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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Maria Sofia Quinonez

MSI & MSII PATIENT ASSESSMENT TOOL .


1 PATIENT INFORMATION

Assignment Date: 2/8/16


Agency: VA

Patient Initials: JKW

Age: 76

Admission Date: 1/31/16

Gender: Male

Marital Status: Single

Primary Medical Diagnosis: worsening LLE


swelling, erythema and dyspnea

Primary Language: English


Level of Education: 12th grade

Other Medical Diagnoses: left chest pain, COPD,


CAD, arthritis, and Diabetes

Occupation (if retired, what from?): mechanical engineer/ designed tools


Number/ages children/siblings: 4 children/ 4 siblings

Served/Veteran: yes, Vietnam


If yes: Ever deployed? Yes

Code Status: Full Code

Living Arrangements: lives alone in a 55+ apartment complex.


Sister visits often and helps him out.

Advanced Directives: Yes


Surgery Date: n/a

Culture/ Ethnicity /Nationality: Caucasian/American


Religion: Evolution

Type of Insurance: Medicare

1 CHIEF COMPLAINT: Ive had this wound on my left leg since I fell about 3 weeks ago. I had a
home nurse helping me, but the wound kept getting worse and the swelling in both of my legs got pretty
bad. She insisted I go to the hospital, I was also having a little trouble breathing, but thats always a
problem.

3 HISTORY OF PRESENT ILLNESS: Patient was recently hospitalized from Jan.20-27th for a treatment of
LLE hematoma with cellulitis after incurring an open wound to the left leg as a result from a fall in the
bathroom. Wound was healing well and patient was discharged after treatment to SNF. He did not like the SNF
because they tried to have him do PT which he refused, so he then left the same day. VA set up home health for
him in the meantime. Patient was recently admitted again on 1/31/16 and presented to the ER with complaints
of worsening LLE swelling, erythema, and drainage from the wound on the left leg. Patient also complains
about worsening dyspnea and increasingly thick sputum. Patient states his main pain is the wound on his left leg
and medications make it better, he rates his pain between a 4-5. His wound keeps him from walking long
distances, but patient ambulates short distances and is on fall risk. Drainage from wound has decreased and
dressings are constantly changed. Swelling also has gone done from a 3+ to a 2+ in both lower extremities.
Patient continues to take medication for wound and keeps leg elevated for swelling to go down. Fluid restriction
was asked of the patient and he is following orders. Also, on 2/2/16 at about 10:00 am patient complained about
University of South Florida College of Nursing Revision September 2014

left chest pain leading all the way to his entire left arm. He stated his pain was a 7-8 and he was having anxiety.
An EKG was ordered but a normal sinus rhythm was detected with PR interval and QRS present. Pain went
away later on throughout the day and patient was able to sit up in his chair. Patient continues to take
medications for his heart, shortness of breath, and his wound. The plan for his hospital stay is to completely heal
the wound, so patient is able to return home with no reoccurring problems.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease

Father
Mother
Brother

57

Sister

56

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

Environmental
Allergies

Cause
of
Death
(if
applicable
)
Death at
82
Death at
69

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Fitting and Adjustment of Automatic Implantable Cardiac Defibrillator
Cardiac Catherization related to Coronary Artery Disease
LLE hematoma following trauma

Age (in years)

Date
2/4/14
11/4/15
1/27/16

relationship
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 U
Routine adult vaccinations for military or federal service U
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Date) 10/2015
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NO

Pneumococcal (pneumonia) (Date)


Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Iodine
Theophylline
Beta-blockers
Sulfa-drugs

Medications

Type of Reaction (describe explicitly)


Rash on chest
Arrhythmias in the heart
Shortness of breath and redness on skin
Rash and shortness of breath

