UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Nina Wilczynski

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:

S. S.

Gender:

Assignment Date: 9/24/15

Agency: VA

Age: 68 y.o.

Admission Date: 9/21/15

Marital Status:

Primary Medical Diagnosis : Generalized

weakness

Primary Language: English

Level of Education: Bachelors of Business Administration

Other Medical Diagnoses: (new on this admission)

Generalized weakness

Occupation (if retired, what from?): Retired from photographic

documentation
Number/ages children/siblings:
Daughter 49 y.o.; Brother 73 y.o.
Served/Veteran: Army
If yes: Ever deployed? Yes or No

Code Status: Full code

Living Arrangements: Lives with wife and daughter

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

Culture/ Ethnicity /Nationality: White Non-Hispanic

Religion: Roman Catholic

Type of Insurance: Optimum HE

1 CHIEF COMPLAINT:
I have Bells Palsy
Ive been falling a lot at home

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

Mr. S is a 68 year old Caucasian male with a past medical history of COPD, diabetes mellitus type 2,
hyperlipidemia, hypertension, coronary artery disease and chronic myeloid leukemia. He was recently
discharged on 9/2/15 after admission from the pulmonary clinic for a pleurodesis for recurrent pulmonary
effusion. He came to the ER 9/18/15 for new onset Bells Palsy stating he was in his usual state of health up
until one week after previous discharge. The patient reported that he began to have difficulty with ambulation
due to leg weakness and episodes of falling up to five times. He received a head CT without any acute findings
but with hypersensitivity and artifact evident in the high right frontal lobe. He was discharged the same day with
a plan to follow up outpatient for an MRI. He was admitted again 9/21/15 as a direct admit from the oncology
clinic with concerns of increased falls at home. The patient states he has symptoms of lightheadedness,
dizziness, and a mild sensation that the room is spinning. He denies loss of consciousness, leg pain and changes
in vision. He ambulates with difficulty and is only able to walk small distances. Romberg test was not assessed
due to the patients lower extremity weakness. An MRI of the brain was ordered STAT for 9/22/15 and an MRI
University of South Florida College of Nursing Revision September 2014

of the internal auditory canal was ordered for 9/23/15.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
5/15/2009
10/17/2012

Operation or Illness
Excision of a mass/lipoma of the left chest
Hardware removal right foot following an open reduction internal fixation of a fracture of the right
ankle
Recurrent pulmonary effusion: pleurodesis and single view x-ray of chest revealing mild
progressiong of bibasilar infiltrates or atelectasis with tiny bilateral pleural effusion
ER visit for Bells Palsy: CT head count w/o contrast revealing hypersensitivity and artifact

9/2/15
9/18

Father

91

Mother

45

Brother

73

Daughter

49

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable
)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

evident in the high right frontal lobe

Cardiac
disease

relationship
relationship
relationship

Patient is unsure of age of onset for the disease processes

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 (8/12/2014)
Adult Tetanus (8/12/2014) Is within 10 years?
Influenza (flu) (2014) Is within 1 years?
Pneumococcal (pneumonia) (8/3/2015) Is within 5 years?
Have you had any other vaccines given for international travel or
University of South Florida College of Nursing Revision September 2014

NO

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
Hytrin 2mg capsule

Type of Reaction (describe explicitly)

