UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Gianna Constantine

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 3/24/2016

Agency: SJH

Patient Initials: G.H.

Age: 70

Admission Date: 3/19/2016

Gender: Male

Marital Status: Married

Primary Medical Diagnosis: Spinal Cord

Compression

Primary Language: English

Level of Education: High school

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired, forklift driver at general

motors

Right ankle fracture

Number/ages children/siblings: Two sons, 50 and 47. Three

brothers, two of which have passed.
Served/Veteran: No
If yes: Ever deployed? Yes or No

Code Status: Full code

Living Arrangements: Lives with spouse in a double-wide trailer

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: 3/20
Procedure: Complete
cervical laminectomy C3 & C4

Culture/ Ethnicity /Nationality: White, non-hispanic

Religion: Protestant

Type of Insurance: Blue Cross Blue Shield

1 CHIEF COMPLAINT:
Weakness and neck pain.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
This pleasant 70-year-old male with a past medical history of anterior fusion of the cervical spine ten years ago and
hemochromatosis was transferred here from Winter Haven Hospital for progressive weakness in all four extremities. The
patient had originally arrived at Winter Haven for a fall in which he fractured his ankle. His pain began four days prior to
admission at SJH and resided in his neck bilaterally. It was acute and gradual. On admission, the patient stated that the
pain felt like a heat sensation and also led to a severe headache. Movement aggravated his neck and medication relieved
it. Pain level was 9 out of 10 on admission. The patient continues to have a striking type of sensation and currently, he is
experiencing neck pain that he ranked a 4 out of 10. Aggravating and relieving factors remain the same. MRI on 3/19
revealed severe upper cervical disc herniation with cord compression and edema. There were no complications during
complete cervical laminectomy on 3/20, and doctors stated that it was a success. The patients hospital stay has been
complicated and prolonged due to episodes of Atrial Fibrillation. The plan is to continue current course of care, and to
increase diltiazem due to increase in blood pressure (systolic over 170). Eventually, patient will be discharged to a
rehabilitation center.

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
10 years ago

Operation or Illness
Anterior fusion of the cervical spine

Diagnosed 20
years ago
Diagnosed 10-15
years ago

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

old age

(angina,
MI, DVT
etc.)
Heart
Trouble

87

Gout

Brother
Brother

Glaucoma

old age

Diabetes

85

Cancer

Brother

Bleeds Easily

old age

Asthma

86

Arthritis

Mother

Anemia

88

Environmental
Allergies

Father

Cause
of
Death
(if
applicable
)
old age

Alcoholism

Hypertension: takes medication, such as diltiazem and hydrochlorothiazide-losartan.

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Hemochromatosis: Chelation therapy; takes Exjade 1x daily

77

relationship
relationship

Comments: Include age of onset

Patient states that his family never had any medical problems. When asked about cause of death, he responded old age to both of
his parents and his two brothers.

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? Yes
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
Povidone iodine
topical

Type of Reaction (describe explicitly)

I am just allergic. I break out and get real sick.
Hives, swelling, difficulty breathing

Medications

Shellfish

Hives, swelling, difficulty breathing

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)
A spinal cord injury is a process. It is an on-going condition that can be caused by many things. The patient in this
scenario had suffered spinal cord compression years ago. His current MRI revealed severe upper cervical disc herniation
with cord compression and edema. Spinal cord compression occurs when something impinges on the spinal cord, which
then causes increased pressure. The tissue of the spinal column then responds with demyelination and axonal loss. Rapid
compression will cause edema, which shows in this patients MRI. Edema can lead to an even further progression to the
parenchymal pressure, which is why it is important that it is removed. Anyone is able to develop an injury that can lead to
spinal cord compression, but there a few factors that can lead to an increased risk. Some factors include poor lifting
techniques and people that have osteoarthritis (DePietro, 2013). Genetics do not seem to be a factor related to spinal cord
compression injuries, but race, sex, and age all have shown significance. White males seem to be the most likely to obtain
spinal cord compression injuries (Chin, 2015). Prognosis of a spinal cord compression injury depends on the patient.
Some patients may respond well to treatment while others may not. Since this patient has had a previous history of spinal
cord compression problems, it is likely that his spinal cord injury will not fully heal after his surgery. This is not to say
that he will be in a cervical collar for the rest of his life, but his daily activities may be affected.