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) A hematoma is an abnormal collection of blood outside of a blood vessel. It mainly occurs as a
result from trauma which results in the wall of a blood vessel, artery, veins or capillary, being damaged and
blood can leak into tissues where it does not belong. (Nettleman 2015)It is a type of serious internal bleeding
that is either clotted or forming clots. Hematomas cause a lot of irriation and inflammation and on occasion
edema. Most hematomas can be evaluated and safely treated using laboratory or radiology tests. Depending on
the injury itself or its location, blood tests may be ordered to assess RBCs and clotting studies including the INR
and the PTT to find out the severity of the hematoma. A more detailed characterization og the injury can be
made by using imaging such as an ultrasound or MRI. Symptoms such as an increase or perisistent swelling
after 48-72 hours of the trauma event, an increase in pain, a decrease in peripheral pulses, and a prolonged
limitation of joint caused by uscle weakness are all negeative prognostic factors. It is necessary to consider the
anatomical location where the damage occurred in order to plan the most proper rehabilitation treatment for the
patient. At the moment of the trauma the first aid for any kind of muscle or bone injury is RICE ( Rest, Ice,
Compression, and Elevation). Rest is highly recommended during the first 24-72 hours following the traumatic
event of the injury to prevent further bleeding and exacerbation of fibillar necrosis at the site of the lesion.
Keeping the injurded limb elevated is also crucial because it may keep the blood pressure from falling and keep
venous return from increasing (Conforti). A compression bandage can also be helpful because it can reduce
blood flow by 50%. Icing the effected area can do wonders such as cause vasoconstriction, a reduction of
edema, and an improvement of lymphatic drainage. Another key factor in treating a hemtoma in a lower
extremity is immobilization immediately after the occurrence of the injury itself. It is very difficult to prevent
hematomas because accidents happen and most hematomas are inevitable. If you are in the elderly population
and have trouble ambulating, getting ride of rugs and things on the floor that could cause a potential fall should
be removed. For people taking anit-coagulation medications, it is very critical to avoid participating in any
events with high risk injury.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: etodolac; Lodine

Concentration: Mg

Route: oral

Dosage Amount: 30 mg
Frequency: one capsule 2x a day

Pharmaceutical class: NSAID

Both

Indication: It works by reducing hormones that cause inflammation and pain in the body. Used to treat moderate pain, osteoarthritis, or rheumatoid arthritis.

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Adverse/ Side effects: changes in vision, skin rash, shortness of breath, stomach bleeding, liver and kidney problems, low red blood cells
Nursing considerations/ Patient Teaching: get emergency medical help if you have sgins of an allergic reaction and if you have signs of a heart attack or stroke.
Avoid drinking alcohol and taking aspirin ot other NSAIDs.
Name: Insulin Aspart, NovoLog

Concentration: units

Route: per sliding scale under the skin

Dosage Amount: Blood Glucose 150-199 give 4


units, 200-249 give 8 units, 250-299 give 12
units, 300-349 give 16 units, 350-399 give 20
units
Frequency: omce daily

Pharmaceutical class

Both

Indication: usually used with another type of insulin to treat Type 2 Diabetes. It replaces the insulin normally produced by the body and by helping move sugar
from the blood into other body tissues where it is used for energy. Also stops the liver from producing sugar.
Adverse/ Side effects: redness, swelling, or itiching at the injection site, weight gain, constipation, muscle cramps, abnormal heartbeat, dizziness or rash.
Nursing considerations/ Patient Teaching: make sure to store insulin in the refrigerator , avoid alcohol. Tell your doctor if youve ever had nerve damage caused
by diabetes or heart failure.
Name: Insulin Glargine, Lantus

Concentration: units /ml

Route: Injection under the skin

Dosage Amount: 10 units

Frequency: every evening

Pharmaceutical class

Both

Indication: long- acting insulin (24 hour duration of action) that is also a parental blood-glucose lowering agent.
Adverse/ Side effects: insulin allergy- rash, wheezing, shortness of breath, hypoglycemia or low blood sugar
Nursing considerations/ Patient Teaching: you may experience blurred vision or dizziness due to extremely low or high blood sugar levels. Avoid alcohol and tell
doctor before if you are allergic to insulin.
Name: lisinopril, Prinivil

Concentration: mg

Route: oral

Dosage Amount: 40 mg
Frequency: tablet daily

Pharmaceutical class: ACE inhibitor

Both

Indication: used to treat high blood pressure or congestive heart failure


Adverse/ Side effects: light headedness, kidney problems, headache, dizziness, cough or chest pain.
Nursing considerations/ Patient Teaching: Do not use if you are pregnant. Hold medication for systolic blood pressure less than 100.
Name: metformin, Fortamet or Glucophage

