UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Rachael Lewkowiez

Assignment Date: 10/25/16

MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: STJ
1 PATIENT INFORMATION
Patient Initials: AWT Age: 77 Admission Date: 10/24/16

Gender: F Marital Status: Widow Primary Medical Diagnosis: dialysis catheter

infection
Primary Language: english

Level of Education: GED (highschool equivalent) Other Medical Diagnoses: (new on this admission)

Occupation : housekeeping, childcare DM, HTN, anemia, ESRD, hypoparathyroidism

Number/ages children/siblings: has 9 siblings and 8 kids

Served/Veteran: Code Status: full code

If yes: Ever deployed? Yes or No
Living Arrangements: lives with her daughter, son, and grand Advanced Directives: yes has one
daughter If no, do they want to fill them out?
Surgery Date: Aug. 2016 Procedure:
dialysis catheter placement, right groin- removed
10/25.
Culture/ Ethnicity /Nationality: Af. American
Religion: Pentecostal Type of Insurance: medicare

1 CHIEF COMPLAINT: purulent drainage was coming from the dialysis catheter insertion site and fevers

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient went to dialysis center on 10/24/16 where staff noticed pus coming from the dialysis catheter insertion site in the
right groin. Patient claimed fevers up to 101 F the previous two nights along with weakness, fatigue, and flu like
symptoms. The patient had the right groin catheter removed on 10/25 and the tip was sent for cultures. Patient was started
on IV antibiotics and will return to IR on 10/26 for the insertion of a new dialysis catheter.

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
1957 appendectomy
1987 Partial hysterectomy
2015 Right arm fistula (failed)
2015 Left arm fistula (failed)

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

FAMILY

Mental Health
Age (in years)

Heart Trouble
Bleeds Easily

Hypertension
Cause
Alcoholism

MEDICAL

Glaucoma
of

Problems

Problems
Allergies

Diabetes
Arthritis

Seizures
HISTORY
Anemia

Asthma

Kidney
Death Cancer

Tumor
Stroke
Gout
(if
applicable)
Multiple
Father 87
myeloma
Mother 49 cancer
Brother
Sister
relationship

relationship

relationship

-three of her brothers suffered from alcoholism

- all of her brothers and all but one of her sisters had type 2 diabetes
-she had another brother who dies before she was born who had seizures

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?
Last month
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years? 2014
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 2

 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Bactrim Chest pain
iodine
Medications

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
When the kidneys fail, they can no longer do their job of cleaning and filtering the blood, making hemodialysis necessary
for survival (National Kidney Foundation, 2015). In order to filter and clean the blood for hemodialysis, vascular access
must be established (National Kidney Foundation, 2015). This can be done through an AV fistula, and AV graft, or a
temporary dialysis catheter (National Kidney Foundation, 2015). The dialysis catheters have an arterial opening to remove
blood from the body and a venous opening to return it to the body (National Kidney Foundation, 2015). Because the
dialysis catheter is an opening to central circulation, it makes it easy for bacteria to enter the system and puts the patient at
a high risk for bacteremia (National Kidney Foundation, 2015). To prevent infection, the catheter dressing must remain
clean and dry, no air may get in the line, the catheter can not get wet, and the caps and clamps of the tubing must remain
closed tightly while not in use for dialysis (National Kidney Foundation, 2015). Signs of a catheter infection include fever,
chills, drainage from the site, redness, tenderness, weakness, and feeling ill, and should be reported and treated right away
(National Kidney Foundation, 2015). Catheter infections are diagnosed by culturing wound drainage and removing the
catheter and sending the tip to culture as well (National Kidney Foundation, 2015). An infection is treated with broad-
spectrum antibiotics and then can be changed to more specific antibiotics once the culture results are back (National
Kidney Foundation, 2015).

