UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Evonne Piazza

Assignment Date: 01/22/2016

MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: MPM
1 PATIENT INFORMATION
Patient Initials: A,A Age: 81 Admission Date: 01/20/2016

Gender: Female Marital Status: Married Primary Medical Diagnosis: COPD

Primary Language: English

Level of Education: Bachelors in College Other Medical Diagnoses: (new on this admission)
None
Occupation (if retired, what from?): Retired from Social Work

Number/ages children/siblings: No children or siblings

Served/Veteran: Code Status: Full Code

If yes: Ever deployed? Yes or No

Living Arrangements: Lives in a one story home with her husband Advanced Directives: Yes

Surgery Date: Procedure:

Culture/ Ethnicity /Nationality: American/Caucasian

Religion: Protestant Type of Insurance: Medicare, Medicaid

1 CHIEF COMPLAINT:
Chest pain and trouble breathing

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient is an 81 year old female who was being seen by her pulmonologist today. The patient was recently hospitalized
For GI bleeding and anemia. Since leaving the hospital last week, she has had significant shortness of breath with
Activity of some chest tightness at that time. She is comfortable at rest and O2 dependent. She was directed to
Dr. Mosburg, a HCP, to rule out an acute problem. She was sent to the Morton plant ER. At the ER, her testing
Was unremarkable with stable oxygen saturations on oxygen and/or room air as well as negative EKG, chest x-ray, and
CTA of the chest other than a right upper lobe nodule that will need follow up. Because of the exertional component
Of the dyspnea, it was elected to admit her for both cardiac and pulmonary evaluation and treatment.

University of South Florida College of Nursing Revision September 2014 1

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
Arthritis
2010 Colon Cancer (Resolved)
2006 Diabetes Mellitus, type II
2014 DVT (resolved)
2014 Dyslipidemia
2013 Emphysema
2002 HTN
2011 Pulmonary emboli (resolved)
2011 Renal insufficiency (resolved)
2013 Chronic bronchitis
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma

of
Cancer

Problems

Tumor
Stroke
Allergies

MI, DVT
Gout
MEDICAL Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Heart
Father 83
Attack
Mother 88 Cancer
Brother
Sister
relationship

relationship

relationship

Patients mother died from cancer, however patient cannot remember what kind of cancer her mother had.
Patient does not have any siblings or children.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (U)
Adult Tetanus (2008)
Influenza (flu) (2015)
Pneumococcal (pneumonia) (2013)
Have you had any other vaccines given for international travel or
University of South Florida College of Nursing Revision September 2014 2
 occupational purposes? Please List

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Aleve Hives
Codeine Vomiting
Metformin Hives
Medications
Morphine Nausea, vomiting

NKFA
Other (food, tape, NKTA
latex, dye, etc.) NKLA
NKDA

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)
COPD is a complex syndrome comprised of airway inflammation, mucocillary dysfunction and consequent airway
Structural changes. COPD is characterized by chronic inflammation of the airways, lung tissue and pulmonary blood
Vessels as a result of exposure to inhaled irritants such as tobacco smoke. The inhaled irritants cause inflammatory cells
Such as neutrophils, CD8+ T-lymphocytes, B cells and macrophages to accumulate. When activated, these cells initiate
An inflammatory cascade that triggers the release of inflammatory mediators such as tumor necrosis factor alpha,
Interferon gamma, matrix-metalloproteinases, and c-reactive protein. These inflammatory mediators sustain the
Inflammatory response and lead to tissue damage as well as a range of systemic effects. The chronic inflammation is
Present from the outset of the disease and leads to various structural changes in the lung which further perpetuate airflow
Limitation. Risk factors for COPD include: exposure to tobacco smoke, people with asthma who smoke, occupational
Exposure to dusts and chemical, age and genetics. COPD can be diagnosed by pulmonary function tests, chest x-ray,
CT scan and arterial blood gas analysis. COPD can be managed by smoking cessation, medications, lung therapies,
And surgery. Some medications that can help manage COPD are bronchodilators, inhaled steroids, combination inhalers,
Oral steroids, phosphodiesterase-4 inhibitors, theophylline and antibiotics.
(Huether & McCance, 2012, p. 437-439)

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: Levemir (Insulin Detemir) Concentration Dosage Amount: 10 units