Concentration: mg

Route: oral

Dosage Amount: 1000 mg


Frequency: one tablet by mouth 2x a day

Pharmaceutical class: oral diabetes medicine

Both

Indication: helps control blood sugar level and used for people with Type 2 Diabetes
Adverse/ Side effects: muscle pain or weakness, trouble breathing, stomach pain, shortness of breath, nausea or vomiting
Nursing considerations/ Patient Teaching: some people may develop lactic acidosis so talk to doctor about any risk. Avoid drinking alcohol
Name: metroprolol tartrate, Lopressor

Concentration: mg

Route: Oral

Dosage Amount: 100 mg


Frequency: Take talet 2x daily

Pharmaceutical class: beta-blocker

Both

Indication: treats high blood pressure and long-term treatment of chest pain. It works by reducing the amount of work the heart has to do and the amount of
blood the heart pumps out.
Adverse/ Side effects: dizziness, drowsiness, dry mouth or eyes, headache, muscle aches, rash, cold hands and feet, hallucinations, or mood and mental changes.
Nursing considerations/ Patient Teaching: do not use medication if you have avery slow heart rate or any certain types of irregular heartbeat. Do not take if you
are taking mibefradil and make sure to look out for drug interactions.
Name: pantoprazole, Protonix

Concentration: mg

Route: oral

Dosage Amount: 40 mg
Frequency: once a day before a meal

Pharmaceutical class: proton pump inhibitor

Both

Indication: Decreases the amount of acid in the stomach; used to treat erosive esophagitis(damage to the esophagus from stomach acid) and other conditions
involving an excess in stomach acid.
Adverse/ Side effects: headache, seizures, low magnesium, fever, joint pian, kidney problems, stomach pain, gas, mild diarrhea.
Nursing considerations/ Patient Teaching: DO NOT crush, chew, or break the tablet. Long-term treatment with this medication may make it harder for your
body to absorb vitamin B-12. May also increase your risk of bone fracture in the hip, wrist, or spine. Contact your doctor if you have diarrhea that is watery or

University of South Florida College of Nursing Revision September 2014

bloody.
Name: pregabalin, Lyrica

Concentration: mg

Route: oral

Dosage Amount: 50 mg
Frequency: one capsule 2x daily

Pharmaceutical class: anticonvulsant and neuropathic pain agent

Hospital

Indication: It is thought to bind to certain areas in the brain that help reduce seizures, nerve pain, and anxiety
Adverse/ Side effects: blurred vision, changes in sexual function, constipation, increased appetitie, weakness, numbness, chest pain, muscle aches, loss of
coordination, and mood changes
Nursing considerations/ Patient Teaching: Do not drink alcohol on this mediction. Pregabalin may reduce the number of clot-forming cels in your blood, so
avoid acitivites that may cause bruising or injury. Do not suddenly stop taking pregabalin because it may cause seizrues. People who take this medication may
also be at risk for suicidal thoughts or actions.
Name: tizanidine, Zanaflex

Concentration: mg

Route: oral

Dosage Amount: 4 mg tablet


Frequency: tablet 2x daily

Pharmaceutical class: short-acting muscle relaxer

Both

Indication: It works by blocking nerve impulses that are sent to your brain. It is used to treat spasticity or tremors by temporarily relazing muscle tone.
Adverse/ Side effects: feeling ligh-headed, confusion, slow heart rate, nausea, stomach pain, dark urine, jaundice, dry mouth, sweating and skin rash
Nursing considerations/ Patient Teaching: Do not take more than three doses (36 mg) or tizandine in a 24-hour period, too much of it can damage your liver.
Tizanidine can cause side effects that may impair your thinking or reactions. Be careful if you operte any machinery.

