ulcers, reduce GI bleed

Adverse/ Side effects:
Nursing considerations/ Patient Teaching; notify black tarry stool,diarrhea, abdominal pain, severe headache
Name: Rosuvastatin

Concentration: 20mg/tab

Route: PO

Dosage Amount: 1tab

Frequency: once daily

Pharmaceutical class: hmg coa redctase inhibitor

Home

Hospital

or

Both

Indication: hypercholesterolemia
Adverse/ Side effects: Rhabdomyolysis
Nursing considerations/ Patient Teaching: notify unexplained muscle pain, tendernss, weakness accompanied by fever or malaise
Name: spironolactone

Concentration: 25mg/tab

Route: PO

Dosage Amount: 1 tab

Frequency: once daily

Pharmaceutical class: potassium sparing diuretic

Home

Hospital

or

Both

Indication: hyperaldosteronism
Adverse/ Side effects: hyperkalemia, rash, arrhythmias
Nursing considerations/ Patient Teaching: report rash,muscle weakness, cramps, fatigue, severe nausea, vomiting, diarrhea

Name: oxycodone

Concentration 325mg/tab

Route: PO

Dosage Amount 2 tab, 625mg

Frequency: Q4H PRN

Pharmaceutical class: opioid agonist

Home

Hospital

or

Both

Indication: severe pain

Adverse/ Side effects: constipation, respiratory depression, confusion, sedation
Nursing considerations/ Patient Teaching: teach about orthostatic hypotension,call for assistance when ambulating

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?
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Low sodium
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patients diet is adequate for his comorbidities. The
patients protein, vegetable and fiber intake is adequate.
Patient must incorporate more fruits and milk/yogurt as
they consist of less than 50% based on a daily value.
Patients sodium intake is less than 2000mg which is
appropriate.
Breakfast: oatmeal, boiled egg
Lunch: grilled/baked chicken with boiled vegetables, turkey
sandwich
Dinner: low sodium vegetable soup, baked fish, potato
Snacks: crackers, almonds,
Liquids (include alcohol): coffee
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? wife
How do you generally cope with stress? or What do you do when you are upset?
Watch TV, read books, talk to wife

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? ___no____________________________________________________

University of South Florida College of Nursing Revision September 2014

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
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: The patient is in her late adulthood with an integrity stage. When reflecting on his or her life, the older adult may
feel a sense of satisfaction (integrity) or failure (despair) (Myers, 2008, p.87).
Reference:
Myers, D. G., (2008). Development through the life span: Psychology in everyday life (pp. 78) New York, Worth Publishers.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is a very strong and positive thinking man. Even with his BKA he seems to deal with it in a positive way with
the help of his wife and kids who support him very well.

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

Hospitalization seems to worry him little bit, but no major changes in developmental stage.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Life style and diet
What does your illness mean to you?
Interruption in daily activites

+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? _____________________________________________________________
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?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? __________________________________

University of South Florida College of Nursing Revision September 2014

How long have you been with your current partner?____41yrs___________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? ___no______________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
no

University of South Florida College of Nursing Revision September 2014

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

What importance does religion or spirituality have in your life?
goes to church when
possible_____________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
___not much _______________________________________________________________________________________________
______________________________________________________________________________________________________

+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? cigarette
Former smoker

How much?(specify daily amount)

1/day

Yes
No
For how many years? Since
1961
(age

15

thru 66

If applicable, when did the

patient quit? 2013

Pack Years: 18 pack/year

Does anyone in the patients household smoke tobacco? If
so, what, and how much? Yes, unknown

Has the patient ever tried to quit? no

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

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What?
How much? 2-4 times a month
Volume:
Frequency:
If applicable, when did the patient quit?

