UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Elizabeth Trujillo

MSI & MSII PATIENT ASSESSMENT TOOL .

Agency: TGH

1 PATIENT INFORMATION
Patient Initials:
Gender:

F.B.

Male

Assignment Date: 09/18/15

Age:49

Admission Date:09/11/15

Marital Status: Single

Primary Medical Diagnosis: hypotension,

Primary Language: English

Generalized weakness, orthostatic hypotension

Level of Education: Bachelors degree

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Head of financial operations for

several auto dealerships
Number/ages children/siblings: 1 sister who is currently in New
York.

None

Served/Veteran: No
If yes: Ever deployed? Yes or No

Code Status: Full

Living Arrangements: Pt is a single man who lives on a first floor

apartment with a dog.

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date:
None
Procedure: N/A

Culture/ Ethnicity /Nationality: Irish American

Religion: None

Type of Insurance: Humana

1 CHIEF COMPLAINT:
The pt reports feeling so dizzy. [The dizziness] would come and go so I always thought it might be a one time thing or
related to something else I was doing. Pt. expresses feeling depressed. Pt. continued saying, the dizziness was
debilitating.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Pt. was admitted to the ER following almost a week of constant dizziness and inability to stand due to the dizziness. Pt.
reports not being able to ambulate in home because of how unsteady he was on his feet. Because of his history as a
heart transplant recipient, he knew to seek medical care. after being admitted to the ER on 09/11/15, he was then
transferred to 7f to continue receiving care. During his time here, pt. did have a fall, and experienced a small laceration
on his posterior occipital lobe. He has since been evaluated by pt/ot and has been classified as a candidate for rehab. Pt is
currently awaiting a room to be sent to rehab.
Dizziness:
O- August 30, 2015
L- head, but also numbness on both arms
D- 3-4 minutes an average cycle
C-debilitating, immobilizing
A-None
R-Sitting down
T-Coming to the hospital
S-To the point of being totally disabled at home.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease

Father

70

Mother

72

Sister

45

Parental
grandmother

88

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable
)
Heart
failure
Stroke

Environmental
Allergies

Heart transplant
Pericardial window
Transesophageal echo cardiogram (intra op only)
CXR
EKG
Echocardiogram
Depression
Anxiety
CHF
Cataracts surgery
Diabetes Type 2

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness

Age (in years)

Date
06/17/13
06/23/13
06/23/13
09/11/15
09/11/15
09/11/15
Date unknown
Date unknown
Date unknown
Date unknown
Date unknown

Throat
cancer

relationship
relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

ACE Inhibitors

Hard for [pt] to breathe

Iodine
Shellfish

Hard for [pt] to breathe

Hard for [pt] to breathe

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)
Orthostatic (postural) hypotension is a sudden decrease in arterial blood pressure when a person is standing (Huether,
McCance, Brashers, Rote, 2008). The clinical presentation of this condition is frequently seen with dizziness, temporary
loss of vision, syncope, or fainting. The patient may complain of generalized weakness and a feeling as if they are going
to fall (Huether, et. al, 2008). It is diagnosed by taking the blood pressure vitals in three different positions: supine,
sitting, and standing. Normally, when an individual stands up, the body compensates for gravity and will detect a change
using baroreceptors and utilize compensatory mechanisms, such as arteriolar and venous constriction and increased
heart rate in order to ensure that arterial blood pressure is maintained (Huether, et. al, 2008). In patients with orthostatic
hypotension, the normal compensatory mechanism of vasoconstriction is absent and blood begins to pool in the muscle
vasculature, splanchnic, and renal beds (Huether, et. al, 2008). Orthostatic hypotension may be acute or it may be
chronic. Acute orthostatic hypotension is caused by the regulatory mechanisms being absent due to altered body
chemistry (e.g. a patient with diabetes is hypoglycemia), drug action (e.g. ACE inhibitors), prolonged immobility,
starvation, physical exhaustion, volume depletion, or venous pooling (e.g. pregnancies) (Huether, et. al, 2008). People
live with this condition as part of their everyday lives have chronic orthostatic hypotension which may be secondary to a
disease process or idiopathic or primary meaning it has no known initial cause. This typically affects more men than
women and occurs between 40 and 70 years of age (Huether, et. al, 2008). The prognosis is favorable, although there is
curative treatment. Orthostatic hypotension can be managed with a combination of nondrug and drug therapies (Huether,
et. al, 2008).