Dizziness

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)
Weakness is reduced strength in one or more muscles (MedlinePlus, 2015). Generalized weakness occurs all over the
body. However, weakness can also be localized to one area. Weakness in one area is more easily assessed and noticeable
(MedlinePlus, 2015). A number of factors can cause weakness. For example, the cause of weakness can be infectious,
neurologic, endocrine, inflammatory, rheumatologic, genetic, metabolic, electrolyte-induced, or drug-induced (Saaguil,
2005). Some risk and causative factors for weakness include stoke, injury to a nerve, or multiple sclerosis flare ups
(MedlinePlus, 2015).If a specific cause for weakness is suspected, then lab tests should be conducted to verify its cause.
Treatment would then be to treat the cause of the weakness (Saguil, 2005). However, more times than not the cause of the
weakness is unclear. If the cause is unknown, then electromyography can aid in detecting myopathies, neuropathies or
diseases of the neuromuscular junction (Saguil, 2005). If the electromyography provides unclear results, then diagnosing
the cause of weakness can be done through a prioritized progression of studies. The progression begins with blood
chemistries and a TSH assay to look for electrolyte and endocrine causes (Saguil, 2005).Then, a physician may look at
creatine kinase levels, erythrocyte sedimentation rates, and antinuclear antibody assays to evaluate for rheumatologic,
inflammatory, genetic, and metabolic causes (Saguil 2005). Lastly, a physician may order a muscle biopsy to diagnose the
cause of the weakness (Saguil, 2005). Once the cause of the weakness is determined, treatment can be directed at that
cause. The prognosis for weakness varies greatly on its cause and severity. For example, weakness caused by Bells palsy
has a likelihood of returning to normal strength whereas weakness caused by muscular dystrophy has a likelihood of
getting worse over time. Genetics plays a big role in the inheritance and acquisition of a number of illnesses that can cause
weakness.

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

Concentration

Dosage Amount 400mg

Route PO

Frequency Q8hr

Pharmaceutical class Gamma-Aminobutyric Acid

Indication Neuropathic pain

Home

Hospital

or

Both

Side effects/Nursing considerations May cause confusion, depression, dizziness, drowsiness. May cause rare but life threatening side effects including suicidal
thoughts, rhabdomyolysis, and multiorgan hypersensitivity reaction. Antacids may decrease absorption of gabapentin. Do not take with chamomile or other
depressants, including alcohol, opiods and sedatives, as may increase risk of CNS depression. Monitor pain levels. Monitor for signs of suicidal thoughts and
depression.
Name Enoxaparin Inj
Route SC

Concentration 40mg/0.4mL

Dosage Amount

Frequency QD

University of South Florida College of Nursing Revision September 2014

Pharmaceutical class Low molecular weight heparin

Home

Hospital

or

Both

Indication Prophylaxis for hospitalization, prevents thrombus formation

Side effects/Nursing considerations Heightened risk of causing patient harm when used incorrectly; may cause active, major bleeding and anemia. Assess for
signs of bleeding, including gum line, nose bleeds, easy bruising and occult blood in stool. Monitor CBC and platelets closely, esp. in event of thrombocytopenia.

Name Aspirin

Concentration (mg/ml)

Route PO

Dosage Amount (mg) 81mg

Frequency QD

Pharmaceutical class Salicylates

Home

Hospital

or

Both

Indication Prophylaxis of transient ischemic pain and MI

Side effects/Nursing considerations: Watch for signs of life threatening anaphylaxis, laryngeal edema and GI bleeds. May cause dyspepsia, epigastric distress,
nausea and tinnitus. May increase the risk of bleeding when taken with heparin or warfarin; provide for patient safety including non-skid socks, lowering bed
and raising side rails, and placing call light next to patient to prevent risk of injury and bleeding. Dont take in conjunction with Ibuprofen as cardioprotective
effects may decrease. Increased risk of GI irritation when taken in conjunction with NSAIDs. Monitor patient pain level, temperature and signs of toxicity
including tinnitus, headache, hyperventilation, agitation and diaphoresis.

Name Albuterol/Ipratropium

Concentration

Dosage Amount 1 inhalation

Route PO

Frequency Q 6H

Pharmaceutical class Adrenergics/Anticholinergics

Home

Hospital

or

Both

Indication Alleviates Bronchospasms/ Maintenance therapy of reversible airway obstruction due to COPD
Adverse/ Side effects: nervousness, restlessness, tremor, chest pain, palpitations, paradoxical bronchospasms with excessive use
Nursing considerations/ Patient Teaching Hold for SBP <100, DBP <55, HR <55. Beta blockers may negate therapeutic effect. Use with MAO inhibitors may lead
to hypertensive crisis. Risk of hypokalemia with concurrent use of potassium losing diuretics. Assess lung sounds, pulse and BP before administration and
during peak of administration. Note color, amount and character of sputum produced.
Name Prednisone

