UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Aimee Achat

Assignment Date: 08/30/16
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: STJ
1 PATIENT INFORMATION
Patient Initials: MD Age: 53 Admission Date: 08/28/16
Gender: Female Marital Status: Divorced Primary Medical Diagnosis
Primary Language: Spanish (secondary is English) Acute appendicitis
Level of Education: Associates Degree Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Department of Health
Number/ages children/siblings: Daughter 34, Daughter 30

Served/Veteran: N/A Code Status: Full

If yes: Ever deployed? Yes or No
Living Arrangements: Lives with 30 year old daughter with 2 grand Advanced Directives: No
children If no, do they want to fill them out? No
Surgery Date: 08/28/16 Procedure:
Culture/ Ethnicity /Nationality: Puerto Rican Appendectomy
Religion: Roman Catholic Type of Insurance: Av med

1 CHIEF COMPLAINT:
Pain in lower right abdominal area

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient felt throbbing pain on Saturday at 4am in the lower right abdomen. Any activity made it worse and the patient
took Gabapentin to see if it will help with the pain. The pain got progressively worse later in the morning and she elected
to come to the hospital.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
2009 Total hysterectomy
2009 Artificial bladder sphincter

N/a Bursitis in the right knee

N/a Arthritis

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause
Alcoholism

MEDICAL

Glaucoma

Problems

Problems
Allergies

of

Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY
Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father 74 Heart attack
Mother 81
Brother 61
Brother 55
relationship

relationship

relationship

Comments: Include age of onset

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 (Date) U
Adult Tetanus (Date) Is within 10 years? U
Influenza (flu) (Date) Is within 1 years? U
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List Hepatitis A and B
If yes: give date, can state U for the patient not knowing date received

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 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
NKMA N/A

Medications

NKA N/A
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)
Appendicitis is the inflammation of the appendix. According to the National Institute of Diabetes and Digestive and
Kidney Diseases [NIDDK] (2013), the exact cause of appendicitis is unknown, however, there are a few possible causes
such as: blockage of the opening, enlarged tissue in the wall due to infection in GI tract, IBD, any growths that can clog
the appendiceal lumen, and trauma to the abdomen. Many patients have sharp abdominal pain in the lower right quadrant
and it is further diagnosed by different methods: physical exams such as Rovsings sign and Psoas sign, lab tests such as
blood tests and urinalysis, and Imaging tests such as an ultrasound, MRI, or CT scan (NIDKK, 2013). There are a few risk
factors if it is not treated quickly usually in laparoscopic surgery or laparotomy which result in peritonitis or an
appendiceal abscess (NIDKK, 2013).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: Wellbutrin or bupropion Concentration Dosage Amount 300mg

Route orally Frequency Take 2 tablets by mouth daily

Pharmaceutical class: Antidepressant Home Hospital or Both
Indication: To help with smoking cessation and major depression
Adverse/ Side effects: Nausea, vomiting, constipation, dry mouth, loss of appetite, severe headache, confusion, hallucinations, seizures
Nursing considerations/ Patient Teaching: Avoid alcohol because it may increase drowsiness. It may also take up to 3 weeks to be effective.

Name Lexapro or escitalopram Concentration Dosage Amount 20mg

Route orally Frequency Take 1 tablet by mouth daily

Pharmaceutical class: Antidepressant Home Hospital or Both
Indication: To treat major depression symptoms or anxiety
Adverse/ Side effects: Worsening in mood or behavior changes, weight changes, nausea, vomiting, blurred vision, racing thoughts,
Nursing considerations/ Patient Teaching: Make sure patient is not taking any MAOI drugs. Do not drink any alcohol.

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Name Prevacid or lansoprazole Concentration Dosage Amount 30mg

Route orally Frequency Take 1 tablet by mouth daily

Pharmaceutical class: Proton Pump Inhibitor Home Hospital or Both
Indication: To treat stomach and duodenal ulcers, GERD
Adverse/ Side effects: Diarrhea, rash, headache, dizziness, abdominal pain, nausea, anxiety, muscle pain.
Nursing considerations/ Patient Teaching: Take 30 minutes or more before a breakfast.