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

Klonopin (Clonazepam)

Concentration

Dosage Amount: 0.5 mg

Route Oral

Frequency: BID

Pharmaceutical class Benzodiazepines

Home

Hospital

or

Both

Indication: Prophylaxis of seizures; panic disorder with or without agoraphobia.

Adverse/ Side effects: suicidal thoughts, behavioral changes, drowsiness, fatigue, slurred speech, ataxia, sedation, abnormal eye movements, diplopia, nystagmus,
elevated secretions, palpitations, rash, constipation, diarrhea, hepatitis, weight gain, dysuria, nocturia, urinary retention, anemia, eosinophilia, leukopenia,
thrombocytopenia, ataxia, hypotonia, fever, physical dependence, psychological dependence, tolerance
Nursing considerations/ Patient Teaching: Instruct patient and family to notify health care professional of unusual tiredness, bleeding, sore throat, fever, clay-colored
stools, yellowing of skin, or behavioral changes. Advise patient and family to notify health care professional if thoughts about suicide or dying, attempts to commit
suicide; new or worse depression; new or worse anxiety; feeling very agitated or restless; panic attacks; trouble sleeping; new or worse irritability; acting aggressive;
being angry or violent; acting on dangerous impulses; an extreme increase in activity and talking; other unusual changes in behavior or mood occur.
Name: Lexapro (Escitalopram)
Route

Oral

Concentration

Dosage Amount: 10 mg
Frequency Daily

University of South Florida College of Nursing Revision September 2014

Pharmaceutical class SSRI

Home

Hospital

or

Both

Indication: Major depressive disorder; generalized anxiety disorder

Adverse/ Side effects: neuroleptic malignant syndrome, suicidal thoughts, insomnia, dizziness, drowsiness, fatigue, diarrhea, nausea, abdominal pain, constipation, dry
mouth, indigestion, anorgasmia, libido, ejaculatory delay, erectile dysfunction, sweating, syndrome on inappropriate secretion of antidiuretic hormone (siadh),
hyponatremia, serotonin syndrome, appetite
Nursing considerations/ Patient Teaching: Instruct patient to take escitalopram as directed. Take missed doses on the same day as soon as remembered and consult
health care professional. Resume regular dosing schedule next day. Do not double doses. Do not stop abruptly; should be discontinued gradually.
May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts
about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability,
aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if rash or symptoms of serotonin syndrome occur.
Name: Magnesium Oxide
Route

Concentration

Dosage Amount: 400 mg

Frequency: Daily

Oral

Pharmaceutical class: mineral and electrolyte replacements/supplements

Home

Hospital

or

Both

Indication: Treatment or prevention of hypomagnesemia

Adverse/ Side effects: diarrhea, flushing, sweating
Nursing considerations/ Patient Teaching: Advise patient not to take this medication within 2 hr of taking other medications, especially fluoroquinolones,
nitrofurantoin, and tetracyclines
Name Novolog (insulin aspart)

Concentration

Dosage Amount 2-10 units

Route: SubQ

Frequency: 3X with food and at bedtime

Pharmaceutical class: Pancreatics

Home

Hospital

or

Both

Indication: Control of hyperglycemia in patients with Type 1 and Type 2 diabetes

Adverse/ Side effects: hypoglycemia, lipodystrophy, pruritis, erythema, swelling, allergic reactions including anaphylaxis
Nursing considerations/ Patient Teaching: Instruct patient on proper technique for administration. Include type of insulin, equipment (syringe, cartridge pens, external
pumps, alcohol swabs), storage, and place to discard syringes. Discuss the importance of not changing brands of insulin or syringes, selection and rotation of injection
sites, and compliance with therapeutic regimen. Caution patient that insulin pens should not be shared with others, even if clean needles are used. Advise patient to notify
health care professional if nausea, vomiting, or fever develops, if unable to eat regular diet, or if blood sugar levels are not controlled. Instruct patient on signs and
symptoms of hypoglycemia and hyperglycemia and what to do if they occur.
Name: Lantus (insulin glargine)

Concentration

Dosage Amount: 28 units

Route: SubQ

Frequency: BID

Pharmaceutical class: pancreatics

Home

Hospital

or

Both

Indication: Control of hyperglycemia in patients with Type 1 and Type 2 diabetes

Adverse/ Side effects: hypoglycemia, lipodystrophy, pruritis, erythema, swelling, allergic reactions including anaphylaxis
Nursing considerations/ Patient Teaching: Instruct patient on proper technique for administration. Include type of insulin, equipment (syringe, cartridge pens, external
pumps, alcohol swabs), storage, and place to discard syringes. Discuss the importance of not changing brands of insulin or syringes, selection and rotation of injection
sites, and compliance with therapeutic regimen. Caution patient that insulin pens should not be shared with others, even if clean needles are used. Advise patient to notify
health care professional if nausea, vomiting, or fever develops, if unable to eat regular diet, or if blood sugar levels are not controlled. Instruct patient on signs and
symptoms of hypoglycemia and hyperglycemia and what to do if they occur.
Name Cellcept (Mycophenolate mofetil)