Concentration

Dosage Amount 40 mg

Route PO

Frequency QD

Pharmaceutical class- anti-inflammatory steroidal

Home

Hospital

or

Both

Indication Decreases the inflammatory response as with Bells Palsy

Adverse/ Side effects: depression, euphoria, hypertension, anorexia, nausea, peptic ulceration, acne, decreased wound
healing, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression, thromboembolism, muscle wasting, osteoporosis, cushingoid appearance (moon face,
buffalo hump), susceptibility to infection
Nursing considerations/ Patient Teaching- Taper down by 10 mg per day until complete. Do not abruptly stop the drug as it may cause adrenal insufficiency
(anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). Taper the dose down. Watch for a positive guaiac- stool test for dark and tarry
stools; report this to the provider. Monitor intake and output ratios and daily weight. Observe for weight gain, edema and adventitious lung sounds such as
crackles and rales. May increase risk of infection.
Name Oxycodone

Concentration

Dosage Amount 10mg

Route PO

Frequency Q6H

Pharmaceutical class Opiod agonist

Home

Hospital

or

Both

Indication Pain management for leukemia

Adverse/ Side effects- Confusion, sedation, respiratory depression, constipation
Nursing considerations/ Patient Teaching- This medication bears a heightened risk of causing significant patient harm when it is used in error. Do not take with
alcohol. Monitor bowel sounds for signs of paralytic ileus. Use cautiously in patients receiving MAO Inhibitors. Assess pain level before and during peak of
administration. Assess BP, pulse and respirations before and periodically during administration. Prolonged use may lead to physical and psychological
dependence and tolerance. This should not prevent patient from receiving adequate analgesia.
Name Insulin

Concentration 70/30 NPH/ Reg Novo Inj

Route SC

Dosage Amount 18 units

Frequency QPM

Pharmaceutical class Pancreatics

Home

Hospital

or

Both

Indication Control of hyperglycemia in patients with diabetes mellitus

Adverse/ Side effects hypoglycemia, anaphylaxis

University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching- This medication bears a heightened risk of causing significant patient harm when it is used in error. Beta blockers
may cause signs of hypoglycemia. Corticosteroids may increase insulin requirements. Stress and infection may temporarily increase insulin requirements. Assess
for symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; difficulty in concentration; trouble
sleeping; excessive hunger; nausea; tachycardia; tremor; weakness; unsteady gait)and hyperglycemia (confusion, drowsiness; flushed, dry skin; fruit-like breath
odor; rapid, deep breathing, polyuria; loss of appetite; nausea; vomiting; unusual thirst) during therapy. Monitor body weight periodically.

Name Atenolol/Chlorthalidone

Concentration 50/25mg

Route PO

Dosage Amount 1 tab

Frequency QD

Pharmaceutical class Beta blockers/ Thiazide diuretics

Home

Hospital

or

Both

Indication Treatment of mild to moderate HTN

Adverse/ Side effects: hypokalemia, fatigue, weakness, bradycardia, heart failure, pulmonary edema, erectile dysfunction
Nursing considerations/ Patient Teaching- Hold for SBP <100, DBP <55, HR <55. Use cautiously in DM as may mask signs of hypoglycemia. Do not take with
alcohol. May alter the effectiveness of insulin. Monitor BP, ECG, and pulse frequently. Monitor intake and output ratios and daily weights. Assess routinely for
HF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention). Instruct patient to change positions slowly to avoid orthostatic
hypotension.
Name Finasteride

Concentration

Dosage Amount 5mg

Route PO

Frequency QD

Pharmaceutical class - Androgen Inhibitors

Home

Hospital

or

Both

Indication BPH
Adverse/ Side effects: prostate cancer, breast cancer
Nursing considerations/ Patient Teaching- Assess for symptoms of prostatic hyperplasia (urinary hesitancy, feeling of incomplete bladder emptying, interruption
of urinary stream, impairment of size and force of urinary stream, terminal urinary dribbling, straining to start flow, dysuria, urgency). A digital rectal exam
should be done periodically to assess for BPH. At least 6-12 months may be needed to know if a patient will respond to the medication.
Name Insulin Aspart Human