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Name : digoxin, Lanoxin

Concentration: mg

Route: oral

Dosage Amount: 0.125 mg


Frequency: one tablet in the morning

Pharmaceutical class: cardiac glycoside

Hospital

Indication: used to treat heart failure and chronic atrial fibrillation. It works by affecting sodium and potassium inside heart cells, this reduced strain on the
heart and helps it maintain a normal, steady strong heartbeat.
Adverse/ Side effects: fast, slow, or uneven heart rate. Bloody or tarry stools, blurry vision, confusion, hallucinations, headache, mild skin rash, or loss of
appetite.
Nursing considerations/ Patient Teaching: An overdose of digoxin can be fatal. Avoid becoming overheated or dehydrated during exercise, because digoxin
overdose can occur more easily when dehydrated.

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Name : rosuvastatin, Crestor

Concentration: mg

Route: oral

Dosage Amount: 20 mg
Frequency: once daily

Pharmaceutical class: HMG-CoA Reductase Inhibitor (Statin)

Both

Indication: used to lower high cholesterol and triglycerides in patients. It also increase HDL (good cholesterol). It slows down the process of atherosclerosis and
helps reduce the risk of heart attack or stroke.
Adverse/ Side effects: constipation, stomach pain, bloody or dark urine, muscle pain, depression, chest pain, or confusion.
Nursing considerations/ Patient Teaching: This medication may cause liver problems and muscle problems. If patient has diabetes, rosuvastatin may affect blood
sugar levels. Can be taken with or without food.

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5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Normal/ sugar free diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular, watches sugar
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: eggs(pouched), hash browns, rye toast, bacon,
fruit
Lunch: sandwich or salad with dressing with either chips or
fruit on the side
Dinner: A lot of fish, swordfish, chicken, steak, pork,
broccoli, oysters, tuna.
Snacks: celery, potato chips, frozen fruit, and strawberries.
Liquids (include alcohol): scotch- 1 shot and a beer (dark),
red wine on occasion. Drinks a lot of water for tremors.
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.
Patient is diabetic so he watches his sugar intake. Compared to
My Plate patient is getting more than enough protein and
vegetables in his daily diet. Patient also claims fish is a huge part
of his diet that he atleast consumes it 3-4 times a week. Another
source of protein, comes from the chicken and pork, but he
mainly eats seafood as his main course when it comes to dinner.
He likes to eat salads and sandwiches for lunch and tends to
follow that with potato chips as a snack or frozen fruit. Patient
does have to watch his sodium intake as the recommened daily
limits for sodium according to My plate is 2300 mg, and with
this daily diet patient is consuming 3607 mg. Patient suffers from
multiple episodes of heart failure, so sodium is a part of his diet
he needs to elimate. Since patient suffers from many health
conditions, he should increase the amount of vegetables and fruits
and try to eliminate things such as potato chips and fatty foods.
According to My Plate my patient is also falling behind in thd
whole grain daily recommendation along with the diary portion.
So maybe it would be important to put some variety in my
pateints diet and mention to increase his whole grain and diary
dialy intake. Patient drinks alcohol, but recently states that he has
been watching how much he drinks because of his recent
hospitalizations. He usually sticks to 1-2 drinks a week, usually
scotch or nice glass of red wine.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Home health nurse helped patient for a while when caring for wound. Patients sister visits
on occasion (atleast once a week) and helps him out with food.
How do you generally cope with stress? or What do you do when you are upset? Patient plays bridge at country club when
he can. Music helps patient unwind and he is a big fan of big named bands. Reading biblical history also is a big hobby of
patient.

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Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient states he has no feeling of depression, but does suffer from anxiety on a daily basis. He says he doesnt have a hard
time making friends and still enjoy flirting.

+2 DOMESTIC VIOLENCE ASSESSMENT


Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are safe.
Have you ever felt unsafe in a close relationship? No
Have you ever been talked down to? No Have you ever been hit punched or slapped? No
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? No
If yes, have you sought help for this?
Are you currently in a safe relationship? yes, I mean I live alone.