Concentration

Dosage Amount: 1000 mg

Route: Oral

Frequency: Daily

Pharmaceutical class: immunosuppressant

Home

Hospital

or

Both

Indication: Prevention of rejection in allogenic renal, hepatic, and cardiac transplantation (used concurrently with cyclosporine and corticosteroids).
Adverse/ Side effects: progressive multifocal leukoencephalopathy, anxiety, dizziness, headache, insomnia, paresthesia, tremor, edema, hypertension, hypotension,
tachycardia, rashes, hypercholesterolemia, hyperglycemia, hyperkalemia, hypocalcemia, hypokalemia, hypomagnesemia, gi bleeding, anorexia, constipation, diarrhea,
nausea, vomiting, abdominal pain, renal dysfunction, leukocytosis, leukopenia, thrombocytopenia, anemia, pure red cell aplasia, cough, dyspnea, fever, infection
(including activation of latent viral infections such as polyomavirus-associated nephropathy or hepatitis b/c), risk of malignancy
Nursing considerations/ Patient Teaching: Instruct patient to take medication as directed, at the same time each day. Take missed dose as soon as remembered, but not if
almost time for next dose. Do not skip or double up on missed doses. Do not discontinue without consulting health care professional. Reinforce the need for lifelong
therapy to prevent transplant rejection. Review symptoms of rejection for the transplanted organ, and stress need to notify health care professional immediately if signs of
rejection or infection occur. Instruct patient to notify health care professional immediately if signs and symptoms of infection (temperature 100.5F, cold symptoms
[runny nose, sore throat], flu symptoms [upset stomach, stomach pain, vomiting, diarrhea], earache or headache, pain during urination, frequent urination, white patches in
mouth or throat, unexpected bruising or bleeding, cuts, scrapes, or incisions that are red, warm, and oozing pus) or multifocal leukoencephalopathy.
Name: Zyprexa (Olanzapine)

Concentration

Dosage Amount: 15 mg

University of South Florida College of Nursing Revision September 2014

Route: Oral

Frequency: Daily

Pharmaceutical class: Antipsychotics; mood stabilizers

Home

Hospital

or

Both

Indication: Treatment-resistant depression

Adverse/ Side effects: neuroleptic malignant syndrome, seizures, suicidal thoughts, agitation, delirium, dizziness, headache, restlessness, sedation, weakness, dystonia,
insomnia, mood changes, personality disorder, speech impairment, tardive dyskinesia, amblyopia, rhinitis, salivation, pharyngitis, cough, dyspnea, bradycardia, chest
pain, orthostatic hypotension, tachycardia, constipation, dry mouth, liver enzymes, weight loss or gain, abdominal pain, appetite, nausea, thirst, impotence, libido,
urinary incontinence, agranulocytosis, leukopenia, neutropenia, photosensitivity, amenorrhea, galactorrhea, goiter, gynecomastia, hyperglycemia, dyslipidemia,
hypertonia, joint pain, tremor, fever, flu-like syndrome
Nursing considerations/ Patient Teaching: Advise patient and family to notify health care professional if thoughts about suicide or dying, attempts to commit suicide;
new or worse depression; new or worse anxiety; feeling very agitated or restless; panic attacks; trouble sleeping; new or worse irritability; acting aggressive; being angry
or violent; acting on dangerous impulses; an extreme increase in activity and talking, other unusual changes in behavior or mood occur. Advise patient to use sunscreen
and protective clothing when exposed to the sun. Extremes of temperature (exercise, hot weather, hot baths or showers) should also be avoided; this drug impairs body
temperature regulation. Instruct patient to use saliva substitute, frequent mouth rinses, good oral hygiene, and sugarless gum or candy to minimize dry mouth. Consult
dentist if dry mouth continues for >2 wk.. Instruct patient to notify health care professional promptly if sore throat, fever, unusual bleeding or bruising, rash, symptoms of
Post-Injection Delirium/Sedation Syndrome, or weakness, tremors, visual disturbances, dark-colored urine, clay-colored stools, menstrual abnormalities, galactorrhea or
sexual dysfunction occur.
Name: Protonix (pantoprazole)

