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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Shannon OShea

MSI & MSII PATIENT ASSESSMENT TOOL .


1 PATIENT INFORMATION

Assignment Date: 11/13/15


Agency: BMC

Patient Initials: BF

Age: 54

Admission Date: 11/10/15

Gender: Male

Marital Status: Married

Primary Medical Diagnosis: Cellulitis

Primary Language: English


Level of Education: Culinary School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired Chef


Number/ages children/siblings: 2 brothers, one 47 and one passed at
age 45
Served/Veteran: No
If yes: Ever deployed? Yes or No
Living Arrangements: The patient and his wife live in a single
room. They were previously evicted from their apartment, and were
homeless for a time.

Code Status: Full Code


Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: NA

Procedure:

Culture/ Ethnicity /Nationality: German


Religion: Presbyterian

Type of Insurance: Medicaid- Stay Well

1 CHIEF COMPLAINT:
My legs were red and swollen.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
A 54-year-old patient who looks older than his actual age. Patient came to hospital for an acute attack of his chronic
cellulitis and edema to bilateral lower extremities. Patient states that the swelling and pain in his lower legs has made it
hard to walk the past few days. He states he needed to constantly rest and elevate his legs to help with the swelling and
pain. Patient has been seen at Bayfront hospital several times in the last few months for cellulitis and COPD. The patient
is down to 3 cigarettes a day, and is unable to use nicotine patches due to his allergies. Patient was counseled on smoking
cessation. Patient had chest x-ray and a bilateral ultrasound of the lower extremities. The CXR shows probable bibasilar
scarring, and the ultrasound was negative for DVTs.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
2014

Operation or Illness
Patient was hospitalized 14 times in 2014 for COPD and cellulitis.

University of South Florida College of Nursing Revision September 2014

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

47

Bleeds Easily

Brother

Asthma

45

Arthritis

Brother

Father

Anemia

Mother

Cause
of
Death
(if
applicable)
Lung
72
Cancer
64 Lung Cancer

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Alcoholism

Patient was hospitalized 9 times in 2015 for COPD and cellulitis.


Age (in years)

2015

Unknown

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? 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
1 ALLERGIES
OR ADVERSE
REACTIONS

Medications

Other (food, tape,


latex, dye, etc.)

NAME of
Causative Agent
Penicillin
Bactrim
Anything derived
from egg or horse
serum
Iodine

NO

Type of Reaction (describe explicitly)

Rash and swelling.


Respiratory distress with penicillin and Bactrim.

Eggs
Chocolate
Lobster

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)
Cellulitis is an inflammation process usually caused by a staphylococcus or streptococcus infection (Osborn, Wraa,
Watson & Holleran, 2014). The inflammation affects the skin and subcutaneous tissue, but is non-necrotizing. The

University of South Florida College of Nursing Revision September 2014

incidence of cellulitis is equal in men and women, and is not age specific. There is an increased risk for individuals who
are obese or those with venous insufficiency. The inflammatory process is often not reported, so it is hard to track the
prevalence of the disorder. Cellulitis often develops after a patient receives a cut, laceration, ulcer or surgical wound
(Osborn, Wraa, Watson & Holleran, 2014). Due to these openings in the skin organisms are able to easily enter the body.
Once inside the dermis they begin to multiply. All though any area of the body can be affected, the lower extremities and
face are two of the most common sites for cellulitis. A patient with Cellulitis will present with redness, tightness, swelling
and tenderness. In addition, the skin may have blisters or abscesses. With Cellulitis the patient may experience chills,
fever, vomiting and a headache. To diagnose Cellulitis a patients white blood cell count will be measured, and a wound
culture may be taken. Treatment of cellulitis is with antibiotics. The patient should have blood samples taken to identify
the cause of infection, and more specific antibiotics can then be given. Rest, pain management and elevation of the
affected site should also be used in treatment. The patient might also require a consult to wound care. Treatment of
cellulitis is important, if not treated the bacteria could travel to the patients blood stream and they can develop septicemia.