5 MEDICATIONS: Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2011). Davis's drug guide for nurses. Philadelphia: F.A.
Davis.
Name Insulin Detimir Concentration 100 u/ml Dosage Amount 18 units

Route SQ Frequency 2x daily

Pharmaceutical class insulins Home Hospital or Both
Indication type 2 diabetes management
Adverse/ Side effects hypoglycemia, hypokalemia, hypersensitivity rxn, anaphylaxis, injection site pain, myalgia, rash, weight gain, headache
Nursing considerations/ Patient Teaching- monitor for s/s of hypoglycemia, know baseline cr, no known risk in pregnancy or lactation,

Name Insulin aspart Concentration 100 u/ml Dosage Amount sliding scale

Route SQ Frequency ACHS

Pharmaceutical class insulins Home Hospital or Both
Indication type 2 diabetes management
Adverse/ Side effects- hypoglycemia, hypokalemia, hypersensitivity rxn, anaphylaxis, injection site pain, myalgia, rash, weight gain, headache
Nursing considerations/ Patient Teaching- monitor for s/s of hypoglycemia, know baseline cr, no known risk in pregnancy or lactation,

University of South Florida College of Nursing Revision September 2014 3

Name Zosyn Concentration 2.25g/50ml Dosage Amount 50 ml over 30 minutes

Route IVPB Frequency Q12 hrs

Pharmaceutical class- penicillins Home Hospital or Both
Indication- infection
Adverse/ Side effects- anaphylaxis, hypersensitivity, serum sickness, exanthematous pustulosis, erythema multiforme, stevens-johnson syndrome, toxic
epidermal necrosis, c.diff, leukopenia, neutropenia, bleeding, seizures
Nursing considerations/ Patient Teachingmonitor cr art baseline, cbc, give electrolyte if low k+, finish full dose. /

Name Vancomycin Concentration pulse dosing Dosage Amount pulse dosing

Route IVPB Frequency pulse dosing

Pharmaceutical class- glycopeptides Home Hospital or Both
Indication - infection
Adverse/ Side effects- anaphylaxis, hypotension, thrombophlebitis, tissue necrosis, vasulitis, exfoliative dermatitis, SJ syndrome, nephrotoxicity, ototoxicity, c
diff, superinfection
Nursing considerations/ Patient Teaching- monitor therapeutic drug levels, monitor parameters, BUN/cr at baseline, monitor for kindey levels, monitor for
changes in hearing

Name aspirin Concentration 81mg/tab Dosage Amount 81 mg

Route PO Frequency daily

Pharmaceutical class -antiplatelet Home Hospital or Both
Indication reducing platelet adhesion, clot prevention
Adverse/ Side effects- angioedema, bronchospasm, bleeding, DIC, pancytopenia, aplastic anemia, nephrotoxicity, hepatotoxicity, reye syndrome, dyspepsia,
nausea
Nursing considerations/ Patient Teaching- do not use in patients with nsaid induced asthma, GI bleeds, coagulation disorders, uncontrolled HTN, avoid alcohol.
Monitor liver enzymes, monitor kidney function.

Name atorvastatin Concentration 10mg/tab Dosage Amount 10mg

Route PO Frequency 1x daily

Pharmaceutical class- HMG-CoA reductase inhibitor Home Hospital or Both
Indication hyperlipidemia
Adverse/ Side effects: myopathy, tendon rupture, rhabdomyolosis, renal failure, hepatotoxicity, anaphylaxis, photosensitivity, SJ syndrome, leukopenia, DM
Nursing considerations/ Patient Teaching take at night times before going to sleep, monitor kindey function, monitor liver enzymes, monitor glucose levels

Name cinacalcet Concentration 30mg/tab Dosage Amount 90 mg

Route PO Frequency daily

Pharmaceutical class- calcimimmetics Home Hospital or Both
Indication- hypoparathyroidism
Adverse/ Side effects- hypersensitivity rxn, hypocalcemia, QT prolongation, arrhythmias, adynamic bone disease, seizures, n/v, myalgia, cough, hypotension
Nursing considerations/ Patient Teaching- monitor calcium levels in the blood, do not take with hypocalcemia

Name ergocalciferol Concentration 50,000 intl units/cap Dosage Amount 50,000 intl units

Route PO Frequency once

Pharmaceutical class vitamin d2 Home Hospital or Both
Indication: hypoparathyroidism
Adverse/ Side effects: excess vitamin D, hypercalcemia, hypercalcuria, soft tissue, calcification, nephrotoxicity, hyperphosphatemia, bone disease, cr elevated,
n/v, anorexia
Nursing considerations/ Patient Teaching: monitor BUN, calcium, alk phos. Bone xray until stable, monitor urinary calcium.