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

Concentration:

Dosage Amount: 20 mg

Route: PO
Frequency: 1x daily
Pharmaceutical class: hmg coa reductase inhibitor
Home
Hospital
or
Both
Indication: Management of hypercholesterolemia and prevention of heart disease
Adverse/ Side effects: abdominal cramps, constipation, diarrhea, heart burn, rashes
Nursing considerations/ Patient Teaching: avoid grapefruit juice; should be used in conjunction with diet restrictions (i.e. low
cholesterol diet); notify physician of all medications/oral supplements; notify physician if any unexplained muscle pain occurs.
Name: deferasirox (Exjade)

Concentration:

Dosage Amount: 125 mg

Route: PO
Frequency: 1x daily
Pharmaceutical class: Chelating agents
Home
Hospital
or
Both
Indication: hemochromatosis
Adverse/ Side effects: urinating less than usual or not at all, feeling short of breath, rapid weight gain, nausea, jaundice, claycolored stools, stomach bleeding; dizziness, blurred vision
Nursing considerations/ Patient Teaching: Make sure doctor is aware of all allergies before taking this medication, as it contains

University of South Florida College of Nursing Revision September 2014

some inactive ingredients that may cause allergic reactions to other problems. Do not drive until you are sure you can drive
safely due to the possibility of dizziness and blurred vision; tell doctor if you have kidney disease or liver disease.
Name: ceFAZolin (Ancef)

Concentration: 2g/50 mL

Dosage Amount: 50mL

Route: IVPB
Frequency: q8hour
Pharmaceutical class: 1st generation cephalosporins
Home
Hospital
or
Both
Indication: periop prophylaxis; tx of infections due to susceptible organisms
Adverse/ Side effects: diarrhea, n/v, rash, pain at IM site, and phlebitis at IV site.
Nursing considerations/ Patient Teaching: Report signs of superinfection (furry overgrowth on tongue, loose or foul-smelling
stools) and allergy. Notify physician if rash or fever and diarrhea develop, especially if diarrhea contains blood, mucous, or pus.
Name: diltiazem (Cardizem)

Concentration:

Dosage Amount: 360 mg

Route: PO
Frequency: 1x daily
Pharmaceutical class: calcium channel blocker
Home
Hospital
or
Both
Indication: Hypertension
Adverse/ Side effects: hypotension, peripheral edema, bradycardia, dizziness, weakness
Nursing considerations/ Patient Teaching: change positions slowly to minimize orthostatic hypotension; avoid driving; maintain
good dental hygiene; self-monitor pulse
Name: docusate (Colace)

Concentration

Dosage Amount: 100 mg

Route: PO
Frequency: 1x daily
Pharmaceutical class: stool softener
Home
Hospital
or
Both
Indication: prevention of constipation
Adverse/ Side effects: throat irritation, mild cramps, diarrhea, rashes
Nursing considerations/ Patient Teaching: used as short-term therapy. Encourage other forms of bowl regulation (increasing
fluid intake); avoid straining during bowel movement
Name: enoxaparin (Lovenox)

Concentration: .4mL/40mg

Dosage Amount: 40mg

Route: subcutaneous injection

Frequency: 1x daily
Pharmaceutical class: antithrombotic; LMWH
Home
Hospital
or
Both
Indication: prevention of DVT
Adverse/ Side effects: bleeding, anemia, constipating, n/v
Nursing considerations/ Patient Teaching: watch for signs of bleeding. Tell patient to report any unusual bleeding. Dont take
aspirin/ibuprofen without consulting physician
Name: hydrochlorothiazide-losartan
Concentration
Dosage Amount: 50mg-12.5mg
(Hyzaar)
Route: PO
Frequency: 1x daily
Pharmaceutical class: thiazide diuretics/ARBS
Home
Hospital
or
Both
Indication: hypertension
Adverse/ Side effects: stomach or back pain, dry cough, hypokalemia, diarrhea, angioedema
Nursing considerations/ Patient Teaching: Assess for signs of angioedema; take as directed, even if feeling well; avoid salt
substitutes containing potassium, move positions slowly. Comply with additional hypertension interventions.
Name: pantoprazole (Protonix)

Concentration

Dosage Amount: 40mg

Route: PO
Frequency: 1x daily
Pharmaceutical class: proton pump inhibitor
Home
Hospital
or
Both
Indication: prophylactic for stress ulcers
Adverse/ Side effects: hyperglycemia, hypomagnesemia, abdominal pain, diarrhea
Nursing considerations/ Patient Teaching: Assess routinely for epigastric/abdominal pain and/or occult blood in stool/emesis.