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: Integrity vs. Despair is the final stage of Ericksons development theory. It begins at age 65 and ends at death. It
begins as the adult begins to age anf starts to tackle the problem of his or her mortality(Cherry 2015). It is often triggeed by life events
such as retirement, the loss of a spouse, or facing a terminal illness. Many people at this time reflect back on the life they have lived, the
memories they have made and the joys and pains of their experiences. Successfully resoliving the crisis at this stage is known as ego
integrity. If people are able to look back on their life with contentment and no regrets they have a sense of integrity. These people feel
proud of their accomplishments and also what they are leaving behind in this world. Those who feel unsuccessful during this phase and
feel like their life has just been a series of sadness and regrets enter into a time of despair. The person will be left with feelings of
bitterness and many regrets for the life they were given (Cherry 2015).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is currently in the Ego Integrity vs.Despair phase because as a 76 year old he has already started to slow down
on productivity in his life. He is a retired veteran and his poor health conditions have set him back from a lot of things in
life. He lives alone and wishes he had the abilities to do the things he used to do such as play golf and bridge with his
friends. He says he has a lot of bottled up anger from his past choices and life happenings that he sometimes regrets. In this
stage he is reminiscing on his life and wondering if he could have done anything differently. He is pretty content where he is
in life right now, just angry at how much his illness has set him back. Living alone is hard because he feels like no one is
ever there to fully take care of him. My patient portrays feelings of despair, and although he tries to enjoy life as much as he
can he still blames many people for his problems. Losing his partner of 25 years not too long ago also set him back and left
him with no one to live the rest of life with anymore.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: Ranging form
his multiple heart attacks to his diabetes, my patients illness has slowed him down tremendously. He stated multiple times that he
wishes he was well again to go back to all the things he was once able to do. He also suffers from tremors that keep him from drawing
like he used to in the past or even keep his coordination for short periods of time. His wound on his leg now has caused edema on both
lower extremeties that has taken away his ability to walk without assistance. My patient hates the hospital, but loves the company he
gets because he much rather be with people than alone at home with no one to tal to. He wants to get better, but at this point he has had
so many problems he thinks there is no turnin back. It just gets worse from here patient says, but he is going to try his best to still eat
healthy and enjoy whats left of the life he created for himself.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? Agent orange 100%, it all started with my first heart attack at 41.

University of South Florida College of Nursing Revision September 2014

What does your illness mean to you? Patient states Inabilities to do life, used to play tennis and golf, and that stopped. I
feel like Ive been cheated on from some of my life. I have lost so much, and with that comes my anger and anxiety.

+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, havent been in a while. 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? Condoms
How long have you been with your current partner? I live alone
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

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10

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


What importance does religion or spirituality have in your life?
Patient states that spirituality doesnt have a lot to do with his life. Patient states that he believes in evolution, but that doesnt mean
Christ doesnt exist.
Do your religious beliefs influence your current condition? Patient states that his religious beliefs have nothing to do with his illness.

+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? Patient smoked cigarettes.
How much?(specify daily amount)
About 1 pack a day

Yes
For how many years? 43 years
(age 13

thru

56 )

If applicable, when did the


patient quit? June 13th, 1996

Pack Years: 43
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No.

Has the patient ever tried to quit?


If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? Scotch, a good whiskey
How much? 2 drinks a day
Red wine and beer
Volume: 24 ounces
Frequency: per few weeks
If applicable, when did the patient quit?

For how many years?


(age 18

thru present )

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?


Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Agent orange exposure
5. For Veterans: Have you had any kind of service related exposure?
Agent orange exposure

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11

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:
Bathing routine: showers
Other:

Be sure to answer the highlighted area


HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections: right ear
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems: upper dentures
Routine brushing of teeth
1x/day
Routine dentist visits
1 x/year
Vision screening
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?
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:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:5 to 6
x/day
Bladder or kidney infections

Hematologic/Oncologic

Other:

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

Pulmonary
Difficulty Breathing
Cough: productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 2/2/16

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? 3 years ago
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
Mumps
Polio
Scarlet Fever
Chicken Pox

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12

Other:

Other:

Other:

General Constitution
Recent weight loss
How many lbs? 10 lbs
Time frame? 2 weeks
Intentional? No, patient has recently lost his appetite and doesnt know where its coming from
How do you view your overall health? Not too good, but this recent injury is really setting patient back.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No, no other problem mentioned during the interview.