Name heparin Concentration 5000 units/ml Dosage Amount 5000 u

Route SQ Frequency Q12

University of South Florida College of Nursing Revision September 2014 4

Pharmaceutical class- anticoagulation Home Hospital or Both
Indication- clot prevention
Adverse/ Side effects- hemorrhage, thrombocytopenia, HIT, hypersensitivity, anaphylaxis, bleeding, prolonged clotting,
Nursing considerations/ Patient Teaching- monitor for signs of HIT, monitor for signs of bleeding ( tarry stools, bleeding gums, monitor cbc

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? Consistent carb 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: oatmeal almost everyday, sometimes toast and
eggs

Lunch: a turkey sandwich if I eat lunch

Dinner: maybe fish, shrimp and grits, with mixed veggies,

sometimes ill have a burger. I never cook anymore my
daughter makes dinner now.

Snacks: Cheetos, sour cream chips, I rarely snack but if I do

I eat something I enjoy

Liquids (include alcohol): mostly water but also tampeco

juice

MyPlate.gov recommends fruits and veggies making up half of

the diet, and gains and proteins making up the other half, with at
least half of the grains made of whole grains. It also recommends
reducing sodium, saturated fats, and added sugars. For this
patient, her priorities are sticking to a renal diet and a consistent
carb diet to help control her blood sugar. With a renal diet, the
goal is to minimize the amount of wastes in the body because
they can build up in the blood in between dialysis treatments
(Nephcure kidney international, 2016). Critical components of a
renal diet include low sodium, low potassium, and low
phosphorous (Nephcure kidney international, 2016). Byproducts
of protein and fluids are also filtered by the kidneys and must be
tightly controlled (Nephcure kidney international, 2016).
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? I like to stay out of bed and do things so I dont constantly think about being sick.

How do you generally cope with stress? or What do you do when you are upset?
I dont really have a lot of stress or conflict because everyone in my house respects each other. My kids know they arent
going to go smoking and drinking and leaving things a mess.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
No I feel good, Im right where I need to be so I can get better

+2 DOMESTIC VIOLENCE ASSESSMENT

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

Have you ever felt unsafe in a close relationship? _no__________________________

University of South Florida College of Nursing Revision September 2014 6

Have you ever been talked down to?__yes, my first husband was not physically abusive but he was verbally abusive. ___
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? My last
boyfriend stole money from me_____ If yes, have you sought help for this? ________no, I just realized hes no good for
me ______________

Are you currently in a safe relationship? Im not seeing anyone anymore

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:
Ego integrity versus despair: the task of this stage is the acceptance of ones life, worth, and eventual death. Ego integrity reflects a
satisfaction with life and an understanding of ones place in the life cycle. A sense of loss, discomfort with life and aging, and a fear
of death are seen in despair. a (Treas, Wilkinson 2014, 164)

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 Ego integrity stage of ego integrity vs. despair. I believe this because the Ego integrity stage is characterized by
acceptance of ones life, and acceptance of death and ones place in the life cycle (Treas, Wilkinson 2014, 164). I believe she is in
this stage because she seems at peace with her declining health and she voiced acceptance of the temporary nature of her life on earth.
She speaks warmly of her life that she has lived and all of her experiences and is proud of the people her children have become. She
told me about how she no longer needs to take care of them because they have grown into well-adjusted adults and now take care of
her. She also is very comforted by her spirituality, which helps her accept her death in the future. She says that she knows it is okay
for her to suffer a little bit now because she will spend an eternity in heaven with Jesus.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
I think my patients illness has helped her into her developmental stage by forcing her to confront her own mortality. She
may not have the most thorough understanding of how to best care for herself but she does try to keep herself healthy with
the information she does have. She also seems to have a great support system with her children, in particular her son and
daughter that she lives with.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I dont know, I really dont know.

What does your illness mean to you?

It means my health isnt good, but I have to try my best to get better and trust in the doctors and in god that my kidneys
will start back up.

+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, thats what led to my
hysterectomy______________________________
University of South Florida College of Nursing Revision September 2014 7
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? ______none________________________

How long have you been with your current partner?_n/a____________________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? __im too tired now to worry about
that I have my own problems______________________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
I worry that someone could have aids and if they dont tell you theres no way to know

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?
_______it is everything, simple as that. Everything. ________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
__of course, they keep me going. I know that if the doctors cant get my kidneys to start up again that god can and I just have to keep
the faith in jesus christ and hell take care of me. I know I have to do my share of suffering on this earth to get eternal bliss in the
afterlife. I just keep reminding myself that.