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

Name: aspirin

Concentration

Dosage Amount: 81 mg

Route: PO
Frequency: Daily
Pharmaceutical class: salicylates
Home
Hospital
or
Both
Indication: Prophylaxis of transient ischemic attacks and myocardial infarctions.
Adverse/ Side effects: Tinnitus, GI bleeding, dyspepsia, epigastric distress, nausea, abdominal pain, anorexia,
hepatotoxicity, vomiting, anemia, hemolysis, rash, urticaria.
Nursing considerations/ Patient Teaching: Use cautiously in patients with bleeding disorders, ulcers, chronic alcohol use,
hepatic or renal disease. Administer after meals or with food to minimize gastric irritation. Should be withheld for 1 week
prior to any surgeries.
Name: diltiazem, Cardizem

Concentration

Dosage Amount: 240 mg

Route: PO
Frequency: Daily
Pharmaceutical class: Calcium Channel Blockers
Home
Hospital
or
Both
Indication: Hypertension, angina pectoris, supraventricular tachyarrhythmias or rapid ventricular rates in atrial fib or
flutter.
Adverse/ Side effects: Anxiety, confusion, dizziness, drowsiness, headache, weakness, psychiatric disturbances, blurred
vision, epistaxis, tinnitus, cough, dyspnea, arrhythmias, heart failure, peripheral edema, chest pain, bradycardia, anorexia,
constipation, diarrhea, dysuria, polyuria, Steven-Johnson syndrome, flushing, sweating, photosensitivity, hyperglycemia,
anemia, leukopenia, thrombocytopenia, muscle cramps, joint stiffness, tremors, gingival hyperplasia.
Nursing considerations/ Patient Teaching: Contraindicated in sick sinus syndrome, 2nd or 3rd degree heart blocks, systolic
BP< 90 mmHG, recent MI or pulmonary congestion. Do not take with grapefruit juice. Monitor blood pressure and pulse
prior to therapy. Monitor ECG during treatment, may cause prolonged PR interval.
Name: diphenhydramine, Benadryl

Concentration

Dosage Amount: 25 mg

Route: PO
Frequency: PRN, HS (at bedtime)
Pharmaceutical class: Antihistamines
Home
Hospital
or
Both
Indication: Relief of allergic symptoms caused by histamine release.
Adverse/ Side effects: Drowsiness, dizziness, headache, blurred vision, tinnitus, hypotension, palpitations, anorexia, dry
mouth, constipation, nausea, dysuria, urinary retention, photosensitivity, chest tightness, thickened bronchial secretions,
wheezing.
Nursing considerations/ Patient Teaching: Use cautiously in severe liver disease, angle-closure glaucoma, seizure
disorders, prostatic hyperplasia, peptic ulcer, hyperthyroidism. Increased risk of CNS depression with other antihistamines,
alcohol, opioid analgesics and sedatives.
Name: famatodine, Pepcid

Concentration

Dosage Amount: 20 mg

University of South Florida College of Nursing Revision September 2014

Route: PO
Frequency: Daily
Pharmaceutical class: Histamine h2 antagonists
Home
Hospital
or
Both
Indication: Management of gastroesophageal reflux disease.
Adverse/ Side effects: Confusion, dizziness, drowsiness, hallucinations, headache, arrhythmias, constipation, diarrhea,
nausea, erectile dysfunction, gynecomastia, agranulocytosis, aplastic anemia, neutropenia, thrombocytopenia.
Nursing considerations/ Patient Teaching: Assess for epigastric or abdominal pain and frank or occult blood in the stool
or emesis. Monitor CBC during therapy. Administer with meals or immediately afterward and at bedtime to prolong effect.
Name: furosemide, Lasix