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

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13

10 PHYSICAL EXAMINATION:
General Survey:

Height: 67 in (170.2
cm)
Pulse: 82
Respirations: 20

Weight: 246.3 lbs


BMI: 38.7
Pain: (include rating and
(112 kg)
location): 7-8 on left arm
(chest pain)
Blood Pressure: (include location):
3-4 on LLE
107/56 (right arm)
Temperature: (route
Is
the
patient
on
Room
Air
or
O
2:
SpO2: 97%
taken?)
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
Appropriate behavior and communicates well
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
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:
Location:
Date inserted:
Fluids infusing?
no
yes - what? Normal saline and vancomycin

flat
loud

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 / 3mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- yes, 10 inches & left ear- yes 10 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
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thin
Amount: small
Color: darkish gray
Lung sounds: regular
RUL: Clear
LUL: Clear
RML: Diminished
LLL: Diminished
RLL: Diminished

Chest expansion

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

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Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
Patient did not have a teli strip, but did receive an EKG while I was at the hospital. These are the findings from the EKG
reading.

Pa
Calf pain bilaterally negative
Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
Carotid: 2+
Brachial: 2+
Radial: 2+
Femoral: 2+
Popliteal: 2+ DP: 2+
PT: 2+
No temporal or carotid bruits
Edema: +3 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: LLE 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 2 / 1 / 16 ) Formed
Color: Medium Brown
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: with assistance
CVA punch without rebound tenderness

850 mLs N/A

Musculoskeletal: Full ROM intact in all extremities without crepitus


Strength bilaterally equal at 5 RUE 5 LUE 4 RLE & 3 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

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Stereognosis, graphesthesia, and proprioception intact


Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: +2

Biceps:

+2

Brachioradial:

+2

Patellar:

+1

Achilles: +2

Ankle clonus: negative Babinski: negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
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.

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Lab
Na+

Dates
141

(1/31/16)

138
Normal: (135-145)

(2/2/16)

K+
4.5

(1/31/16)

4.3
Normal: (3.5-5.2)

(2/2/16)

BUN
25

(1/31/16)

22
Normal: ( 8-23)

(2/2/16)

Creatine
1.3

(1/31/16)

1.1
Normal: (.8-1.3)

Glucose:
168

(2/2/16)

(1/31/16)

130
Normal: (65-110)

(2/2/16)

Trend

Analysis

Sodium levels remained


within limits from the time
of admission to two days
later. Patient has normal
sodium electrolyte levels.

Sodium is a major positive


ion in fluid outside cells.
Na+ regulates the total
amount of water in the body
and plays a critical role in
body functions. It is an
important electrolyte that
helps with allowing muscles
to fire and the brain to work.
The levels are in a normal
range, so the patient is in
stable condition.
Potassium is the electrolyte
mostly conecentrated inside
the cells of the body. It is
essential for conducting
nerve impulses and muscle
contractions. Levels are
within normal range of the
patient. This is importamt
because the patient suffers
from many heart problems,
if there was an increase in
potassium that could mean
life threatening heart
rhythms.
The BUN (blood urea
nitrogen) test is used to
evaluate kidney function.
Increased BUN levels
suggest impaired kidney
function, this may be due to
acute or chronic kidney
disease. It may also be due
to a condition that results in
decreased blood flow to
kidneys such as CHF, shock,
heart failure, or stress.
Creatine works hand in
hand with BUN. High levels
can signify impaired kidney
function. As kidneys come
impaired for any reason, the
creatine level in the blood
will rise due to poor
clearance of the creatine
from the non- functioning
kidneys.
Keeping blood glucose
levels within normal range
for a patient with diabetes is
very important. The target
range for preprandial

Potassium levels are within


normal limits from
admission to now.

BUN levels are very high


for the patient and since
admission they have
progressively gone down,
but it should still be closely
monitored because high
BUN levels can bring
complications.

Levels are also a little bit


higher than usual, but still
within normal limits.
Creatine level has also
decreased since admission.

Glucose levels are a little


high according to this range.
Patient suffers from
diabetes, so levels are still
normal.

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WBC:
8.18

(1/31/16)

7.11
Normal: ( 3.9-9.9)

RBC:
3.7

(2/2/16)

(1/31/16)

3.3
Normal: (4.1-5.7)

(2/2/16)

WBC levels are within


the range, which
indicated the body isnt
fighting an infection or
any sort of allergic
response.