Route: SubQ injection Frequency: 2 x daily

Pharmaceutical class: Pancreatics Home Hospital or Both
Indication: Control of hyperglycemia in patients with type 1 (IDDM) and type 2 (NIDDM) diabetes mellitus.
Adverse: Hypoglycemia, anaphylaxis
Side effects: pruritus, erythema, swelling
Nursing considerations: Assess patient for signs and symptoms of hypoglycemia (anxiety, restlessness, tingling in the hands, feet lips, tongue; chills; cold sweats;
confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness;
tachycardia; tremor; weakness; unsteady gait. Overdose is manifested by symptoms of hypoglycemia. Mild hypoglycemia may be treated by ingesting oral
glucose. Severe hypoglycemia is a life-threatening emergency treatment consists of IV glucose, glucagon, or epinephrine.

Patient Teaching: Instruct patients on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur. Overdose is manifested by symtoms
of hypoglycemia. Mild hypoglycemia may e treated by ingestion of oral glucose. Severe hypoglycemia is a life-threatening emergency; treatment consists of IV
glucose, glucagon, or epinephrine. Notify health care professional if signs and symptoms of either hypoglycemia or hyperglycemia occur.

University of South Florida College of Nursing Revision September 2014 3

Name: Cyanocobalamine (Vitamin B12) Concentration Dosage Amount: 1,000 mcg

Route: IM Frequency: 1 x daily

Pharmaceutical class: Water-soluble vitamin Home Hospital or Both
Indication: Vitamin B12 deficiency
Adverse effects: Anaphylaxis
Side effects: headache, diarrhea, itching
Nursing considerations: Vials should be protected from the light.

Patient Teaching: Encourage pt to comply with diet recommendations of health care professional. Explain that the best source of vitamins is a well-balanced diet
with foods from the four basic food groups.

Name: Pravachol (Pravastatin) Concentration Dosage Amount: 40 mg

Route: PO Frequency
Pharmaceutical class: hmg coa reductase inhibitors (statins) Home Hospital or Both
Indication: adjunctive management of primary hypercholesterolemia and mixed dyslipidemias.
Adverse effects: rhabdomyolysis
Side effects: abdominal cramps, constipation, diarrhea, heartburn, erectile dysfunction
Nursing considerations: If patient develops muscle tenderness during therapy, CPK levels should be monitored. If CPK levels are markedly increased or
myopathy occurs, therapy should be discontinued.

Patient Teaching: Instruct patient to notify health care professional if unexplained muscles pain, tenderness, or weakness occurs, especially if accompanied by
fever or malaise. Instruct patient to avoid grapefruit juice while taking this medication.

Name: Novolog (Insulin aspart) Concentration Dosage Amount: Sliding Scale Insulin

Route: SubQ injection Frequency: 1 x daily hs

Pharmaceutical class: Pancreatics Home Hospital or Both
Indication: Control of hyperglycemia in patients with type 1 or type 2 diabetes mellitus.
Adverse effects: Hypoglycemia, Anaphylaxis
Side effects: pruritus, erythema, swelling
Nursing considerations: Assess patient for signs and symptoms of hypoglycemia (anxiety, restlessness, tingling in the hands, feet lips, tongue; chills; cold sweats;
confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness;
tachycardia; tremor; weakness; unsteady gait. Overdose is manifested by symptoms of hypoglycemia. Mild hypoglycemia may be treated by ingesting oral
glucose. Severe hypoglycemia is a life-threatening emergency treatment consists of IV glucose, glucagon, or epinephrine.

Patient Teaching: Teaching: instruct patients on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur.

Name: Furosemide (Lasix) Concentration Dosage Amount: 40 mg

Route: PO Frequency: 1 x daily

Pharmaceutical class: loop diuretics Home Hospital or Both
Indication: Hypertension
Adverse effects: erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, aplastic anemia, agranulocytosis

Side effects: dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis, blurred vision,
dizziness
Nursing considerations: Assess pt for skin rash frequently during therapy. Discontinue furosemide at first sign of rash; may be life threatening. Steven-Johnson
syndrome, toxic epidermal necrolysis, or erythema multiforme may develop. Treat symptomatically; may recur once treatment is stopped. Monitor electrolytes,
renal and hepatic function, serum glucose and uric acid levels before and periodically throughout therapy. A decrease is serum potassium is commonly seen.
Furosemide may also cause a decrease in serum sodium, calcium, and magnesium concentrations. May also cause an increase in BUN, serum glucose, creatinine,
and uric acid levels.