Concentration 100 Units/mL

Route SC

Dosage Amount

Frequency QID

Pharmaceutical class- Pancreatics

Home

Hospital

or

Both

Indication Control of hyperglycemia in type 2 diabetes

Adverse/ Side effects- hypoglycemia, anaphylaxis
Nursing considerations/ Patient Teaching- Per Sliding Scale BG 150-199 1unit, BG 200-249, 3units, BG 250-299 5units, BG 300-349 7units, BG 350-399 9units,
BG >399 9 units and call MD. This medication bears a heightened risk of causing significant patient harm when it is used in error. Beta blockers may cause signs
of hypoglycemia. Corticosteroids may increase insulin requirements. Stress and infection may temporarily increase insulin requirements. Assess for symptoms of
hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; difficulty in concentration; trouble sleeping; excessive
hunger; nausea; tachycardia; tremor; weakness; unsteady gait)and hyperglycemia (confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep
breathing, polyuria; loss of appetite; nausea; vomiting; unusual thirst) during therapy. Monitor body weight periodically. Do not confuse Novolog with Novolin.
Administer in the abdominal wall, thigh, or upper arm within 510 min before a meal. Rotate injection sites.
Name Trazadone

Concentration

Dosage Amount 100mg

Route PO

Frequency QHS

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name Valcyclovir

Concentration

Dosage Amount 100omg

Route PO

Frequency Q8H

Pharmaceutical class Antivirals

Home

Hospital

or

Both

Indication Treatment/ suppression of genital herpes

Adverse/ Side effects: headache, nausea, renal failure, thrombotic thrombocytopenic purpura/ hemolytic uremic syndrome with very high doses in immunecompromised patients
Nursing considerations/ Patient Teaching- Continue to take for a total of seven days with the last dose to be taken 9/25/15. Assess facial drooping and genital
lesions before and daily during therapy. Do not confuse with Valcyte. Inform patient that valacyclovir does not prevent the spread of herpes labialis to others.

University of South Florida College of Nursing Revision September 2014

Advise patient to avoid contact with lesions while lesions or symptoms are present.
Name Oxybutynin Chloride

Concentration 50mcg/1spray

Route PO

Dosage Amount 10mg

Frequency QD

Pharmaceutical class Anticholinergics

Home

Hospital

or

Both

Indication Urinary incontinence

Adverse/ Side effects: dizziness, drowsiness, dry mouth, constipation, nausea, urinary retention, anaphylaxis, angioedema
Nursing considerations/ Patient Teaching: Do not take with alcohol. Monitor voiding pattern and intake and output ratios, and assess abdomen for bladder
distention prior to and periodically during therapy. Do not confuse Ditropan XL (oxybutynin) with Diprivan (propofol).
Name Fluticasone

Concentration

Dosage Amount

Route Nasal

Frequency BID

Pharmaceutical class Corticosteroids

Home

Hospital

or

Both

Indication Seasonal or perennial allergic rhinitis.

Adverse/ Side effects: anaphylaxis, angioedema, headache, nausea, vomiting, rash, cough
Nursing considerations/ Patient Teaching: Monitor for signs and symptoms of hypersensitivity reactions (rash, pruritis, swelling of face and neck, dyspnea).
Monitor degree of nasal stuffiness, amount and color of nasal discharge, and frequency of sneezing. Instruct patient in correct technique for administering nasal
spray. Shake well before use. Before first-time use, prime unit by spraying 6 times. If not used for at least 7 days or if cap left off for more than 5 days, reprime
unit. Warn patient that temporary nasal stinging may occur.