Concentration

Dosage Amount: 40 mg

Route: Oral

Frequency: BID before meals

Pharmaceutical class: Proton pump inhibitors

Home

Hospital

or

Both

Indication: Erosive esophagitis associated with GERD

Adverse/ Side effects: headache, pseudomembranous colitis, abdominal pain, diarrhea, eructation, flatulence, hyperglycemia, hypomagnesemia (especially if treatment
duration 3 mo), bone fracture
Nursing considerations/ Patient Teaching: Instruct patient to take medication as directed for the full course of therapy, even if feeling better.
Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation.
Advise patient to report onset of black, tarry stools; diarrhea; or abdominal pain to health care professional promptly. Instruct patient to notify health care professional
immediately if rash, diarrhea, abdominal cramping, fever, or bloody stools occur and not to treat with antidiarrheals without consulting health care professional
Name Prednisone (Rayos)

Concentration

Dosage Amount: 2.5 mg

Route: Oral

Frequency: Daily

Pharmaceutical class: anti-inflammatories

Home

Hospital

or

Both

Indication: used systemically and locally in a wide variety of chronic diseases including: inflammatory, allergic, hematologic, neoplastic, autoimmune disorders.
Adverse/ Side effects: depression, euphoria, headache, intracranial pressure (children only), personality changes, psychoses, restlessness, cataracts, intraocular
pressure, hypertension, peptic ulceration, anorexia, nausea, vomiting, acne, wound healing, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression,
hyperglycemia, fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis, thromboembolism, thrombophlebitis, weight gain, weight loss, muscle
wasting, osteoporosis, avascular necrosis of joints, muscle pain, cushingoid appearance (moon face, buffalo hump), susceptibility to infection
Nursing considerations/ Patient Teaching: Instruct patient on correct technique of medication administration. Advise patient to take medication as directed. Take missed
doses as soon as remembered unless almost time for next dose. Do not double doses. Stopping the medication suddenly may result in adrenal insufficiency (anorexia,
nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life-threatening.
Glucocorticoids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible
infections immediately. Caution patient to avoid vaccinations without first consulting health care professional. Review side effects with patient. Instruct patient to inform
health care professional promptly if severe abdominal pain or tarry stools occur. Patient should also report unusual swelling, weight gain, tiredness, bone pain, bruising,
nonhealing sores, visual disturbances, or behavior changes. Advise patient to notify health care professional of medication regimen before treatment or surgery. Discuss
possible effects on body image. Explore coping mechanisms. Instruct patient to inform health care professional if symptoms of underlying disease return or worsen.
Advise patient to carry identification describing disease process and medication regimen in the event of emergency in which patient cannot relate medical history. Explain
need for continued medical follow-up to assess effectiveness and possible side effects of medication. Periodic lab tests and eye exams may be needed. Long-term
Therapy: Encourage patient to eat a diet high in protein, calcium, and potassium, and low in sodium and carbohydrates (see food sources for specific nutrients). Alcohol
should be avoided during therapy

Name: Xarelto (rivaroxaban)

Concentration

Dosage Amount: 15 mg

Route: Oral

Frequency: Daily with dinner

Pharmaceutical class: antithrombotics; anticoagulants

Home

Hospital

or

Both

Indication: Prevention of deep vein thrombosis that may lead to pulmonary embolism following knee or hip replacement surgery.
Reduction in risk of stroke/systemic embolism in patients with nonvalvular atrial fibrillation
Adverse/ Side effects: syncope, blister, prutitus, bleeding, wound secretion, extremity pain, muscle spasm
Nursing considerations/ Patient Teaching: Instruct patient to take medication as directed. Take missed doses as soon as remembered that day. If taking 15 mg twice
daily, may take two 15-mg tablets to achieve 30 mg daily dose, then return to regular schedule. If taking 10 mg, 15 mg, or 20 mg once daily, take missed dose
immediately. Inform health care professional of missed doses at time of checkup or lab tests. Inform patients that anticoagulant effect may persist for 25 days following
discontinuation. Advise patient to read Medication Guide before starting therapy and with each Rx refill in case of changes. Caution patients not to discontinue medication
early without consulting health care professional.
Advise patient to report any symptoms of unusual bleeding or bruising (bleeding gums; nosebleed; black, tarry stools; hematuria; excessive menstrual flow) and
symptoms of spinal or epidural hematoma (tingling; numbness, especially in lower extremities; muscular weakness) to health care professional immediately.