Patient teaching: Advise patient to contact health care professional immediately if rash, muscle weakness, cramps, nausea, dizziness, numbness, or tingling of the
extremities occur. Instruct pt to take furosemide as directed. Take missed doses as soon as possible; do not double dose. Caution pt to change positions slowly to
minimize hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods of time during therapy may enhance
orthostatic hypotension.

Name: Cozaar (Losartan) Concentration Dosage Amount: 50 mg

Route: PO Frequency: 1 x daily

Pharmaceutical class: angiotensin II receptor antagonists Home Hospital or Both
Indication: alone or with other agents in the management of hypertension, prevention of stroke In patients with hypertension and left ventricular hypertrophy

University of South Florida College of Nursing Revision September 2014 4

Adverse effects: Angioedema

Side effects: diarrhea, dizziness, fatigue, headache, insomnia, weakness, weight gain
Nursing considerations: Assess patient for signs of angioedema (dyspnea, facial swelling)

Patient Teaching: Instruct patient to notify health care professional if swelling of face, eyes, lips, or tongue or if difficulty swallowing of breathing occur.
Emphasize the importance of continuing to take as directed, even If feeling well, taking missed doses as soon as remembered if not almost time for next dose; do
not double doses. Medication controls but does not cure hypertension. Instruct patient to take medication at the same time each day. Warn patient not to
discontinue therapy unless directed by health care professional.

Name: Mucinex (Guaifenesin) Concentration Dosage Amount: 600 mg

Route: PO Frequency: q 12 hr
Pharmaceutical class: Expectorant Home Hospital or Both
Indication: Coughs associated with viral upper respiratory tract infections
Adverse effects: None
Side effects: dizziness, headache, nausea, vomiting, stomach pain
Nursing considerations: Inform patient that drug may occasionally cause dizziness. Avoid driving or other activities requiring alertness until response to drug is
known.

Patient Teaching: Caution parents to avoid OTC cough and cold products while breast feeding or administering to children <4 yrs. Teach pt that this medication
works by reducing viscosity of tenacious secretions by increasing respiratory tract fluid. The desired outcome of this medication is for easier mobilization and
expectoration of mucus from cough associated with upper respiratory infection. Teach patient that each dose of guaifenesin should be followed by a full glass of
water to decrease viscosity of secretions. Extended-release PO medication tablets should be swallowed whole; do not open, break, crush, or chew.

Name: Spiriva (Tiotropium) Concentration Dosage Amount: 18 mcg

Route: INH Frequency: rt 1 x daily

Pharmaceutical class: Anticholinergics Home Hospital or Both
Indication: Long-term maintenance treatment of bronchospasm due to COPD, reducing exacerbations in patients with COPD.
Adverse effects: Angioedema

Side effects: dry mouth, constipation, tachycardia, urinary retention, rash

Nursing considerations: Assess respiratory status (rate, breath sounds, degree of dyspnea, pulse) before administration and at peak of medication.

Patient Teaching: Advise patient to notify health care professional immediately if signs and symptoms of angioedema (selling of the lips, tongue, or throat,
itching, rash). Teach patient that this medication is a long acting, 24 hour, anticholinergic bronchodilator. Inform patients on how to use the Spiriva inhaler.
First, open the dust cap by pulling upward. After the dust cap is open, open the mouthpiece as well. When the mouthpiece is open insert one end of the capsule
into the center chamber and close the mouthpiece. With the dust cap still open, press the piercing button once to release the medicine. Before inhaling the
medication, exhale away from the inhaler. Keeping the mouthpiece in your mouth inhale quick and deep. Hold your breath for 10 seconds and exhale slowly
through your mouth or nose. Inhale through the mouthpiece once again to ensure you get your completed dose. When you have finished the medication, open the
mouthpiece and remove the used capsule. When storing the inhaler make sure the dust cap is closed.

Name: Synthroid (Levothyroxine) Concentration Dosage Amount: 25 mcg

Route: PO Frequency: 1 x daily

Pharmaceutical class: Thyroid preparations Home Hospital or Both
Indication: Thyroid supplementation in hypothyroidism
Adverse effects: None

Side effects: Hyperthyroidism, headache, insomnia, irritability, abdominal cramps, sweating, heat intolerance
Nursing considerations: Assess apical pulse and BP prior to and periodically during therapy. Assess for tachyarrhythmias and chest pain.