University of South Florida College of Nursing Revision September 2014

Monitor bowel function. Avoid alcohol, NSAIDS, and take full course. Notify physician if rash, diarrhea, abdominal cramping,
fever/bloody stools occurs
Name: PARoxetine (Paxil)

Concentration

Dosage Amount: 20mg

Route: PO
Frequency: 1x daily
Pharmaceutical class: SSRI
Home
Hospital
or
Both
Indication: major depressive disorder/anxiety
Adverse/ Side effects: drowsiness, headaches, dry mouth, weakness, sweating, serotonin syndrome, constipation, diarrhea,
nausea
Nursing considerations/ Patient Teaching: Do not take with MAOI. Assess for suicidal tendencies. Assess for serotonin syndrome
(mental changes, GI symptoms, autonomic instability, neuromuscular aberration). Follow up appointments are important to
monitor progress. Notify physician if headache, weakness, nausea, anorexia, anxiety, or insomnia persists

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? Regular
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? No iron diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Whole wheat toast (2 slices of bread), 1 cup of
Adding 1 cup of low fat milk to breakfast will help to
grapes, 1 banana. Margarine on toast, both slices.
increase his dairy by 33%! Also, changing the margarine to
real unsalted butter will help decrease sodium levels and
will be a healthier option.
Lunch: 1 cup of melon, 1 cup of grapes or strawberries.
Sandwich with whole wheat bread with 3 slices of ovenroasted turkey low in sodium.

Fruit seems to take up a lot of the patients diet. While fruit

is healthy, it also contains a lot of sugar. Switching to just
one type of fruit per meal will decrease the amount of sugar
that the patient is consuming, and adding 1 cup of
vegetables during lunch time will also help to increase the
amount of vegetables the patient is consuming. If the
patient does not like vegetables by themselves, he can try
making a salad filled with spinach leaves, tomatoes,
cucumbers, and possibly adding a protein like chicken to
help increase his protein intake. Eating this salad without
dressing is ideal, but if dressing is necessary, choosing a
low-fat dressing would be best.

Dinner: 1 piece of cod fish, cooked with margarine. Salt

and pepper put on fish.

Patient needs to add vegetables to diet. Add 1 cup of

broccoli or other type of vegetables to his dinner.

Snacks: Maybe a cookie or two. Patient referring to

chocolate chip cookies.

Have a low sodium cheese stick and some vegetables

instead of cookies will help to increase dairy levels and
vegetable levels.

Liquids (include alcohol): Iced tea, 2 Coca-Colas a day (not

diet), 2-3 glasses of water, socially drinks 3-5 beers.

Eliminate soda from diet. If unable to eliminate, switch to

diet soda. Reducing number of beers he drinks socially to
1-2 beers instead of 3-5. This will reduce sodium levels.

**Patient was not very forthcoming when asking questions

about nutrition. When asked a question he would reply, I
dont know until I provided him an example, to which he
would reply, Yes.

https://supertracker.usda.gov/foodtracker.aspx

University of South Florida College of Nursing Revision September 2014

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
My wife.
How do you generally cope with stress? or What do you do when you are upset?
I cope pretty good. I do whatever I want.

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

University of South Florida College of Nursing Revision September 2014

No.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? ___No___________________________________________________
Have you ever been talked down to?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: Integrity versus despair is the eighth and final stage of Erik Erikson's theory of psychosocial

development. This stage occurs during late adulthood from age 65 through the end of life. During this period of
time, people reflect back on the life they have lived and come away with either a sense of fulfillment from a life well
lived or a sense of regret and despair over a life misspent (Cherry, n.d.).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is in the integrity stage because he feels a sense of fulfillment about how he has chosen to live his life.
Although he did not talk to me much about his family life, he seemed very content with how he chose to spend his
life with his wife. He did not seem to care about the materialistic things in life; he just seemed to care about the
world as a whole. This stages main characteristic is wisdom, and I feel that this patient truly has attained a
considerable amount of wisdom in his lifetime. He is very proud of all his accomplishments. This means that even
when he is confronting death, he will attain wisdom.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

I feel that my patients illness will not set him back in his developmental stage of life. Although his current state
may prevent him from resuming his usual physical activities and performing self-care, I believe he will still
appreciate everything that life has offered him. He is fully aware of his condition, and he does not let it define him.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Age.
What does your illness mean to you?
I dont know what that means well its not good.