University of South Florida College of Nursing Revision September 2014

Instruct patient not to drink alcohol or take other Rx, OTC, or herbal products, especially those containing aspirin or NSAIDs, or to start or stop any new medications
during rivaroxaban therapy without advice of health care professional.
Name: Tacrolimus (Prograf)

Concentration

Dosage Amount: 2 mg

Route: Oral

Frequency: Daily

Pharmaceutical class: immunosuppressants

Home

Hospital

or

Both

Indication: Prevention of organ rejection in patients who have undergone allogenic liver, kidney, or heart transplantation (used concurrently with corticosteroids).
Adverse/ Side effects: seizures, dizziness, headache, insomnia, tremor, abnormal dreams, agitation, anxiety, confusion, emotional lability, depression, hallucinations,
psychoses, somnolence, abnormal vision, amblyopia, tinnitus, cough, pleural effusion, asthma, bronchitis, pharyngitis, pneumonia, pulmonary edema, hypertension,
peripheral edema, qtc interval prolongation, gi bleeding, abdominal pain, anorexia, ascites, constipation, diarrhea, dyspepsia, liver enzymes, nausea, vomiting,
cholangitis, cholestatic jaundice, dysphagia, flatulence, appetite, oral thrush, nephrotoxicity, urinary tract infection, pruritus, rash, alopecia, herpes simplex, hirsutism,
sweating, photosensitivity, hyperglycemia, hyperkalemia, hyperlipidemia, hypokalemia, hypomagnesemia, hypophosphatemia, hyperphosphatemia, hyperuricemia,
hypocalcemia, hyponatremia, metabolic acidosis, metabolic alkalosis, anemia, leukocytosis, leukopenia, thrombocytopenia, coagulation defects, pure red cell aplasia,
arthralgia, hypertonia, leg cramps, muscle spasm, myalgia, myasthenia, osteoporosis, paresthesia, neuropathy, allergic reactions including anaphylaxis, fever, generalized
pain, abnormal healing, chills, risk of lymphoma/skin cancer
Nursing considerations/ Patient Teaching: Instruct patient to take tacrolimus at the same time each day, as directed. Do not skip or double up on missed doses. Do not
discontinue medication without advice of health care professional. Advise patient to read the Medication Guide prior to starting and with each Rx renewal; new
information may be available.
Reinforce the need for lifelong therapy to prevent transplant rejection. Review symptoms of rejection for transplanted organ and stress need to notify health care
professional immediately if they occur.
Advise patient to avoid grapefruit or grapefruit juice and eating raw oysters or other shellfish; make sure they are fully cooked before eating.
Name Trazodone (Desyrel)

Concentration

Dosage Amount: 150 mg

Route: Oral

Frequency: Daily

Pharmaceutical class: Antidepressants

Home

Hospital

or

Both

Indication: Major depression

Adverse/ Side effects: suicidal thoughts, drowsiness, confusion, dizziness, fatigue, hallucinations, headache, insomnia, nightmares, slurred speech, syncope, weakness,
blurred vision, tinnitus, hypotension, arrhythmias, chest pain, hypertension, palpitations, qt interval prolongation, tachycardia, dry mouth, altered taste, constipation,
diarrhea, excess salivation, flatulence, nausea, vomiting, hematuria, erectile dysfunction, priapism, urinary frequency, rash, anemia, leukopenia, myalgia, tremor
Nursing considerations/ Patient Teaching: Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health
care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks,
insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome
occur. Instruct patient to notify health care professional if signs of serotonin syndrome (mental status changes: agitation, hallucinations, coma; autonomic instability:
tachycardia, labile BP, hyperthermia; neuromuscular aberrations: hyperreflexia, incoordination; and/or gastrointestinal symptoms: nausea, vomiting, diarrhea) occur