Patient Teaching: instruct patient to take medication as directed at the same time each day and take it on an empty stomach. Take missed doses as soon as
remembered unless almost time for next dose. If more than 2-3 doses are missed, notify health care professional. Do not discontinue without consulting health
care professional.

University of South Florida College of Nursing Revision September 2014 5

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Cardiac diet Analysis of home diet (Compare to My Plate and
Diet patient follows at home? No specific diet Consider co-morbidities and cultural considerations):
24 HR average home diet: According to my plate, this patient is consuming a
Breakfast: Multigrain bagel with 3 tablespoons on cream Significantly high amount of grains (175%). This patient is
Cheese, 2 cups of regular brewed coffee with one Also consuming a low amount of dairy (72%), protein
Creamer in each cup. (97%), and vegetables (39%). This patient did not consume
Any fruits in her 24 hour recall. This patient consumed
Lunch: 2 slices of white bread, 1 slice of American cheese, More calories than the daily limit (2510). This patient also
3 slices of white meat turkey with skin, and 2 cups of Consumed more than the daily limits for sugars (55g),
Homemade chocolate milk made with 2% milk. Saturated fat (34g), and sodium (4196 mg).

Dinner: 2 cups of rotini pasta cooked with salt, 1 link of (United States Department of Agriculture, n.d.)
Italian sausage, and 1 glass of red wine.
Snacks: I would educate the patient that a healthy diet would help
her body fight off infections which she is prone to
Liquids (include alcohol): 1 bottled water throughout day Due to COPD. Eating a balanced diet and maintaining a
Healthy weight are important parts of managing COPD.
I would recommend for this pt to eat low-fat protein foods
Such as lean cuts of meat, poultry, and fish, particularly
Oily fish. Whole grains foods such as whole grain bread,
Brain, brown rice, and oats. These foods are also high in
Fiber, which help improve the function of the digestion
System. I would also recommend eating fresh fruits and
Vegetables. They contain essential vitamin, minerals,
And fiber. I would lastly recommend that the patient cut
Down on her overall caloric consumption.

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 husband

How do you generally cope with stress? or What do you do when you are upset?
I usually talk to my husband if something is bothering me. But if hes the one thats upsetting me I usually just try
to get out of the house to get a break from him.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I have been feeling a little depressed and lonely. I am also anxious from being here.

University of South Florida College of Nursing Revision September 2014 6

+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?_Yes________ 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____

Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion 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: Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of
Wisdom, while failure results in regret, bitterness, and despair.
(Gilbert, Schacter, Wegner, 2014)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient seemed to be in the despair stage. Those who are unsuccessful during the integrity vs despair stage feel that
Their life has been wasted and will experience many regrets, When I asked my patient if she felt a feeling of overall
Satisfaction when she look back at her life she said Absolutely not, I never had any of my own children. When I was
Young my husband and I decided that we never wanted to have any children of our own. But as time went on I realized
I actually would have liked to have children, but my husband never agreed to it. I have some resentment toward him now.
Now that I am old and sick, I sometimes wonder what it would be like if I was a mother, or even a grandmother. But it is
Too late for that now. I feel like I basically wasted my life. I contributed nothing to this world.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
I feel that this hospitalization has made my patient focus on that fact that she never had any children of her own. She
Stated a few times that she feels lonely and that her husband only came to visit her once since she has been in the
Hospital. I believe that her feelings of loneliness influenced her to wonder how different her life would have been if she
Decided to raise of family.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Well, I smoked for many years and was never as healthy as I should have been.

What does your illness mean to you?

It means that I was stupid in the past. But I quit smoking a few years ago so hopefully that helped my health a little.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)

Have you ever been sexually active? Yes

__________________________________________________________________
University of South Florida College of Nursing Revision September 2014 7
 Do you prefer women, men or both genders? Men
_____________________________________________________________
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? __________________________________

How long have you been with your current partner? 52 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 8

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
_Gives me something to believe in.
_____________________________________________________________________________________________________
______________________________________________________________________________________________________
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? Yes No
If so, what? How much?(specify daily amount) For how many years? 40 years
Cigarettes 1 pack per day (age 18 thru 58 )

If applicable, when did the

Pack Years: 40
patient quit? 23 years ago

Has the patient ever tried to quit? Yes

Does anyone in the patients household smoke tobacco? If
If yes, what did they use to try to quit? Nicotine patches
so, what, and how much? No
and gum

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years?
Volume: (age thru )
Frequency:
If applicable, when did the patient quit?