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
2000 Calorie Carb Controlled Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Healthy Diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patient ate less than the daily recommended amount of
calories. His diet allowed for 2000 calories per day but he
ate 1807 calories (United States Department of Agriculture,
2015). The patient is obese, so a lower calorie intake is
actually beneficial to his health.
Breakfast: 2 poached eggs, whole wheat toast with 2 tbs
The patients protein intake was 134% of the daily
butter,
recommended amount of protein. He needs to eat 2 ounces
of protein less in order to be within his daily recommended
amount of protein (United States Department of
Agriculture, 2015). He also only ate 69% of his daily
recommended amount of vegetables (United States
Department of Agriculture, 2015). The patient needs to
increase his vegetable intake. To decrease his protein intake
and increase his vegetable intake, the patient could put less
lunch meat in his sandwich at lunch and add other
vegetables. The patient could also eat only one egg for
breakfast to decrease his protein intake.
The patient had 100% of his daily recommended amount of
fruit. However, he only ate 85% of his daily recommended
amount of grains and only 47% of his daily recommended
amount of dairy (United States Department of Agriculture,
2015). He needs to increase his grain and dairy intake. The
patient could have a snack that would incorporate these two
food groups. For example, he could eat crackers with a
glass of milk.
Lunch: a sandwich with ham, roast beef, provolone cheese, Moreover, the patient ate 3035mg of sodium with a
lettuce, tomato and mayonnaise,
2300mg daily recommendation (United States Department
of Agriculture, 2015). To decrease his sodium intake, the
patient could choose to make his own sandwich meat rather

University of South Florida College of Nursing Revision September 2014

than buying processed meats.

The patients saturated fat intake was 30g with a daily
recommended amount of 22g (United States Department of
Agriculture, 2015). To decrease his saturated fat intake, the
patient could add sugar free jelly to his toast for breakfast
rather than butter.
Dinner: One baked chicken breast, 1 cup asparagus, 1 cup
brown rice, 3 scoops sugar free ice cream
Snacks:
Liquids (include alcohol): 2 cubs orange juice, 1 cup coffee
7 cups 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 helps me. I live with my wife and my daughter. They both care for me
How do you generally cope with stress? or What do you do when you are upset?
I dont get upset, Im fine really

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Nope, Im doing alright

+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? _____Oh, well yes________________________________________
Have you ever been talked down to?__Uh, ya. If you want to know what talked down to looks like, join the army_____
Have you ever been hit punched or slapped? __Yes, to both of those____________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_____Ya, I have been_____________________________________
If yes, have you sought help for this? ___No___________________
Are you currently in a safe relationship?

Yes

University of South Florida College of Nursing Revision September 2014

 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:
Integrity- 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.(Cherry, 2005)
Despair-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.(Cherry, 2005)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is in the integrity stage. He continually would recall different experiences he went through in life. He would
offer me advice based off his life experiences, indicating he has attained wisdom. He spoke of his life as though he had no
regrets and laughed often at his past. He showed no signs of bitterness or despair for the life he had lived.

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

The patient was happily relating his life events without consideration for his hospitalization. His condition did not seem to
effect his developmental stage of life.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
My nerves are irritated. Its causing them to droop. Its related to my herpes
What does your illness mean to you?
Well, its going to go away, but it sure is a pain trying to go to the bathroom

+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? _______I dont really care honestly. I prefer women.________________
Are you aware of ever having a sexually transmitted infection? ____Ya. I gave herpes to my wife__________________
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? __Ya, with my wife_________________________ 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? ____Me and my wife are too old for that______
How long have you been with your current partner?_____37 years__________________________________________
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?
______Oh ya, I need to talk to the priest. I grew up Catholic. I have to do confessionals weekly. Ill say my prayers right, and I go to
mass. Its important to me. No one is perfect. Right? But its good to go and to help out God. _______________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
________Sometimes the priest will come in and pray with 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)
Cigars
1

Yes
No
For how many years? X years
(age 35

thru

58

If applicable, when did the

patient quit? Age 58 y.o.

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much?
His wife, cigarettes, 2 per day

Has the patient ever tried to quit? Yes

If yes, what did they use to try to quit? 2005

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? Methamphetamine
How much? 0.25g/day
For how many years? 7
(age 35

Is the patient currently using these drugs?

Yes No

thru 42

If not, when did he/she quit?

1889

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?
Haha, ya Ive got plenty of exposure!