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? ADA 1800
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? ADA 1800
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The pt. has a nutritious breakfast, very small and simple.
my only added suggestion is that the pt consider switching
Breakfast: 1 cup of Cheerios cereal, 1 raw apple
to a whole wheat cheerios or another cereal that has whole
wheat so that he can experience variety, but still get his
whole wheat needs accomplished. The sandwich that the
Lunch: 1 turkey, ham, roast beef, tomato, and lettuce
pt usually eats is important for his protein intake, but could
sandwich with a 1 cup of macaroni (pasta salad), made with be improved by adding more vegetables (e.g. spinach,
mayonnaise
shredded carrots) into his sandwich. The other
improvement is to consider another type of salad instead of
a macaroni salad with mayonnaise. The salad itself is
riddled with carbohydrates, but not the most nutritious.
Dinner: 1 boneless, baked chicken breast, and 1 cup of
The pt could much better munch on an actual salad or
Caesar salad
maybe a low calorie, low sodium vegetable soup. For
dinner, the baked chicken breast is appropriate and satisfies
the pts protein intake of the day. However, the Caesar
salad leaves much to be desired because of its unusually
Snacks:1 slice of string cheese (part skim)
high sodium and fat content due to the creamy Caesar
dressing. While he is actually eating greens in the salad,
the amount of calories from the dressing and the croutons
does not make it the most appealing choice for this pt. The
string cheese is a decent snack so long as he does not eat it
every day with every meal. A better alternative could be
raw almonds or nuts or even a sliced seasonal fruit. Water
is truly the best choice for this pt, but he can also try
drinking more milk with his dinner for the calcium and
vitamins found in milk. The crystal light should not be
drunk multiple times a day because eventually those sugars
and carbohydrates will creep up on the pt. It is better to
have simple water with maybe a sliced fruit or vegetable
(e.g. a lemon or zucchini) in the water for flavor.
Liquids (include alcohol): water, low-calorie powdered
According to the MyPlate, the pt was over the sodium limit
Crystal light
(2300 mg) when he consumed 3192 mg of sodium. He also
went over the amount of oils he could consume in a day (6
tsp) when he ate 7 tsp. of oils. Lastly, he is considered
under the national suggestions for vegetables, fruits, and
dairy (SuperTracker).
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? Pt reports having no one.

University of South Florida College of Nursing Revision September 2014

How do you generally cope with stress? or What do you do when you are upset? Pt. feels he does not cope with stress.
I just believe everything has a solution and I just trust my doctors and health team.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Feelings of depression constantly because sometimes [the pt] feels like he is an outsider looking in.

+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? ____N/A_______________
Are you currently in a safe relationship? No, the pt is single.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: Generativity vs. self-absorption is defined as satisfying life goals that include beginning a family, satisfaction in

a career or society and developing concerns for their own future (Halter, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The pt is in the self-absorption/stagnation stage. Because he is alone and cares for himself, he is extremely self-reliant
and slightly closed off. Based on the interview, while he was kind, he was not positive about his future or envisioned
a better future for himself. He was so focused on his disease process and his feelings of being disabled that he did not
express
interest in other portions of his life. Also, because of his transplant, he quit his job and began living a more stress free
lifestyle. While that is beneficial to an extent, it also limits his social interactions, opportunities to meet new people, and
have a constant focus or goal.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

Based on my interview with my patient and understanding his perception of his health, I would say that it has had a
tremendous impact on my patients developmental stage of life because of all the sacrifices he has had to made to remain
safe and healthy.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Virus when [pt] got a cold that started eating away at my heart.
What does your illness mean to you?
Disability and being disabled.

University of South Florida College of Nursing Revision September 2014

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?___Yes______________________________________________________________
Do you prefer women, men or both genders? ___Women__________________________________________________
Are you aware of ever having a sexually transmitted infection? _____No_____________________________________
Have you or a partner ever had an abnormal pap smear?____No______________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___No_____________________________________
Are you currently sexually active? _____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? ____Condoms______________________________
How long have you been with your current partner?__N/A, Pt is single __________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _______Yes_________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision September 2014

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
__________None____________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
________None, no, they do not______________________________________________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)
Smoking cigarettes
4 individual cigarettes a day
Pack Years: 4 Pack Years
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Yes
No
For how many years? 20 years
(age 19

thru 39

If applicable, when did the

patient quit?
10 years ago
Has the patient ever tried to quit? Yes
If yes, what did they use to try to quit? Pt quit Cold
turkey. Pt did not use medications, gum, or patches.

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What?
How much? 4-5 drinks
Rum and coke
Volume: 5 ounces
Frequency: 1X a month
If applicable, when did the patient quit?
The pt has not quit.

No
For how many years?
(age 21 thru 49

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
None
How much? N/A
For how many years? N/A
(age

Is the patient currently using these drugs?

Yes No

thru

) N/A

If not, when did he/she quit?