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 thru )

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Not that I know of.

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

University of South Florida College of Nursing Revision September 2014 9

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: Diverticulitis Life threatening allergic reaction
Bathing routine: Once a day before bed Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy? 01/14/2016
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer, colon cancer
Blood Transfusions, pt received blood
Sinus pain or infections polyuria
on 01/21/2016
Nose bleeds kidney stones Blood type if known: AB
Post-nasal drip Normal frequency of urination: 4 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2 x/day Diabetes Mellitus Type:2
Routine dentist visits 2 x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Pt has never had a vision screening Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? 6/2015 Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? 14 Encephalitis
last CXR? 01/20/2016 menopause age? 53 Meningitis
Date of last Mammogram &Result:
Other: Other:
1/2015, negative
Date of DEXA Bone Density & Result: Pt
Has never had DEXA Bone Density test.
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
University of South Florida College of Nursing Revision September 2014 10
 Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, 01/22/2016 Arthritis Chicken Pox
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 11

10 PHYSICAL EXAMINATION:

General Survey: Pt Height: 55 Weight:210 BMI: 34.9 Pain: (include rating and
appearance correlates Pulse: 84 Blood Pressure: (left upper arm) location)
with her age. Patient is Respirations:14 149/98 Pain upon exertion in chest
alert and oriented with 5/10
symmetrical facial
features. No signs of
acute distress. Weight
and height are not within
the normal range, pt has
a BMI or 34.9. Pt is able
to stand erect and sit
comfortably. Gait is
coordinated. Patients
walk is smooth and well
balanced and has full
mobility of joints. Patient
maintains eye contact
with appropriate
expression and is very
cooperative and
comfortable. Speech is
clear. Pt seems to be
clean and well groomed.
Temperature: (route SpO2 : 92% Is the patient on Room Air or O2:
taken?) 3L nasal cannula
97.6 (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

Peripheral access device Type: IV 20 gauge Location: Upper inner forearm Date inserted: 01/22/2016
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 2 mm /2 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
University of South Florida College of Nursing Revision September 2014 12
 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: Patient reports routine brushing of teeth 2-3 day, routine dentist visits 2x a year. Patient denies any dental problems.
Comments:

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
Pt had diminished breath sounds, prolonged expiratory time, and expiratory wheezing. Upon examination the pt
Also had a barrel chest and seemed to be using their accessory muscles when breathing.

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: WH LUL: WH
RML:WH LLL: D, WH
RLL: D, WH

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

Cardiovascular: No lifts, heaves, or thrills
Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
Unable to retrieve patients ECG tracing. ECG strip was not yet uploaded to patient chart.
The finding for the ECG were uploaded to the patient chart. However, the actual strip from the monitor was not on the
report. Therefore, I was only able to get the final results that were interpreted from the strip without actually being able to
look at the strip.

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:73 Carotid: 74 Brachial:74 Radial:83 Femoral: 75 Popliteal:72 DP: 72 PT:73
No temporal or carotid bruits Edema: [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: LLE and 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 01 / 21 / 2016 ) Formed Semi-formed Unformed Soft Hard Liquid Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red

Nausea emesis Describe if present:

Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe:

GU Urine output: Clear Cloudy Color:Yellow Previous 24 hour output: 1220 mLs
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

University of South Florida College of Nursing Revision September 2014 13

 Strength bilaterally equal at ___5____ RUE ___5____ LUE ___4____ RLE & ___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:+2 Biceps:+2 Brachioradial: +2 Patellar:+1 Achilles:+1 Ankle clonus: positive negative Babinski: positive negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS :

Lab Dates Trend Analysis

RBC Upon admit, the patients When the RBC count is
RBC count was lower lower than the normal
L 2.77 01/21/2016 than the normal limits. limits it can indicate a
The RBC count trended clue for anemia, bleeding,
L 3.21 01/22/2016 upward, however, was bone marrow failure,
still lower than the deficiency of
normal limits. erythropoietin, RBC
destruction due to
transfusion, leukemia, or
malnutrition. This patient
does have a history of
renal cancer which may
have caused a deficiency
of erythropoietin leading
to a low RBC count.
HGB Upon admit, the HGB A lower than normal
count was lower than the hematocrit may indicate:
L 7.9 01/21/2016 normal limits. The HGB an insufficient supply of
count did trend upwards, healthy red blood cells
L 9.1 01/22/2016 however was still lower (anemia), a large number
than the normal limits. of white blood cells,
usually a very small
portion of your blood, due
to long-term illness,
University of South Florida College of Nursing Revision September 2014 14
 infection, leukemia,
lymphoma or other
disorders of white blood
cells. Vitamin or mineral
deficiencies can also
cause a low HGB count.
The patient was given
vitamin supplements in
the hospital that seemed
to increase the overall
HGB level. Pt was also
given a blood transfusion
that could have helped
increase the HGB level.
HCT Upon admit, the patients Low hematocrit levels
HCT count was lower usually indicate anemia.
L 24.3 01/21/2016 than the normal limits. This may be caused by
The HCT count did trend the patients kidney
L 27.8 01/22/2016 upwards, however, the failure. Severe and
HCT count was still chronic kidney diseases
lower than the normal lead to decreased
limits. production of
erythropoietin. This
patient also has a vitamin
B12 deficiency which can
also cause the HCT level
to be low.
RDW Upon admit, the patients RDW is a parameter that
RDW count was lower measures variation in
H 16.6 01/21/2016 than the normal limits. RBC size or red blood
The patients RDW count cell volume. Elevated
H 16.4 01/22/2016 continued to trend RDW helps provide a
downwards. clue for a diagnosis or
early nutritional
deficiency such as iron,
folate, or vitamin B12
deficiency as it becomes
elevated earlier than other
red blood cell parameters.
Segs Upon admit, the patients Segs is an abbreviation
segs count was within the for segmental neutrophils.
70.2 01/21/2016 normal limits. However, These are the primary
the patients segs count white blood cells
H 88.7 01/22/2016 trended upwards outside responsible for fighting
the normal limits. infection. High levels of
neutrophils indicate
infection.
Lymphs Upon admit, the patients These white blood cells
Lymph levels were within are responsible for
University of South Florida College of Nursing Revision September 2014 15
 the normal limits. fighting infection and also
22.4 01/21/2016 However, the lymph develop antibodies to
levels trended upwards protect the body against
L 10.0 01/22/2016 outside of the normal future attacks. Low levels
limits. can indicate viral
infections affecting the
bone marrow or sepsis.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

Diagnostic tests:
Echo 1/21/2016: there is a mid-concentric Left ventricular hypertrophy. Ejection Fraction is normal between 60-
65%, no regional wall motion abnormalities noted. The mitral valve leaflets appear thickened
But open well. There is mild mitral regurgitation. There is mild tricuspid regurgitation. Pulmonary
Artery pressure <25 mmHg, Aortic sclerosis is without stenosis.

EKG 01/22/2016: sinus rhythm with 1st degree AV block. PR interval has increased.
EKG 01/21/2016: normal sinus rhythm, normal ECG.

CT scan- contrast dose 75 ml omnpaque 350. Thick MIP images are submitted for volumetric analysis.
5 mm somewhat lobular noncalcific density right upper lung nodule. Atherosclerotic calcification of the aorta and
coronary arteries. No evidence for pulmonary arterial embolic disease.

Consults:
Consult to physician (in process) cardiac status/dyspnea

Physician to nurse diagnostic test: obtain and order 12 lead EKG STAT as needed for chest pain and/or sudden
rhythm changes (01/20/2016)

Cardiac diet (01/20/2016)

Physician to nurse diet instructions for CBG <70 mg/dl or hypoglycemia symptoms, awake and on tube
Feedings. Give 4 oz juice or 6 oz regular soda via tube feedings.

Labs
CBC W/PLT: blood, tomorrow AM collect, 1 x daily, 01/20/2016- 01/21/2016

CMP: Blood, tomorrow AM collect, 1 x daily, 01/20/2016- 01/21/2016

8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Ineffective airway clearance r/t bronchoconstriction, increased mucus, and ineffective cough AEB persistent cough
With sputum, use of accessory muscles, and abnormal breath sounds.