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
no
5. For Veterans: Have you had any kind of service related exposure?
no

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:
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:
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
2/day
x/year

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

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other: diminished bases bilaterally

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

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
Arthritis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox

University of South Florida College of Nursing Revision September 2014

10

Other:

Other:LBKA,R toe amputation, popbypass

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

11

10 PHYSICAL EXAMINATION:
General Survey:

Height 193cm
Pulse: 90
Respirations 20
SpO2 98%

Weight 180.3lb
BMI 21.94
Blood Pressure: brachial 132/87

Pain: 5, RLE incisional

Temperature: (route
Is the patient on Room Air or O2 NC 2L
taken?) 98.7
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
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: peripheral 18
Location: right forearm
Date inserted: 3/4/2015
Fluids infusing?
no
yes - what? D5 @ 50
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 earinches & left earinches
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:
RUL
Cl
LUL CL
RML
D
LLL D
RLL D

Chest expansion

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

University of South Florida College of Nursing Revision September 2014

12

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:
Carotid:
Brachial:
Radial:
Femoral:
Popliteal:
DP: doppler
pulses
PT:
No temporal or carotid bruits
Edema: RLE
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
RLE
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
/
/
)
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:
GU
Urine output:
Clear
Cloudy
Color: yellow
N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Not assessed, patient alert, oriented, denies problems

Previous 24 hour output:
without assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __5_____ RUE ___5____ LUE __2_____ RLE

or

mLs

with assistance

& ___BKA____ 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

University of South Florida College of Nursing Revision September 2014

13

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
accucheck

Dates
3/13/15

Trend
150 high

Analysis
diabetes

creatinie

3/13/15

1.7-1.8 high

PT/INR

3/13/15

9.1/ 2.3

Hemoglobin

3/13/15

12 low

Patients baseline with

Bumex
Antiplatelet therapy
level
anemia

+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.)
Incentive spirometer, VS Q4H,
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. pain
2. fall risk
3. impaired mobility
4. ineffective breathing pattern
5.risk for infection

University of South Florida College of Nursing Revision September 2014

14

 15 CARE PLAN
Patient Goals/Outcomes
Pain level<4
Safety-patient will remain free
from falls

Improved mobility

Effective breathing pattern

Patient will be free from infections

Nursing Diagnosis: Nursing Diagnosis goes here

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Assess pain level, provide comfort To obtain desired pain relief
measures, medicate as EMAR,
monitor VS
Located near nurses station, call
To make sure patient does not
light in place and educated to use,
move out of bed without assistance
bed alarm, non-skid socks, fall risk to avoid risk of fall
arm band, top side rails up, bed
positioned in the lowest possible
height , hourly rounds, monitor VS,
monitor BP for orthostatic
hypotension
Assess ROM, Perform
To ensure improvement of mobility
active/passive ROM to all
extremities as possible, turn and
position every 2 hours, maintain
limbs in functional alignment,
encourage early ambulation with
assistance and devices, encourage
use incentive spirometer, high
protein diet, proper fluid intake,
provide positive reinforcement
during activity.
Assess respiratory rate and depth,
To avoid respiratory dysfunction
monitor breathing pattern, O2,
pneumonia,
ABGs, assess pain, sputum color,
quantity, consistency. Encourage
use of IS, use NC at 2L if O2 drops
below 95%., turn cough and deep
breath
Assess surgical incision for
To detect any infection possibility
University of South Florida College of Nursing Revision September 2014

Evaluation of Goal on Day Care

is Provided
Not met
All interventions are done
unresolved

Not met

Not met

Not met
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infection signs- pain, redness,

swelling, itching. Monitor VS,
temperature, heart rate, monitor
WBC, proper management of
incision sites- assess for abnormal
drainage. Assess foley for UTI,
monitor nutritional status, assess
immunization status

early enough to initiate treatment

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
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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References
Myers, D. G., (2008). Development through the life span: Psychology in everyday life (pp. 78) New York,
Worth Publishers.
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software]. Retrieved
from http://www.unboundmedicine.com/products/nursing_central

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