University of South Florida College of Nursing Revision September 2014

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?____Yes________________________________________________________
Do you prefer women, men or both genders? _____Women_______________________________________________
Are you aware of ever having a sexually transmitted infection? _No_________________________________________
Have you or a partner ever had an abnormal pap smear?____No ________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___No____________________________________
Are you currently sexually active? _______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? None_______________________________
How long have you been with your current partner? Over 50 years___________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? Current condition_____
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?
____Its not important.__________________________________________________________________________________
____________________________________________________________________________________
Do your religious beliefs influence your current condition?
_______No__________________________________________________________________________________________
______________________________________________________________________________________________________

+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?
Yes
What? Beer
How much?: 3-5 beers
Volume: 36-50 fl oz
Frequency: socially
If applicable, when did the patient quit?
N/A

No
For how many years? Current
Since the age of 20

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?
N/A

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:30
Bathing routine: 1x/day
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? 2014
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: Hemochromatosis

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

6x/day

Hematologic/Oncologic

Metabolic/Endocrine
2x/day
1x/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? 3/20
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 3/24

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? 1x/yr
Date of last prostate exam? 3/2015
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

11

Other:

Other:

Other:

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

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

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

University of South Florida College of Nursing Revision September 2014

12

10 PHYSICAL EXAMINATION:
General Survey: clean,
appropriate, calm, resting

Height: 61
Pulse: 94
Respirations: 17
SpO2: 98

Weight: 231 lbs

BMI: 30.5
Blood Pressure: (include location)
143/78: left upper arm
Is the patient on Room Air or O2:

Pain: (include rating and

location) 4- neck

Temperature: (route
taken?) 97.8 oral
Room air
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
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
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:
Location:
Date inserted:
Fluids infusing?
no
yes- what?

flat
loud

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 2mm
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: clean, straight, white teeth. Good oral hygeine
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: Clear
RUL : CL
LUL: CL
RML: CL
LLL: CL
RLL: CL

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

13

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: 2+
Popliteal: 2+ DP: 2+ PT:2+
No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
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 3 / 17 / 16 )
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:
2100 mLs N/A
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 ___5____ RLE

& ___5____ in LLE

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

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: +2

Biceps: +2

Brachioradial: +2

Patellar: +2 Achilles: +2 Ankle clonus: positive negative Babinski: positive negative

University of South Florida College of Nursing Revision September 2014

14

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
WBC: 18.7, 18.6, 17.5,
17.3, 16.9, 14.5, 14.2,
13.1

Dates
3/17,3/18/3/19,3/20,3/21,
3/22,3/23,3/24

HGB: 17.1, 17.4, 15.2,

15.1, 14.3, 14.6, 12.1,
11.7

3/17,3/18/3/19,3/20,3/21,
3/22,3/23,3/24

HCT: 34.2, 33.7, 35.3,

36.9, 38.1, 38.7, 39.5,
39.9

3/17,3/18/3/19,3/20,3/21,
3/22,3/23,3/24

Lymphocytes: 1.1, 1.4,

1.3, 1.7, 2.1, 1.9, 1.8, 2.0

3/17,3/18/3/19,3/20,3/21,
3/22,3/23,3/24

Trend
High on admission, but
has decreased throughout
stay.

Analysis
Since the patient
presented with a high
WBC count, an infection
might have been present
on admission. However,
with treatment, the white
blood cell counts have
decreased, indicating that
whatever they infection
may have been is getting
better.
Normal on admission,
Typically, low HGB
now have decreased and
levels indicate anemia.
are low
However, he has not been
diagnosed with such. This
low level may be a side
effect of a medication,
such as the Lovenox.
Low on admission, now
Hematocrit levels can
are normalized
often detect anemia,
polycythemia, and
hydration status. This
patient may have had
decreased HCT levels on
admission due to the
stress of his injuries,
however, now that the
patient has been given
fluids and is receiving
proper care, his levels
have normalized.
These levels have been
Since the patient came
low throughout the entire into the hospital with low
admission process, but
lymphocyte levels, which
they have been improving have proceeded to remain