2. Impaired gas exchange r/t ventilation-perfusion inequality AEB barrel chest.

3. Risk for imbalanced nutrition r/t less than body requirements.

4. Risk for infection r/t inadequate primary defenses and chronic disease process.

University of South Florida College of Nursing Revision September 2014 16

5. Risk for self-care deficit r/t intolerance to activity and decreased strength/endurance.

University of South Florida College of Nursing Revision September 2014 17

 15 CARE PLAN
Nursing Diagnosis: Ineffective airway clearance r/t bronchoconstriction, increases mucus, and ineffective cough AEB persistent cough with sputum,
use of accessory muscles, and abnormal breath sounds.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will demonstrate behaviors Keep environmental pollution to a Precipitators of allergic type of
to improve airway clearance by end minimum such as dust, smoke, and respiratory reactions that can
of shift. feather pillow, according to trigger or exacerbate onset of acute
individual situation. episode.

(Ackley, & Ladwig, 2014, p.129)

Assist patient to assume position of This technique prevents the glottis

comfort (elevate head of bed, have from closing during the cough and
patient lean on overbed tables or sit is effective in clearing secretions.
on edge of bed)
(Ackley, & Ladwig, 2014, p.129)

Observe characteristics of cough Cough can be persistent but

(persistent, hacking, and moist). ineffective, especially if patient is
Assist with measures to improve elderly, acutely ill, r debilitated.
effectiveness of cough effort. Coughing is most effective in an
upright or in a head-down position
after chest percussion.

(Ackley, & Ladwig, 2014, p.130)

Help the client deep breathe and This technique can help reduce Goal was met. Pt was able to
perform controlled coughing. Have sputum clearance and decrease demonstrate behaviors to improve
the client inhale deeply, hold breath cough spasms. Controlled airway clearance by end of shift.
for several seconds, and cough two coughing uses the diaphragmatic
University of South Florida College of Nursing Revision September 2014 18
 or three times with mouth open muscles, making the cough more
while tightening the upper forceful and effective.
abdominal muscles.
(Ackley, & Ladwig, 2014, p.129)

Pt will maintain a patent airway at Encourage activity and ambulation Body movements help mobilize
all times as tolerated. If unable to ambulate secretions.
the client, turn the client from side
to side at least every 2 hours. (Ackley, & Ladwig, 2014, p.130)

(Ackley, & Ladwig, 2014, p.130)

Administer medications such as Bronchodilators decrease airway

bronchodilators or inhaled steroids resistance, improve the efficacy of
as ordered. Watch for side effects respiratory movements, increase
of tachycardia or anxiety with exercise tolerance, and can reduce
bronchodilators, or inflamed symptoms of dyspnea on exertion.
pharynx with inhaled steroids.
(Ackley, & Ladwig, 2014, p.130)
(Ackley, & Ladwig, 2014, p.130)

Encourage fluid intake of up to Fluids help minimize mucosal

2500 mL/day with cardiac or renal drying and maximize ciliary action
reserve. to move secretions.

(Ackley, & Ladwig, 2014, p.130)

Auscultate breath sounds q 1 to 4 Breath sounds are normally clear or

hours scattered fine crackles at bases,

University of South Florida College of Nursing Revision September 2014 19

 which clear with deep breathing.
The presence of coarse crackles
during late inspiration indicate
fluid in the airway; wheezing
indicated an airway obstruction.

(Ackley, & Ladwig, 2014, p.129)

Monitor respiratory patterns, With secretions in the airway, the

including rate, depth, and effort. respiratory rate will increase.

(Ackley, & Ladwig, 2014, p.131)

Monitor blood gas values and pulse An oxygenation saturation of less Goal was somewhat met. Patients
oxygen saturation levels as than 90% or a partial pressure of airway was patent during my shift.
available. oxygen less than 80 indicates However, I was not able to stay
significant oxygenation problems. with the patient until discharge so I
am unaware if the patients airway
(Ackley, & Ladwig, 2014, p.129) remained patent throughout their
hospitalization.

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 Pt needs home oxygen
F/U appointments To evaluate the patient during the progression of their disease.
Med Instruction/Prescription
University of South Florida College of Nursing Revision September 2014 20
 are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH Pt needs home oxygen
Palliative Care

I would explain to the patient the importance of avoiding air pollution, e.g. cigarette smoke and paint fumes.
I would also educate the client to continue to take their medication, regardless of how they are feeling.
Lastly, I would tell the patient to call 911 if they dont experience a relief from an exacerbation of COPD.