N/A

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

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 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen None
SPF: N/A
Bathing routine: Every other day
Other:

Be sure to answer the highlighted area

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth 2 x/day
Routine dentist visits
0 x/year
Vision screening
Other: Pt. has not seen dentist since 2010

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? Never
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily- as part of a medication
side effect
Cancer
Blood Transfusions
Blood type if known:
Other:

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

x/day

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
Type: 2
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies Shellfish
last CXR? 09/11/15
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors: Occasionally tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures-small laceration
from fall
Weakness
Pain
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision September 2014

11

Last EKG screening, when? 09/11/15

Other:

Arthritis
Other:

Chicken Pox
Other:

General Constitution
Recent weight loss or gain. Recent weight gain since transplant
How many lbs? 52 lbs
Time frame? As of 2 years ago (since 2013 transplant)
Intentional? No, because pt is on prednisone.
How do you view your overall health? The pt reports fair.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Yes, back in January, [the pt] contracted a rhino virus.

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

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10 PHYSICAL EXAMINATION:
General Survey: Pt. is a
Height: 510
Weight 118.71 kg
BMI: 37.6
Pain: (include rating and
well-developed 49 y/o
location)
Pulse 104
Blood Pressure: (include location)
who is overweight and
0
121/79
on
Right
arm
Respirations 20
has the appearance of
Cushings Syndrome. Pt.
is in no visible signs of
distress and is alert and
oriented X3.
Temperature: (route
Is the patient on Room Air or O2
SpO2 98
taken?)
Room air
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
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type:
None
Location: N/A
Date inserted:
N/A
Fluids infusing?
no
yes - what?
Pt. did not have any lines or central access devices
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 /4 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Dental hygiene maintained
Comments: The Whisper Test was not performed because the pt. could hear me over moderate to medium loud music and did
not demonstrate any difficulties hearing or understanding during the PAT interview
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:

Chest expansion

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RUL CL
LUL CL
RML CL
LLL CL
RLL CL
No sputum was reported
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
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Pt did demonstrate an irregular heart sound, but it was related to his A-fib and not pertinent to his current visit to TGH.

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 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:
None, 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 09 / 17 / 15
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

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

727 mLs N/A

& __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

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10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
Chest X-Ray (CXR)

Dates
09/11/15

Echocardiogram (Echo)

09/11/15

EKG

09/11/15

Glucose

09/18/15

Trend
This was the pts first and
only CXR during his
current stay at TGH.

This diagnostic
echocardiogram was only
performed once during
the pts current stay.
This diagnostic EKG was
only performed once
during the pts current
hospital stay.

The pt is a type 2 diabetic

and had their glucose
level vary on the time of
day and whether or not
they had eaten.

Analysis
The pts CXR was WDL.
This CXR was done to
rule out any possible
causes of the pts
dizziness. The CXR
would have revealed any
structural abnormalities,
displaced fluids, or any
abscesses. This is the
same diagnostic test that
is used to diagnose
pneumonias, pulmonary
edema, or cardiomegalies.
The echo proved WDL,
except for mild
regurgitation in the mitral
valve.
Because of the pts
history of A-fib and
having an irregular
rhythm, conducting an
EKG was necessary to
rule out any syncopes or
arrhythmias that could be
causing the pt to be
experiencing orthostatic
hypotension. The EKG
did not reveal any
significant findings
related to the patients
current hospital stay or
cause of dizziness.
The pts glucose reading
was 110, indicating that
he only needed his Lantus
for all day coverage.
Because the pt is a type 2

University of South Florida College of Nursing Revision September 2014

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Tacrolimus

09/17/15

The pts tacrolimus level

has consistently stayed
within the normal limits
between (5 to 20). Last
checked (09/17/15), the
pts tacrolimus level was
6.0.

BUN; Creatnine

09/18/15

Potassium

09/18/15

The pts BUN and

creatinine level is 16 and
1.6, respectively. For
BUN the normal range it
is 7-20 and for creatinine
it is 0.5 to 1.3. Since his
current admission, his
levels have stayed within
range. However, while
his creatinine value is .3
higher, it is normal for
this pt. since he
frequently stays between
1.0-1.6.
The pts potassium level
has been consistently
within range. In todays
value, it was 4.0. It does
fluctuate slightly at times,
but for the most part, it
consistently stays within
normal ranges of (3.5 to
5).

diabetic it is important for

him to understand the
importance of monitoring
his glucose at least two or
three times a day and to
always be aware of
symptoms of hypo and
hyperglycemia.
Due to the pts history of
heart transplant, the pt.
has to consistently be
assessed for his
tacrolimus level to ensure
his immunosuppressant
medications are still
actively working.
Because of this patients
history of Afib and being
a transplant recipient, it is
important that we monitor
their BUN and creatinine
levels to ensure kidney
function and adequate
perfusion. While this pts
creatinine is .3 higher
than normal values, it is
still not too concerning
because this is common
for this individual patient.
Potassium is one of the
most important
electrolytes to the cardiac
system so for a pt with a
history of a heart
transplant, potassium is
an electrolyte to always
pay attention to because it
will indicate the electrical
conductivity and overall
function of the heart.