Name Flonase or fluticasone Concentration 50mcg Dosage Amount

Route nostril Frequency Use 2 sprays in each nostril daily

Pharmaceutical class: Corticosteroid Home Hospital or Both
Indication: To treat allergic rhinitis
Adverse/ Side effects: Nosebleeds, bloody nasal secretions, nasal burning or irritation, sore throat.
Nursing considerations/ Patient Teaching: Do not abruptly stop the medication.

Name Neurontin or gabapentin Concentration Dosage Amount 300mg

Route orally Frequency Take 1 capsule by mouth daily as needed

Pharmaceutical class: Anticonvulsant Home Hospital or Both
Indication: To treat neuropathy and arthritis pain
Adverse/ Side effects: Fatigue, dizziness, sedation, blurred vision, fever, seizures, lethargy, mouth sores
Nursing considerations/ Patient Teaching: Report any seizures which could be aplastic anemia. Avoid driving until the effects are known.

Name Ultram or tramadol Concentration Dosage Amount 50mg

Route orally Frequency Take 1 tablet by mouth daily as needed for pain
Pharmaceutical class: Analgesic Home Hospital or Both
Indication: To help manage moderate to severe pain i.e. arthritis
Adverse/ Side effects: dizziness, vertigo, constipation, hallucinations, numbness, tingling in hands or feet
Nursing considerations/ Patient Teaching: Take only as needed as it can be habit-forming.

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Clear liquids Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: caf con leche, cereal (Honey nut Cheerios) Patients BMI is 36, reducing caloric intake by 500 calories
per day will help the patient lose approximately 1lb a week.
Lunch: Rice, pinto beans, chicken Replace white rice with brown rice, quinoa, barley or
cauliflower rice. Adding vegetables to meals will add
Dinner: Rice, pinto beans, beef or chicken nutrition to diet i.e. pico de gallo (fresh tomatoes)
Add small nutritious snacks throughout the day i.e.
Snacks: Nature valley granola bars Fruits, nuts, vegetables, yogurt cups

Liquids (include alcohol): water, juice

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? Neighbor and daughter

How do you generally cope with stress? or What do you do when you are upset?
Lorazepam used for anxiety, Prayer, and has a therapist to talk about anxiety and depression

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

+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? _____Yes__________________________________________________

Have you ever been talked down to? _Yes____ Have you ever been hit punched or slapped? __Yes_________

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? _Yes with psychiatrist__

Are you currently in a safe relationship? Yes

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 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: According to Treas (2014), generativity refers to being an active member of society and the individual will feel as
though they are making a difference in the world. Whereas, stagnation refers to the inability to find a way to contribute to society.

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 generativity stage because she feels like a contributing member of society and is still working. She is
also helping to take care of her grandchildren.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The patients disease will not impact her stage of life because she is eager to go back to work and continue to raise her
grandchildren.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The patient is unsure of what the cause of her illness is.

What does your illness mean to you?

The patient stated that her illness was a surprise and did not realize how dangerous it can be without treatment.

+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? _Men________________________________________________________
Are you aware of ever having a sexually transmitted infection? __No__________________________________________
Have you or a partner ever had an abnormal pap smear?___Yes at age 23_______________________________
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?
____N/A________________ When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? ____No______________________________

How long have you been with your current partner?__N/A__________________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? _N/A_______________________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
_Religion is her first priority in life________________________________________________
_____________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
The patient stated that religion helps to keep her mind off of her illness and to keep her safe.
______________________________________________________________________________________________________

+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? 35 years
10 cigarettes a day (age 18 thru 53 )

If applicable, when did the

Pack Years:
patient quit?
During pregnancy
Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? Her daughter, unsure of amount If yes, what did they use to try to quit? Patches, Bupropion

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? A beer or 2 socially For how many years? 35
Volume: 12 14 oz (age 18 thru 53 )
Frequency: socially
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?
N/A How much? N/A For how many years? N/A
(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

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

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 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: beach SPF: 50 Diverticulitis Life threatening allergic reaction
Bathing routine: Twice a day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy?
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: A+
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 Type:
Routine dentist visits x/year Hypothyroid /Hyperthyroid
Vision screening: 2 years ago Intolerance to hot or cold
Other: 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? April 2016 Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? 11 Encephalitis
last CXR? menopause age? 53 Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
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
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? Arthritis Chicken Pox
Other: Other: Other:

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

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
N/A

Any other questions or comments that your patient would like you to know?
N/A

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10 PHYSICAL EXAMINATION:

General Survey: well- Height: 64 inches Weight: 96 kg BMI: 36 Pain: (include rating and
groomed and dressed Pulse 96 Blood Pressure: (include location) location)
appropriately. Respirations 17 121/74 brachial 4/10 lower right abdomen
Temperature: (route SpO2 : 96% Is the patient on Room Air or O2
taken?) 98 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
Dressing is clean and dry

Central access device Type: n/a 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- yes 13 inches & left ear- yes 13 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: No missing teeth or known dental problems
Comments:

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL CL LUL CL
RML CL LLL CL
RLL CL

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

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 Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

[rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding], 4-bounding]

Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3
No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: n/a 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 08 / 28 / 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: 1000 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

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):

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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.
CT scan positive for appendicitis 08/28/16.

Lab Dates Trend Analysis

WBC The high lab value shows The WBC increased
13.1 8/28/16 that there is an infection slightly after the surgery
14.1 8/29/16 or active inflammation to help the body heal.
HCT Hematocrit is low due to The low lab value post-
36.2 8/28/16 a ruptured appendix surgery indicates the
35.5 8/29/16 incision site

+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.)
Post-surgery the patient will be on a clear liquid diet as tolerated and the lab values will be monitored for any
signs of infection. Due to the patient being stable, vital signs will be taken every 30 minutes for 2 hours then
every hour for 2 hours then every 4 hours if patient is still stable.

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

1. Risk for infection related to incision

2. Risk for bleeding related to surgical procedure

3. Acute pain related to incision sites.

4. Risk for constipation related to anesthesia

5. Impaired body image related to surgery.

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 15 CARE PLAN
Nursing Diagnosis: At risk for bleeding r/t surgery.
Patient Goals/Outcomes Nursing Interventions to Rationale for Interventions Evaluation of Goal on Day Care
Achieve Goal Provide References is Provided
Patient will refrain from activities Change dressings as ordered and A regimen of monitoring dressing Patient will monitor site for any
that can re-open incision site monitor site can reduce bleeding (Ackley, bleeding and incision site will be
2011) clean.

Patient will resume normal Monitor vital signs and helping Monitor for signs of bleeding such Patients incision sites will be
activities within a week patient ambulate as soon as as bruising or abdominal pain healing well and is able to perform
possible. (Ackley, 2011) normal activities.

Include a minimum of one

Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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 15 CARE PLAN
Nursing Diagnosis: At risk for infection r/t incision
Patient Goals/Outcomes Nursing Interventions to Rationale for Interventions Evaluation of Goal on Day Care
Achieve Goal Provide References is Provided
Patient will remain free of Nurse will assess the incision site Redness, warmth, discharge and At the end of the nurses shift, the
infection aeb absence of heat, pain, for any abnormalities at the increased body temperature are dressing will be clean and dry.
redness, unusual drainage at beginning and end of each shift. signs of infection (Ackley, 2011)
incision site.

Patient will engage in proper The nurse will educate the patient Lower rate of MRSA was linked Patient will demonstrate proper
hygiene such as hand washing on how to properly wash hands. to good hand hygiene (Ackley, hand-washing
2011)

Patient will be remain infection- Educate patient about the If the full course of medication is Patient will take all of the
free at home with antibiotics importance of taking the whole not taken, the remaining bacteria antibiotics and will show no signs
prescription of antibiotics. are likely to be resistant to the of infection at office visit.
antibiotic and a new strain may
develop (FDA, 2009)

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

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F/U appointments: To assess incision site and make sure it is free from infection.
Med Instruction/Prescription : Take pain medications only as needed to prevent habit-forming activity
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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 References

Ackley, B.J., & Ladwig, G.B. (2011). Nursing Diagnosis Handbook: An evidence-based guide to

planning care. St Louis, MO: Elsevier.

National Institute of Diabetes Digestive and Kidney Diseases. (2013) Appendicitis. Retrieved

from https://www.niddk.nih.gov/health-information/health-topics/digestive-

diseases/appendicitis/Pages/overview.aspx

Treas, L. S., & Wilkinson, J. M. (2014). Basic Nursing. Philadelphia, PA: F.A. Davis Company.

U.S. Food and Drug Administration. (2009) Are you taking your medications as prescribed.

Retrieved from http://www.fda.gov/downloads/ForConsumers/Consumer

Updates/UCM165097.pdf

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