RBC levels are below range


and since admission
continue to lower that can
indicate some serious
problems.

plasma glucose is 80-130


mg/dl and postprandial
plasma glucose is less than
180 mg/dl. So patient is
between these ranges so
diabetes is being taken care
of with insulin regularaly.
WBC count indicated an
overall increase or decrease
in the number of white
blood cells. A high WBC
count usually indicates
some sort of infection,
inflammation, or leukemia.
A low WBC count can
result from bone marrow
damage, lymphoma, or
dietary deficiencies.
RBCs circulate in the blood
and carry oxygen
throughout the body. Some
cases of low RBC count
include hemolytic anemia,
sudden or chronic bleeding
from the digestive tract,
bone marrow damage, B12
deficiency, or kidney
failure. These levels should
be closely monitored
because the RBC count
keeps loweing meaning
patient might have one of
those problems states above.

+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.). Patient is currently on a fluid restriction
diet to decrease the excess amount of fluid in his lower extremeties. Patient is getting wound(hematoma) on his
LLE checked every day twice a day, and the dressing gets changed every two days. Patient is also currently
receiving vancomycin for his wound and his diet remains the same for a diabetic patient. Patient is asked to
remain off his feet while in the hospital, but is allowed to ambulate on his own. Patient receives an accucheck
every morning, but his blood glucose has remained within normal limits. He has no main procedures at this
moment, main concerns are just to reduce his edema and decrease the shortness of breath he is experiencing.
Also, nurse should focus on caring for his wound and making sure that does not cause any further problems with
the patients health.
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8 NURSING DIAGNOSES (actual and potential - listed in order of priority)


1. Excess fluid volume related to excessive fluid intake, cardiac dysfunction, renal dysfunction, loss of plasms proteins.
2. Impaired walking related to limited physical mobility.
3. Impaired tissue integrity related to debridement, open wound.
4.
5.

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15 CARE PLAN
Nursing Diagnosis: Excess fluid volume related to excessive fluid intake, cardiac dysfunction, renal dysfunction, loss of plasms protiens
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Reduce excess fluid volume in the Monitor location and extent of edema Heart failure and renal failure are
Since admission on 1/31/16,
using the 1+ to 4+ scale. Measure the
patients lower extremeties in the
usually associated with dependent
patients edema in both of the
legs using a millimeter tape in the
next week.
edema because of increased
lower extremeties has decreased. It
same area at the same time each day.
hydrostatic pressure; dependent
is still a 2+ in both legs and patient
Note differences in measurement
edema will cause swelling in the
has trouble ambulating, but the
between extremeties. Also monitor
legs and feet of abulatory clients.
interventions and medications are
intake and output, and note trends
Monitoring
for
edema
at
the
same
currently having a positive impact
reflecting decreasing urine output in
time
every
day,
nurse
can
make
on the patient.
relation to fluid intake.
sure patients edema is decreasing
or increasing.
Patient will keep off feet for a
while only to ambulate to the
restroom.

Patient will keep both legs elevated


with atleast two pillows when laying
down in hospital bed or when patient
is sitting up in chair. Leg where the
hematoma occurred has edema of 3+,
so a closer eye should be put on that
leg and monitored for any excess
swelling.

Patient needs to keep both of his


lower extremeties elevated to help
his hematoma from getting any
worse. Patient has 3+ edema on his
LLE and can barely put pressure on
his foot. Keeping the most pressure
off his lower extremeties will help
patient heal the fastest and also
decrease the amount of edema.

Patient continues to elevate legs


and still complains about
discomfort, but patient himself has
noticed differences in the leg
swelling. The leg with the
hematoma also has gone down.
Patient prefers sitting up on the
chair and elevating his legs.

Patient will maintain clear long


sounds with no evidence of
dyspnea or orthopnea.

Listen to lung sounds for crackles,


monitor respirations for effort and
determine the presence and severity of
orthopnea.

Pulmonary edema can result from


excessive shifting of fluid from the
vascular space into the pulomonary
interstitial space which can result
in dyspnea and orthopnea.