+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.)
Treatment team consists of an RN, transplant physician, cardiologist, physical therapist, consulting doctor,
ADA1800, Accucheck Q6 hours.
University of South Florida College of Nursing Revision September 2014

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1. Impaired physical mobility r/t dizziness as evidenced by patients complaint of feeling weak when ambulating
2. Decreased cardiac output r/t dysfunctional electrical conduction as evidenced by patients history of atrial fibrillation
3. Powerlessness r/t pattern of helplessness as evidenced by the patients complaints of feeling debilitated by his
health disabilities
4.Risk for injury: Risk factors: altered sensory perception, risk for falls as evidenced by the patients complaint of feeling
dizzy.
5.

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 15 CARE PLAN
Nursing Diagnosis: Impaired physical mobility r/t dizziness as evidenced by patients complaint of feeling weak when ambulating
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
At the end of my shift:
Pt will be able to verbalize
Assess the pt for impaired
Some clients choose not to
After active listening to the pt,
less fear of falling due to dizziness mobility by using active listening
ambulate because of fear of falling the pt has thoroughly expressed
when ambulating.
to determine whether the cause is
or mental illness related causes
his willingness to ambulate more
physiological or psychological.
(Ackley, 2011).
freely again, but is genuinely
afraid of falling due to dizziness.
Pt will be able to ambulate between Obtain any assistive devices
the bed and the chair in his room.
needed for activity (e.g. gait belt,
weighted vest, walker) before the
Pt will demonstrate the use of
activity begins. Assess the pts
the walker to help increase
knowledge of how to use walker,
mobility.
and if not consult PT/OT to offer
teachings and further assistance.

Assistive devices can enable pt

to feel more comfortable during
ambulation (Ackley, 2011).

The pt was successfully able to

demonstrate his ability to utilize
the walker and understood the
importance of ambulating with
the assistance of a walker.

Include a minimum of one

Long term goal per care plan

Long term goal: pt will be able to

ambulate without feeling dizzy
and will verbalize feeling
independent and safe to ambulate.
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
University of South Florida College of Nursing Revision September 2014

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 are any of the patients medications available at a discount pharmacy? Yes No

Rehab/ HH
Palliative Care
15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output r/t dysfunctional electrical conduction as evidenced by patients history of atrial fibrillation
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
At the end of my shift:
Observe for chest pain or
Chest pain/discomfort is indicative At the end of my shift, the pt did
Pt will not report any chest
discomfort; note location,
of the heart not receiving the
not report any chest discomfort
adequate
pain or chest discomfort
radiation, severity, quality,
blood supply it needs to maintain
or pain. He expressed feeling 0
duration, OLDCART findings
its function (Ackley, 2011).
pain today.
Pt will feel relaxed and remain
calm and less anxious in his room.

Provide a less stressful ambiance

by minimalizing background noise
and
providing the pt with the option
of listening to his favorite type
of music.

Rest helps lower arterial pressure

and reduce the excitability and

The pt verbalized feeling less

anxious and more comfortable

workload of the heart (Ackley,

2011).

in their hospital room because they

felt hearing their favorite type of
music soothing.

Long term goal: pt will

visit cardiologist regularly and
will consider visiting a musical
therapist to not only help with
his depression, but to also decrease
the workload of his heart.
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:
University of South Florida College of Nursing Revision September 2014

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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**
Consult to Musical Therapy
Palliative Care

University of South Florida College of Nursing Revision September 2014

20

References
Ackley, B.J. (2011). Nursing Diagnosis Handbook: An Evidenced Based Guide to Planning Care. (9th Edition).
St. Louis, Missouri: Mosby Elsevier.
Halter, M.J. (2014). Relevant Theories and Therapies for Nursing Practices. (7th Edition). Varcolis
Foundation of Psychiatric Mental Health Nursing: A Clinical Approach (pg. 23). St. Louis, Missouri:
Elsevier.
Huether, S.E., McCance, K.L., Brashers, V.L., Rote, S.N. (2008). Understanding Pathophysiology. (4th
Edition). St. Louis, Missouri: Elsevier.
SuperTracker. (2014). United States Department of Agriculture. Retrieved September 22, 2015, from
https://www.supertracker.usda.gov/foodtracker.aspx?CategoryID=0-1&FoodDescription=ba

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