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: none
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: Right facial droop,

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? 2010
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: Leukemia

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

2/day

Hematologic/Oncologic

Metabolic/Endocrine
2/day
2/year

Diabetes
Type: 2
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? 9/2/15
Other: Bilateral pleural effusion

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 9/15

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? 3 years
Date of last prostate exam? 6/13
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: Arthralgia of right ankle

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: Mr. S is Height 69 in
Weight 254lbs
BMI 37.6
Pain: (include rating and
a joyful 68 y.o.
location): 8/10 generallized
Pulse 63
Blood Pressure: (include location)
Caucasian male who
157/76
Respirations 14
laughs a lot and responds
readily to questioning
Temperature: (route
SpO2 99
Is the patient on Room Air or O2
taken?) 97.4 (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
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
Cap refill of the lower extremities was greater than 3 seconds. Cap refill of the upper extremities was less than 3 seconds. The
skin was covered with a multitude of tattoos is various locations. The patient says he has had 13 different tattoos.
Central access device Type:
Location:
Date inserted:
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 /3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 12
inches & left ear- 12
inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Some cavities and yellowing of teeth. Black areas around the back teeth near the gum line
Comments: Facial drooping on the right side. Vision adequate with glasses/
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 clear
LUL
clear
RML diminished
LLL
diminished/ crackles
RLL diminished/ 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: 2+
Carotid: 2+ Brachial: 2+ Radial: 2+ Femoral: Not assessed Popliteal: 1+ DP: 1+ PT: 1+
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
Cap refill in lower extremities greater than 3 sseconds
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 / 23
/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
Other Describe: Patient states he has herpes lesions on genetalia
GU
Urine output:
Clear
Cloudy
Color:
yellow
Previous 24 hour output: 1350
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at 5_______ RUE __5_____ LUE ___4____ RLE

mLs N/A

& __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; 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: +1

Biceps: +1 Brachioradial: 0 Patellar:

+1

Achilles: 0

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
Glucose 135
138
140

Dates
9/24/15
9/23/15
9/22/15

CBC: RBC- 4.09

HGB- 11.3
HCT- 32.1

9/24/15

CBC: RBC- 4.25

HGB- 11.6
HCT- 33.4

9/23/15

CBC: RBC- 4.03

HGB- 11.0
HCT- 31.6

9/22/15

MRI brain w&w/o

contrast

9/23/15

Trend
Consistently high

The H/H have been

consistently low and the
RBCs have been low to
borderline low.

Nonspecific 3mm focus

of enhancement in the
distal right internal
auditory canal (IAC) can
be seen with Bells palsy.
Volume loss and mild
white matter disease

Analysis
Patient is a type 2 diabetic
that is currently on a
prednisone taper for
Bells Palsy. The blood
glucose level is likely to
be high.
The patient has a dx of
leukemia that would
likely be the cause of the
low values.

The patient has an active

dx of Bells Palsy and has
been having dizziness and
weakness in the lower
extremities with episodes
of falls. Irritation of the
nerves of the IAC may be
consistent with the
symptoms

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+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.)
Activity- Up with assistance and progress to independent activity as tolerated; Fall precautions
Diet- 2000 Cal Barb Controlled Diet
Consults- Home health
Prosthetics request
Nursing- Please place adult diaper briefs
VTE prophylaxis
Accu checks QID
Vitals per routine. Call MD if T >101/5, P> 110, RR>30, SBP >180 <90, DBP >100 <50
Orthostatic vitals Qam
Weight- record every morning after voiding at same time with same scale
Strict I&O
IS Q2hr while awake
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by diminished lung sounds, history
of COPD and dyspnea.
2. Chronic Pain related to hematological malignancy as evidenced by patients self-report of chronic pain levels.
3. Risk for infection related to chronic disease and immunosuppression.
4. Risk for falls related to decreased lower extremity strength, foot problems, orthostatic hypotension and difficulty with
gait.
5.

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 15 CARE PLAN
Nursing Diagnosis:
Risk for falls related to decreased lower extremity strength, foot problems, orthostatic hypotension and difficulty with gait.

Patient Goals/Outcomes
The patient will use assistive
devices correctly by the end of
shift.
The patient will be able to identify
and eliminate clutter, spills and
glare from the floors by the end of
shift.

The patient will use safe transfer

procedures by the end of the shift.

Nursing Interventions to Achieve

Goal
Put in a PT consult to teach the
patient how to use a walker
correctly. Have the patient use the
walker through a teach back
method to ensure education.
Thoroughly orient the client to the
environment. Check patients LOC
and check if the patient is A&Ox3.
Place the call light within reach
and show the patient how to use it.
Aid the client in identifying risk
factors for falls, such as clutter on
the floor. Patient education on
clutter, spills and glare and how
these can be risk factors for falls.