University of South Florida College of Nursing Revision September 2014

15

low, the cause of this may

be from a medication that
is being taken at home
and at the hospital. These
are being monitored as a
part of the CBC along
with HCT, HGB, and
WBC. Levels also may be
low due to
hemochromatosis.
High the whole admission The monocyte levels in
this patient may just be
high due to stress, or they
can be high due to an
infection. Because the
WBC count decreased
throughout the admission,
an infection is not likely.
Levels may be off due to
hemochromatosis.
Normal cholesterol level. The patient came into the
hospital with a normal
cholesterol level,
indicating that he is
getting a good amount of
cholesterol in his body.
This is healthy.

Monocytes: 1.7, 1.5, 1.8,

1.9, 2.1, 1.6, 1.3, 1.8

3/17,3/18/3/19,3/20,3/21,
3/22,3/23,3/24

Cholesterol: 199

3/21

Sodium: 137, 136, 139,

141, 145, 143, 140, 141

3/17,3/18/3/19,3/20,3/21,
3/22,3/23,3/24

Normal throughout
admission

Normal sodium levels

indicate normal nerve and
muscle function, as well
as adequate hydration and
electrolyte balance.

Potassium: 2.1, 2.5, 2.9,

3.1, 3.4, 3.3, 3.7, 3.8

3/17,3/18/3/19,3/20,3/21,
3/22,3/23,3/24

Critical on admit, levels

normalized post surgery
and vitamin supplements
provided.

Hypokalemia on
admission may have
occurred for many
reasons including
excessive alcohol use,
excessive laxative use,
folic acid deficiency, as
well as vomiting and
diarrhea.

MRI

3/19

N/A

Severe upper cervical disc

University of South Florida College of Nursing Revision September 2014

16

herniation with cord

compression and edema.
+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.)
Ok to ambulate as necessary, vital signs q4 hours, compression device intermittent pneumatic bilaterally,
dressing change 1x daily, I & O q shift, saline lock when taking oral fluids, neuro assessment q 4 hours,
CIWA-AR assessment per protocol, weigh 1x daily, braden score daily, fall risk scale q12 hours, IPE 2x
daily, regular diet, OT additional treatment 3x/week, pt additional treatment 1x daily, non-weight bearing.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Impaired physical mobility r/t recent laminectomy AEB inability to purposefully move and placement of cervical collar.
2. Constipation r/t change in activity level AEB loss of ability to evacuate stool voluntarily.
3. Ineffective breathing pattern r/t impairment of innervation of diaphragm AEB decreased respiratory rate
4. Risk for trauma r/t temporary weakness and instability of spinal column
5.Risk for impaired skin integrity r/t immobility
6. Risk for autonomic dysreflexia r/t altered nerve function
7. Risk for falls r/t immobility and unsteady gait

University of South Florida College of Nursing Revision September 2014

17

 15 CARE PLAN
Nursing Diagnosis: Impaired physical mobility r/t recent laminectomy AEB inability to purposefully move and placement of cervical collar.
Patient Goals/Outcomes

Nursing Interventions to Achieve

Goal
Client will participate in activities
Schedule activity and procedures
that promote mobility of unaffected with rest periods. Encourage
body parts (i.e. arms, legs).
individual participation in ADLs
within individual limitations.

Rationale for Interventions

Provide References
This enhances healing and builds
muscle strength and endurance.
Having the patient participate in
their own ADLs will promote a
sense of independence and control
(Vera, 2014).
This will evaluate the state of the
individuals specific situation.
Motor-sensory impairment is
important to assess, and depending
on assessment results, treatment
may differ (Vera, 2014).
This will promote constant
movement and strengthening
exercises of the legs, arms, and
back (Vera, 2014).

Evaluation of Goal on Day Care

is Provided
Goal met.

Client will not have any evidence

of contractures or foot drop this
shift.

Continually assess motor function

by requesting client to complete
specific actions (i.e. shrug
shoulders, spread fingers, squeeze
and release examiners hands).

Client will participate in care with

PT.

Work closely with the physical

therapy department in order to
determine a proper plan-of-care for
this patient based on the surgical
procedure.