Concentration

Dosage Amount: 40 mg

Route: PO
Frequency: Daily
Pharmaceutical class: Loop diuretics
Home
Hospital
or
Both
Indication: Hypertension, edema due to heart failure, hepatic impairment or renal disease.
Adverse/ Side effects: Blurred vision, dizziness, headache, vertigo, hearing loss, tinnitus, hypotension, anorexia,
constipation, diarrhea, dry mouth, dyspepsia, nausea, vomiting, pancreatitis, excessive urination, Steven-Johnsons
Syndrome, photosensitivity, pruritis, rash, hyperglycemia, dehydration, hypocalcemia, hypochloremia, hypokalemia,
hypomagnesaemia, hyponatremia, hypovolemia, metabolic alkalosis, aplastic anemia, agranulocytosis, hemolytic anemia,
leukopenia, thrombocytopenia, muscle cramps, paresthesia, fever.
Nursing considerations/ Patient Teaching: Use cautiously in severe liver disease, electrolyte depletion, diabetes,
hypoproteinemia, severe renal impairment.
Name: potassium chloride

Concentration

Dosage Amount: 40 mEq

Route: PO
Frequency: Daily
Pharmaceutical class: Mineral and electrolyte
Home
Hospital
or
Both
replacement
Indication: Treatment and prevention of potassium depletion
Adverse/ Side effects: Confusion, restlessness, weakness, arrhythmias, ECG changes, abdominal pain, diarrhea, nausea,
vomiting, GI ulceration, paralysis, paresthesia.
Nursing considerations/ Patient Teaching: Contraindicated in hyperkalemia, renal impairment. Use cautiously in cardiac
disease, diabetes and patients receiving potassium sparing drugs. Monitor serum potassium before and periodically during
therapy. Monitor for symptoms of toxicity.
Name: vancomycin

Concentration: 278 ml

Dosage Amount: 1250 mg

Route: IV
Frequency: Q12
Pharmaceutical class: Anti-infective
Home
Hospital
or
Both
Indication: Treatment of life-threatening infections. Particularly in staphylococcal infections.
Adverse/ Side effects: Ototoxicity, hypotension, nausea, vomiting, nephrotoxicity, rashes, eosinophilia, leukopenia,
phlebitis, back and neck pain, anaphylaxis, chills, fever, red man syndrome, superinfection.
Nursing considerations/ Patient Teaching: May cause ototoxicity and nephrotoxicity with other toxic drugs. Use
cautiously in renal impairment, hearing impairment, intestinal obstruction or inflammation.

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? Cardiac
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:
The patients normal home diet shows that he is meeting
majority of his daily food group goals. The only group that
Breakfast: BLT sandwich, hash browns and fruit
is being neglected according to the input in his dairy intake.
This means the patient is not getting enough calcium in his
Lunch: Chicken Stir Fry, salad and fruit
diet. According to My Plate the patient is taking in too
much sodium, which can increase his hypertension, and risk
Dinner: Seafood (fresh fish), rice and vegetables
for heart disease. Lastly, the patient is under the suggested
amount of iron, this could lead to anemia. The patient
Snacks: Graham crackers, pudding
should add some more red meats or fortified cereal to
increase his iron level.
Liquids (include alcohol): 2 hot teas, juice, a lot of water,
a few alcoholic beverages

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My wife
How do you generally cope with stress? or What do you do when you are upset? I normally have a few drinks or go
for a walk with my wife.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Yes, last year when I lost my job I became pretty depressed and overwhelmed.

University of South Florida College of Nursing Revision September 2014

+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, my first marriage which only lasted 6 months. _______
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? ______________________
Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust


Intimacy vs. Isolation

Autonomy vs. Doubt & Shame


Initiative vs. Guilt
Industry
Generativity vs. Self absorption/Stagnation
Ego Integrity vs.

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: The goal of this developmental stage is to be productive. Whether through relationships or work a person in
this stage should contribute to society productively. If this doesnt occur the patient experiences stagnation, and lead to
decreased motivation to guide them to the next developmental stage (Treas & Wilkinson, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: I believe
my patient is in the self absorption/ stagnation stage of life due to his illness limiting his availability to work. In the past year
the patient lost his job and was placed on disability. I believe this has caused a severe delay on my patients development due to
him feeling lost and inadequate. I believe the only portion of my patients life that isnt stagnant is his relationship with his
wife.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: The patients
disease process has caused him to lose his job, and in turn lose his home. I believe this has severely impacted his stage of life
because he feels empty without working, and put him in a stagnant stage of his life.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? The patient thinks that bed bugs caused his cellulitis. He claims that
in their old apartment the infestation was really bad, and he thinks that is what led to him developing cellulitis.
What does your illness mean to you? The patient feels his illness makes him dirty, and at times he feels paralyzed.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?____Yes________________________________________________
Do you prefer women, men or both genders? __Women____________________________________________
Are you aware of ever having a sexually transmitted infection? __No_________________________________
Have you or a partner ever had an abnormal pap smear? No____________________________________
Have you or your partner received the Gardasil (HPV) vaccination? __No________________________________
Are you currently sexually active? __Yes______ If yes, are you in a monogamous relationship? ____Yes__________
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended

University of South Florida College of Nursing Revision September 2014

pregnancy? _____None_____________________________
How long have you been with your current partner?___25 years.___________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _No._________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No.

University of South Florida College of Nursing Revision September 2014

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


What importance does religion or spirituality have in your life?
___My religion has always been there.____ ___________________________
Do your religious beliefs influence your current condition?
______No.________________________________________________________________________________________________

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


1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
Yes
No
If so, what? Smokes tobacco
How much?
For how many years? 41 years
The patient has a history of 1-3 packs
(age 13 thru 54 )
per day. But is now down to 3
cigarettes per day.
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No, just the patient.

Has the patient ever tried to quit? Yes.


If yes, what did they use to try to quit? Cold Turkey.

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Liquor
How much? 3-4 drinks per day

For how many years? 39 years

If applicable, when did the patient quit?


NA
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what? Marijuana and Cocaine.
How much? Did both drugs as
For how many years? 4
a teenager.
Is the patient currently using these drugs?
Yes No

If not, when did he/she quit?


He stopped as a teenager.

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Possible asbestos from working as a plumber when he was 18 years old.
5. For Veterans: Have you had any kind of service related exposure? N/A

University of South Florida College of Nursing Revision September 2014

10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: Everyday
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 (Dentures)
Routine brushing of teeth
1 x/day
Routine dentist visits (only if problem)
Vision screening (every 6 mos)
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea


Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? 2 years ago
Other:

Chills with severe shaking


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

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: O Neg
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 8-9 x/day
Bladder or kidney infections

Hematologic/Oncologic

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

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 11/10/15
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 11/10/15

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? 2x year
Date of last prostate exam? Recently
BPH
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis

Childhood Diseases
Measles (German measles)
Mumps
Polio
Scarlet Fever
Chicken Pox

University of South Florida College of Nursing Revision September 2014

Other:

Other:

Other:

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?

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

10 PHYSICAL EXAMINATION:
General Survey: Patient is
AOx4. Patient is a 54 y.o white
male who appears older than
actual age. He is sitting in bed
comfortably. He shows no sign of
distress at this time.

Temperature: Oral 98.4

Height: 60
Pulse: 85
Respirations: 18

Weight: 207
BMI: 27.9
Blood Pressure: (include location)
Left Arm: 158/82

SpO2 : 98%

Is the patient on Room Air or O2

Pain: (include rating and


location) 0 out of 10

Room Air

Overall Appearance: [Dress/grooming/physical handicaps/eye contact]


clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
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: Cellulitis of the lower
extremities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
Central access device Type: IV- 22 gauge
Location: Right Wrist
Date inserted: 11/13/15
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 / 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: Upper and lower dentures
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
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: Decreased
LUL: Decreased
RML: Decreased
LLL: Decreased
RLL: Decreased

Chest expansion symmetric

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

University of South Florida College of Nursing Revision September 2014

Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular

No murmurs, clicks, or adventitious heart sounds

No JVD

Calf pain bilaterally negative


Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 82
Carotid: +2
Brachial: NA
Radial: +2
Femoral: NA
Popliteal: NA
Pedal: +2
No temporal or carotid bruits
Edema: +1
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: Lower extremities
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 11 / 12 / 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:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Previous 24 hour output: N/A


without assistance

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

Babinski: positive negative

University of South Florida College of Nursing Revision September 2014

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

Trend

Analysis

WBC: 5.2
4.1

Dates
(11/4/2015)
(11/10/2015)

WBC trended down between


admissions.