Nursing Diagnosis: Impaired gas exchange r/t ventilation perfusion inequality AEB barrel chest
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Demonstrate improved ventilation Assess and record respiratory rate Useful in evaluating the degree of
and adequate oxygenation of and depth. Note use of accessory respiratory distress of chronicity of
tissues by ABGs within patients muscles, purse-lip breathing, and the disease process.
normal range and be free of inability to speak or converse.
symptoms of respiratory distress by (Ackley, & Ladwig, 2014, p.403)
end of shift. (Ackley, & Ladwig, 2014, p.403)

Elevate HOB, assist patient to Oxygen delivery may be improved

assume position to ease work of by upright position and breathing
breathing. Include periods of time exercises to decrease airway
in prone position as tolerated. collapse, dyspnea, and work of
Encourage deep-slow or pursed-lip breathing. Note: recent research
breathing as individually needed or supports use of prone position to
tolerated. increase Pa02.

(Ackley, & Ladwig, 2014, p.403)

(Ackley, & Ladwig, 2014, p.403)

Encourage expectoration of Thick, tenacious, copious

sputum; suction when indicated. secretions are a major source of
impaired gas exchange in small
airways. Deep suctioning may be
required when cough is ineffective
University of South Florida College of Nursing Revision September 2014 21
 foe exportation of secretion.

(Ackley, & Ladwig, 2014, p.404)

Evaluate level of activity tolerance. During severe, acute, or refractory Goal was somewhat met. Patient
Provide a calm, quiet environment. respiratory distress, patient may be remained free of symptoms of
Limit patients activity or totally unable to perform basic self- respiratory distress. However,
encourage bed or chair rest during care activities because of ABGs were not done.
acute phase. Have patient resume hypoxemia and dyspnea. Rest
activity gradually and increase as interspersed with care activities
individually tolerated. remains an important part of
treatment regimen. An exercise
program is aimed at increasing
endurance and strength without
causing sever dyspnea and can
enhance sense of well-being.
(Ackley, & Ladwig, 2014, p.404)

Pt will maintain a usual mental Monitor oxygen saturation An oxygen saturation of less than
status exam throughout continuously using pulse oximetry 90% or a partial pressure of oxygen
hospitalization of less than 80 mm Hg indicates
(Ackley, & Ladwig, 2014, p.404) significant oxygenation problems

(Ackley, & Ladwig, 2014, p.403)

Perform action to decrease fear and Decreasing fear and anxiety can
anxiety. help prevent the shallow and/or
(Ackley, & Ladwig, 2014, p.404) rapid breathing that can occur.

(Ackley, & Ladwig, 2014, p.403)

Watch for signs of psychological Any of these signs can be a .

distress including anxiety, predisposing factor for a change in
University of South Florida College of Nursing Revision September 2014 22
 agitation, and insomnia. Refer for mental status.
counseling as needed.
(Ackley, & Ladwig, 2014, p.405)
(Ackley, & Ladwig, 2014, p.405)

Auscultate breath sounds every 1 to The presence of crackles and Goal was somewhat met. The
2 hours. wheezed may alert the nurse to patient maintained their usually
(Ackley, & Ladwig, 2014, p.404) airway obstruction, which may lead mental status throughout my shift.
to or exacerbate hypoxia. In severe However, I was unable to evaluate
exacerbations of COPD, lung the patient after my shift was over.
sounds may be diminished or
distant with air trapping.

(Ackley, & Ladwig, 2014, p.402)

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 Nutritional intake meeting caloric needs.
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments To continue evaluating the patient throughout their COPD progression
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 23

University of South Florida College of Nursing Revision September 2014 24
University of South Florida College of Nursing Revision September 2014 25
University of South Florida College of Nursing Revision September 2014 26
 References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook An evidence-based guide to

planning care. Maryland Heights, MO: Elsevier

Gilbert, D. T., Nock, M. K., Schacter, D. C., & Wegner, D. M. (2014). Psychology. New York, NY:

Worth.

Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology. Maryland Heights, MO:

Elsevier.

United States Department of Agriculture. (n.d.). My plate. Retrieved from

http://www.choosemyplate.gov/contact-us.html

University of South Florida College of Nursing Revision September 2014 27

University of South Florida College of Nursing Revision September 2014 28