Patient came into hospital


complaining about shortness of
breath, but claims it has diminished
and his inhaler has helped him. No
evidence of crackles in the lung
sound were detected.

Patient will maintain a strict fluid


restriction for the remaining of his
hospital stay.

Schedule fluids for patient around the


clock and include the type of fluids
preferred by the client. Maintain the rate

Fluid restriction may decrease


intravascular volume and
myocardial workload. Keeping

Patient remains on fluid restrctions


and is only sticking to water during
the day. Patient complains about

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of all IV fluids. Also monitor serum and


urine osmolality, serum sodium,
BUN/creatine ratio and hematocrit for
abnormalities. (Patients BUN and
creatine levels were both elevated so nurse
should look further into those labs)

patient on low water intake will


help reduce the edema in the legs.

being thirsty and ice chips were


given. Also patients decrease is
appetite has also taken away his
thirst.

Include a minimum of one


Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult

PT/ OT: Patient should receive PT for atleast a couple weeks to a month after discharge. Patient is having trouble walking and
moving his joints. He suffers from arthritis, and PT would be very beneficial to his health to help him move some of his muscles
and get hime more active throughout the week. Patient has diabetes and does not exercise regularly, so PT would help him
atleast utilize some of his muscles while he still can. Patient also lives alone so a home health nurse coming atleast 3 times a
week to check up on him would be an ideal situation to help him out with his daily activities, since his wound is currently
setting him back drastically.
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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15 CARE PLAN
Nursing Diagnosis: Impaired walking related to limited physical mobility.
Patient Goals/Outcomes Nursing Interventions to
Rationale for
Evaluation of Goal on
Achieve Goal
Interventions
Day Care is Provided
Provide References
Patient will be able to walk Monitor and record
Patient has not been
Patient did not reach
to the restroom without
clients ability to tolerate doing much physical
goals for his wound has
assistance.
acitivty and use all four
activity, so vital signs
not improved. Patient
extremeties, note pulse,
should be monitored to
can get from hospital
blood pressure, dyspnea
see how much activity
bed to chair right next to
and skin color before and patient can tolerate at a
it. He can still ambulate
after activity.
time. Starting slow will
to bathroom but he needs
motivate patient to do
assistance.
more each day.
Patient will increase
moderate-intensity physical
acitivity to atleast 30
minutes every other day.

Assess the client for


cause of impaired
mobility and determine
whether the cause is
physical, psychological,
or motivational. In this
case the patient has a
hematoma that is
restricting his from
mobitity on his left leg.
Before that patient wasnt
very active so increasing
physical acitivty is a
must.

Increasing physical
activity gradually will
help patient get used to it
at short intervals. Patient
suffers from a lot of
health conditions, but
needs to incorporate some
sort of physical activity
while he still can
somewhat walk when
hematoma heals fully.

Patients
hematoma/wound on his
LLE is still in the
process of healing. He
refuses to do much
because he is still in
pain, but nurses keep on
encouraging him to seek
help to help him not lose
complete mobility of his
legs.

Patient will attend a PT


session atleast twice a
week to get his muscles
working and decrease the
stiffness in his lower legs.
Long term***

Consult with physical


therapist for futher
evaluation, strength
training, gait training, and
development of a
mobility plan.

Since patient suffers from


arthritis consulting with
the physical therapist
would be ideal to start an
exercise program that
would incorporate more
aerobic exercise or
resistance exercise. One
that would be beneficial
to a patient with arthritis.

Patient was hesistant for


PT sessions but nurses
keep on encouraging the
importance of getting
help for his impaired
mobility. So far the first
step is to get his wound
healed so he can begin
PT sessions if he agrees.

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Refrences

Cherry, Kendra (2015, December 26), Integrity Versus Despair. Retrieved from: http://psychology.about.com/od/psychosocialtheories/a/integrityversus-despair.htm

Conforti, Maria, The Treatment of Muscle Hematomas. Retrieved from: http://cdn.intechopen.com/pdfs-wm/45590.pdf

Nettleman D. Mary, Wedro, Benjamin (2015, September 17) Hematoma. Retrieved from: http://www.medicinenet.com/hematoma/page2.htm

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