Client will understand the proper

body mechanics needed for
participation in activities.

Educate the client on proper

techniques for body movement so
as not to further injure himself.

This will reduce any risk of

possible muscle strain, injury, or
pain. It will also increase patient
involvement in this progressive
activity (Vera, 2014).

Goal met.

Client will not obtain any bedsores

during this shift.

Assess the clients skin integrity q4

hours with every vital signs check.
Give patient bath 1x/day to make
sure patient is clean. Make sure to
log roll the patient when

This will promote good skin

integrity. Turning a patient will
reduce the likelihood of pressure
sores and hospital acquired
infections (Vera, 2014).

Goal met.

University of South Florida College of Nursing Revision September 2014

Goal met.

Goal met.

18

repositioning.

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

15 CARE PLAN
Nursing Diagnosis: Constipation r/t change in activity level AEB loss of ability to evacuate stool voluntarily.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will have a bowel
Patient will take prescribed stool
Administering this stool softener as Goal not met.
movement this shift.
softener as ordered to promote a
prescribed will stimulate peristalsis
bowel movement. If bowel
and routine bowel evacuation
movement not present by end of
(Vera, 2014).
shift, a suppository will be
necessary.
Patient will eat foods that will
promote bowel movement.

Patient will establish a satisfactory

Encourage well-balanced diet that

includes bulk and roughage.
Consult the registered dietician to
discuss a plan. Adding more fiber
to the diet will likely promote more
bowel movement.

Improves consistency of stool for

movement throughout the bowel
(Vera, 2014).

Establish regular daily bowel

A program like this is necessary to
University of South Florida College of Nursing Revision September 2014

Goal met.

Goal not met.

19

bowel elimination pattern by

discharge.

program, including digital

stimulation, prune juice, warm
beverage, and use of stool softeners
and suppositories.

routinely evacuate the bowel.

Incorporating elements of the
patients usual routine may
enhance cooperation and success of
the program. It is important to have
consistent bowel elimination for
the patients physical independence
and well-being (Vera, 2014).

Patient will have normal bowel

sounds and normal abdominal
assessment this shift.

Auscultate bowel sounds, noting

location and characteristics. Assess
abdomen using auscultation,
palpation, and percussion.

Bowel sounds may be absent if the Goal met.

patient has any type of spinal shock
which can be promoting the
constipation. Also, an abnormal
bowel assessment, such as
tenderness in any of the quadrants,
can indicate an obstruction that
may be causing the constipation
(Vera, 2014).

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

University of South Florida College of Nursing Revision September 2014

20

References
Cherry,K.(n.d.).IntegrityvsDespair:PsychosocialDevelopment.RetrievedApril5,2016,from
http://psychology.about.com/od/psychosocialtheories/a/integrityversusdespair.htm
Chin,L.S.(n.d.).Spinalcordinjuries.Medscape.RetrievedApril4,2016fromhttp://emedicine.medscape.com/article/793582
overview
DePietro, M. A. (2013). Spinal cord compression. Retrieved April 4, 2016 from http://www.healthline.com/health/spinal-cord
Compression
SuperTracker: My Foods. My Fitness. My Health. (n.d.). Retrieved April 5, 2016 from https://supertracker.usda.gov
Vallerand, A.H., Sanoski, C. A., Deglin, J. H., & Mansell, H. G. Daviss Drug Guide. Unbound Medicine, Inc
[Mobile Application Software]. Available from http://nursing.unboundmedicine.com/nursingcentral/ind ex/Davis-Drug
Guide/All_Entries/A
Van Leeuwen, A. M. & Bladh, M. L. (2015). Daviss Laboratory and Diagnostic Tests (Cholesterol; Complete Blood Count;
Hematocrit; Hemoglobin; Lymphocytes; Monocytes; Sodium; Potassium; White Cell Count). Unbound Medicine, Inc.
[Software]. Available from http://nursing.unboundmedicine.com/nursingcentral/ub/index/Davis-Lab-and-Diagnostic
Tests/All/A
Vera, M. (2014, May 10). 12 Spinal Cord Injury Nursing Care Plans - Nurseslabs. Retrieved April 5, 2016, from
http://nurseslabs.com/12-spinal-cord-injury-nursing-care-plans/
University of South Florida College of Nursing Revision September 2014

21

University of South Florida College of Nursing Revision September 2014

22