The pt had a low WBC count


and it decreased more with the
acute case of cellulitis.

Hgb: 11.9
13.3

(11/4/2015)
(11/10/2015)

The Hgb has gone up, but it is


still low.

Hct:

(11/4/2015)
(11/10/2015)

The Hct has gone up, but it is


still low.

Platelet: 155
230

((11/4/2015)
(11/10/2015)

Platelets have gone up, and are


still WNL.

His platelets are regenerating.

Sodium: 140
141

(11/4/2015)
(11/10/2015)

The sodium went up by one.

The sodium is WNL.

Potassium: 3.1
3.9

(11/4/2015)
(11/10/2015)

His K increased between


admissions.

The patients potassium is now


WNL due to K supplements.

Chloride: 105
105

(11/4/2015)
(11/10/2015)

The chloride level remained


the same.

The Chloride is WNL.

CO2: 23.4
27.4

(11/4/2015)
(11/10/2015)

The CO2 level slightly


changed between admits.

The patients CO2 is WNL.

Glucose: 144
119

(11/4/2015)
(11/10/2015)

The glucose has decreased.

The blood sugar has come


down to a normal level for a
non-diabetic, but is still a little
high.

BUN: 7
11

(11/4/2015)
(11/10/2015)

The BUN level has increased.

The BUN is WNL.

Creatinine: 0.7
0.7

(11/4/2015)
(11/10/2015)

The creatinine remained the


same.

The creatinine is WNL.

Calcium: 8.6
8.9

(11/4/2015)
(11/10/2015)

The calcium has slightly risen.

The level increased, and is


WNL.

Vancomycin: 13.0

(11/10/2015)

The Vancomycin level is


WNL.

The patients prescribed Vanco


can be given.

36.1
39.3

The low levels of the patients


Hgb and Hct could mean the
patient is anemic.

EKG: Sinus Rhythm


Chest X-ray: Showed probable bibasilar scarring
Ultrasound of bilateral lower extremities: Negative for DVTs
University of South Florida College of Nursing Revision September 2014

+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.)
The patient is currently on a cardiac diet. Vitals signs are being measured every 4 hours. The patient has a urinal at
bedside, and requires assistance to the restroom for bowel movements. The patient is receiving Vancomycin antibiotic
treatment q12 for his cellulitis. Patient is also receiving respiratory treatments PRN for his underlying COPD. The
patient has no scheduled tests, and his anticipated discharge is in the next 24 hours.

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


1. Ineffective peripheral tissue perfusion rt an inflammatory response damaging skin and underlying tissue aeb red, flaky
skin, edema and extremity pain.
2. Impaired tissue integrity rt tissue distension by accumulation of fluid aeb red, flaky edematous tissue of the lower
extremities.
3. Acute pain rt inflammatory changes in tissue secondary to cellulitis aeb complaints of pain, discomfort and fatigue.
4. Risk for vascular trauma rt infusion of Vancomycin antibiotics.
5. Knowledge deficit rt inadequate information on the prevention of symptoms aeb frequent hospitalizations.

University of South Florida College of Nursing Revision September 2014

15 CARE PLAN
Nursing Diagnosis: Ineffective peripheral tissue perfusion rt an inflammatory response damaging skin and underlying tissue aeb red, flaky skin, edema and
extremity pain.

Patient Goals/Outcomes
1.

2.

3.

4.

Nursing Interventions to Achieve


Goal

Patient will maintain optimal tissue


perfusion as evidenced by strong
pedal pulses and adequate capillary
refill throughout entire shift.
Patients edema in the lower
extremities will reduce from a +2 to a
+1 or 0 by the end of the shift.

1.

Assess q4 for signs of decreased


tissue perfusion such as weak pedal
pulses or capillary refill greater than 3
seconds.
2. The patients legs will be elevated or
propped on pillows to help relieve the
swelling the entire shift. The patient will
also receive his Lasix daily to remove
fluid from the body.
3. Patient will continue to receive
Vancomycin antibiotic treatment q12 to
improve his white blood cell count and
fight infection.
4. Patient will be provided with education
and handouts on the signs and symptoms
of cellulitis. He will also be instructed on
the importance of reporting issues early to
reduce the possibility of sepsis.