+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? X years
(age thru )

If applicable, when did the

Pack Years:
patient quit?

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? no If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes 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
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 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 no SPF: Diverticulitis Life threatening allergic reaction
Bathing routine: everyday Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy? Last year
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:
Post-nasal drip Normal frequency of urination: 0 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 1 x/day Diabetes Type: 2
Routine dentist visits last time was
Hypothyroid /Hyperthyroid
4 years ago x/year
Vision screening 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? Last year Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? 10 Encephalitis
last CXR? menopause age? 1987 Meningitis
Date of last Mammogram &Result:
Other: Other:
november
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 right leg and back Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
University of South Florida College of Nursing Revision September 2014 10
 Last EKG screening, when? 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: patient Height 58 Weight 78kg BMI Pain: (include rating and
is sitting in bed watching Pulse 96 Blood Pressure: (include location) location)
tv Respirations 16
Temperature: (route SpO2 96 Is the patient on Room Air or O2 None currently
taken?) 99.1 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

Central access device Type: Location: Date inserted:

Fluids infusing? no yes - what?

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 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: clear throughout
RUL LUL
RML LLL
RLL

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

University of South Florida College of Nursing Revision September 2014 12

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

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: Carotid: Brachial: Radial: 2+ Femoral: Popliteal: DP: 2+ PT:
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 10 / 24 / 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 Not assessed, patient alert, oriented, denies problems
Other Describe:

GU Urine output: Clear Cloudy Color: no urine produced Previous 24 hour output: 0
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 ___4+____ RUE __4+_____ 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,wbc +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
University of South Florida College of Nursing Revision September 2014 13
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

Lab Dates Trend Analysis

wbc 10/25 8.4 An elevated white blood cell count
10/24 10.2 could be an indicator of infection, so
it is an important value in a patient
with a possible catheter infection.
The normal range for WBCs is 4.5-
11, so while these labs are within
normal limits they are trending up,
indicating there could be an
infection growing. (Treas,
Wilkinson, 2014)
rbc 10/25 3.24 RBC count is an important lab to
10/24 3.52 monitor because this patient has
kidney failure. The kidneys are
responsible for making
erythropoietin, which makes red
blood cells, which could be low in
someone whose kidneys arent
functioning anymore. The normal
range for RBCs is 3.6-5.4, so hers
are within normal limits. (Treas,
Wilkinson, 2014)
hgb 10/25 11 HGB is important to monitor in this
10/24 11.7 patient because she has chronic
anemia. Hemoglobin is the oxygen
carrying molecule in the blood, and
the normal range is 12-16. This
patients levels are slightly low
which is to be expected in someone
with anemia(Treas, Wilkinson,
2014)
hct 10/25 32.5 HCT is the volume percentage of
10/24 35.7 RBCs in blood. Normal is 37-47 so
the patients is low which is to be
expected as mentioned earlier
because of the lack of erythropoietin
in patients with kidney failure.
(Treas, Wilkinson, 2014)
K+ 10/25 3.9 K+ is excreted through the kidneys.
10/24 3.6 In a dialysis patient, it is removed
from the body during dialysis. In
between dialysis appointments,
potassium will build up in the body
so it is expected to be trending up.
The normal limits are 3.5-5, so the
patients are within normal limits
University of South Florida College of Nursing Revision September 2014 14
 because she was dialized yesterday,
but they will continue to increase
until the next dialysis appointment.
(Treas, Wilkinson, 2014)

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: accuchecks ACHS, minimal

assist, MWF dialysis, daily labs, vanco trough levels,

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

1. knowledge deficit r/t information misinterpretation as evidenced by statement about needing lots of protein in diet and
development of preventable conditions

2.risk for injury r/t muscle weakness

3. ineffective protection r/t abnormal blood profile aeb decreased erythropoietin, decreased rbc production

4. risk for decreased cardiac output r/t ineffective volume regulation

5. fatigue r/t effects of chronic uremia and anemia

6. risk for impaired skin integrity r/t decreased mobility

7. impaired urinary elimination r/t esrd aeb anuria

8. risk for vascular trauma r/t infusion of antibiotics

University of South Florida College of Nursing Revision September 2014 15