Rationale for Interventions

Provide References
Walkers help to prevent falls and
assist the patient with ambulation.
Patient demonstration of using a
walker ensures patient education.

Evaluation of Goal on Day Care

is Provided
The patient correctly was able to
use a walker by the end of shift and
was able to ambulate with
supervision.

Checking the patients LOC and

A&O status helps to assess the
patients cognitive status and if he
is able to identify risk factors for
falls. Orienting the client to the
environment is key because the
hospital space and be small and
cramped. Making sure the patient
understands that clutter, spills and
glare can all lead to falls aids in
patient fall prevention education.
Teaching the patient how to use the
call button ensures he is able to
have help ambulating in case the
area is unsafe and cramped.
Safe transfer methods help prevent
falls in times of ambulation from
one area to another, or in changes
of sitting to standing, etc.
Orthostatic hypotension education
promotes patient understanding of
slow postural change to prevent
dizziness and lightheadedness
leading to falls.

The patient is A&Ox3 and is alert

and oriented. He is able to
ambulate around his hospital space
and to the restroom. He was able to
ask for assistance in picking up a
comb from the floor. He can
identify clutter, spills and glare as
risk factors for falls.

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Put in a PT consult to teach the

patient how to correctly transfer
from a sitting position to standing,
and other transfer methods. Teach
the patient about orthostatic
hypotension and the necessity to
change positions slowly to prevent
falls.

The patient is knowledgeable of

orthostatic hypotension and the
need to change positions slowly.
He is able to recreate safe transfer
methods with the physical
therapist.

The patient will be able to educate

his wife and daughter on falls
prevention behavior upon
discharge.

Nursing and PT patient education

on falls prevention behavior
throughout the hospital stay will
enable the patient to teach the
family members living in his
household about falls prevention.

The client will remain free of falls

upon discharge.

Assist client with ambulation to the

restroom with bathroom checks
Q2hours. Put up side rails on bed.
Place non-skid socks on patients
feet. Keep bed at lowest level
possible. Make sure a falls risk
wristband is on the patient at all
times. Place a call button near the
patient and ensure the patient
understands how to use it. Promote
adequate lighting in the area at all
times with easy access to light
switch during the night time.

The family members living in the

patients household will play a role
in assisting the patient with
ambulation after discharge. They
need to know falls prevention
strategies such as the use of
assistive devices, eliminating glare,
clutter and spills from floors and
safe transfer methods.
Promoting ambulation to the
restroom will prevent patient falls
should the patient try to get to the
restroom too quickly. Side rails
prevent a patient from falling out
of the bed. Non-skid socks provide
friction upon ambulation and
prevent falls. Keeping the bed at
the lowest level minimizes the
distance the patient needs to go to
touch the ground. Fall risk
wristband promotes awareness to
others around the patient to aid the
patient with ambulation and not
block his path. The call button will
have the patient ask for help with
tasks he is unable to do instead of
having him attempt to support
himself. Adequate lighting with
easy access to a light switch will
aid the patient in seeing his
surrounds and avoiding fall risks.

The patients family members were

not in to see the patient at the time
of shift. Unable to assess the
familys knowledge of falls
prevention strategies.

All of the interventions were

successful put in place and the
patient experienced no falls by the
end of the shift.

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
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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
Cherry, K. A. (2005). Erikson's stages of psychosocial development. Retrieved from
http://psychology.about.com/od/psychosocialtheories/a/psychosocial.htm
Choosemyplate.gov. (2015, January 1). Food Tracker. Retrieved from
https://www.supertracker.usda.gov/foodtracker.aspx
MedlinePlus. (2014). Weakness. Retrieved from https://www.nlm.nih.gov/medlineplus/ency/article/003174.htm
Saguil, A. (2005). Evaluation of the patient with muscle weakness. American Family Physician, 71(7), 1327-1336. Retrieved from
http://www.aafp.org/afp/2005/0401/p1327.html

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