Patients white blood cell count will


increase to within normal limits, and
signs of infection will decrease by
discharge in the next 24 hours.
*Patient will verbalize and
demonstrate how to check and
monitor his body for signs and
symptoms of acute cellulitis flair ups
at home.

Rationale for Interventions


Provide References
1.

Assessing q4 will show any positive


or negative changes to the patients
baseline.

2. Elevation of the affected limb will help


reduce and prevent further swelling to the
extremity.

Evaluation of Goal on Day Care


is Provided
1. The patients tissue perfusion has
remained the same. Pedal pulses are
still +2 and capillary refills are less
than 3 seconds.
2. The patients swelling greatly decreased
by the end of the shift. The right leg
showed +1 edema, and the left leg had
returned to its normal size.

3. Antibiotic treatment will help to rid the


patient of infection, and increase his white
blood cell count which is low at 4.1.

3. The patient received his Vancomycin


treatment intravenously at 10 am. Patient
is scheduled for his next dose at 10 pm.

4. Providing the patient with knowledge


on how to protect them self from
developing an infection is important in
their already fragile state of health.

4. The patient verbalized and did a teach


back on the ways to identify cellulitis, and
the importance of reporting symptoms.

Nursing Diagnosis: Acute pain rt inflammatory changes in tissue secondary to cellulitis aeb complaints of pain, discomfort and fatigue.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
1. Patients pain level will remain under 5
out of 10 throughout the entire shift.

2. Patient will remain relaxed, comfortable


and able to sleep throughout hospital stay.

3. Patient will be able to participate in

1. Investigate complaints of pain, and


record the location and intensity on a scale
of 0-10 q2. Provide pain meds when
needed, especially prior to ambulation and
completing ADLs.
2. Help the patient assume a comfortable
position in bed, and encourage stress
management techniques such as
progressive relaxation and deep breathing
q2.
3. Assist patient with getting out of bed at

1. Assists in determining the need for pain


management. Providing pain management
will keep the patient calm, and better the
healing process.

1. Patients pain level remained at 3 out of


10 or lower the entire shift.

2. Increased relaxation will help the


patient to recover faster, and may give him
a sense of control. This may also allow for
better coping with his disease.

2. Patient remained calmed and used


distraction methods such as reading and
watching television throughout the shift.

3. Patient should ambulate frequently to

3. Patient sat up in the chair for each meal

University of South Florida College of Nursing Revision September 2014

ADLs and ambulate to the restroom when


needed throughout shift.

least three times a day and provide pain


meds when needed, especially prior to
ambulation and completing ADLs.

increase circulation. Performing ADLs


with minimal assistance will help with his
independence on discharge.

4. *Patient will demonstrate and teach


back how to properly take his pain
medications after discharge by the end of
shift.

4. Patient will be provided education on


when and how to properly take his pain
medications, and the importance of taking
the medications before performing
activities.

4. Helping the patient to develop a proper


pharmacological program will keep him
compliant with his medications, and
decrease his chance of improperly taking
his medications.

and ambulated to the restroom for bowel


movements. Pain meds were provided
before activity to increase patients ability
and motivation.
4. Patient correctly demonstrated how and
when to take his medications to the nurse
after demonstration.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs

*F/U appointments
*Med Instruction/Prescription
Are any of the patients medications available at a discount pharmacy? *Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

References
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (Tenth ed.). Maryland Heights, Missouri:
Mosby Elsevier.
Osborn, K., Wraa, C., Watson, A., & Holleran, R. (2014). Caring for the Patient with Diabetes. In Medical-Surgical Nursing: Preparation for
Practice (2nd ed., pp. 1417-1464). Upper Saddle River, NJ: Pearson Education.
Treas, L., & Wilkinson, J. (2014). Development: Infancy through Middle Age. In Basic Nursing (pp. 163-164). Philadelphia, Pennsylvania: F.A Davis
Company.

University of South Florida College of Nursing Revision September 2014