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COLLEGE OF NURSING
Student: Melissa Lopez
Assignment Date: 2/14/17
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: SMH
1 PATIENT INFORMATION
Patient Initials: MM Age: 59 Admission Date: 2/11/17
Gender: Male Marital Status: Married Primary Medical Diagnosis: Diverticulitis of colon
with perforation
Primary Language: Gurati Other Medical Diagnoses: (new on this admission)
Level of Education: Bachelor’s Degree Perforation of colon
Occupation: Manager of computer network storage company
Culture/ Ethnicity /Nationality: English (Indian descent) Type of Insurance: Blue Cross
Religion: Muslim
1 CHIEF COMPLAINT:
Patient laughed and said, “Pain! Pain in the abdomen and rectum.”
2
Stomach Ulcers
Environmental
Mental Health
Age (in years)
FAMILY
Heart Trouble
Bleeds Easily
Hypertension
Cause
Alcoholism
MEDICAL
Glaucoma
Problems
Problems
Allergies
of
Diabetes
Arthritis
Seizures
Anemia
Asthma
Kidney
HISTORY
Cancer
Tumor
Stroke
Death
Gout
(if
applicable)
Double
Father 54
pneumonia
Mother 92 N/A
Brother 67 N/A
Sister
relationship
relationship
relationship
Comments:
Mother developed glaucoma 40 years ago, dementia 6-8 months ago, and arthritis 2 years ago.
Father developed diabetes after the patient was born, per the patient.
Brother is a surgeon, so the patient is not aware of any of his medical problems.
1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
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
In 2008 patient traveled to Saudi, and stated he “got everything –
meningitis, Hepatitis B, tetanus” and did not list any more.
1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Penicillin Reaction occurred at 5 years old; but has tolerated amoxicillin in the past
Medications
5 MEDICATIONS:
Name Enoxaparin (Lovenox) Concentration 30 mg Dosage Amount 30 mg injection
Patient Teaching
Instruct patient in correct technique for self-injection, care, and disposal of equipment.
Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to health care
professional immediately.
Instruct patient not to take aspirin, naproxen, or ibuprofen without consulting health care professional while on enoxaparin therapy.
Patient Teaching
Instruct patient to take medication as directed for the full course of therapy, even if feeling better. Take missed doses as soon as remembered but not if almost
time for next dose. Do not double doses.
Advise patients taking OTC preparations not to take the maximum dose continuously for more than 2 wk without consulting health care professional. Notify
health care professional if difficulty swallowing occurs or abdominal pain persists.
Inform patient that smoking interferes with the action of histamine antagonists. Encourage patient to quit smoking or at least not to smoke after last dose of the
day.
May cause drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to the drug is known.
Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation.
Inform patient that increased fluid and fiber intake and exercise may minimize constipation.
Advise patient to report onset of black, tarry stools; fever; sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional
promptly.
Name Piperacillin/Tazobactum (Zosyn) Concentration 3.375 mg/100 ml NS over 60 min Dosage Amount 3.375 mg
Patient Teaching
Advise patient to report rash and signs of superinfection (black furry overgrowth on tongue, vaginal itching or discharge, loose or foul-smelling stools) and
allergy.
Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus. Advise patient not to treat
diarrhea without consulting health care professional. May occur up to several weeks after discontinuation of medication.
Patient Teaching
Instruct patient on how and when to ask for pain medication. Do not stop taking without discussing with health care professional; my cause withdrawal
symptoms if discontinued abruptly after prolonged use.
Advise patient that hydromorphone is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the individual for whom it
was prescribed.
May cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving or other activities
requiring alertness until response to medication is known.
Advise patient to notify health care professional if pain control is not adequate or if side effects occur.
Advise patient to change positions slowly to minimize orthostatic hypotension.
Instruct patient to avoid concurrent use of alcohol or other CNS depressants.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional
before taking any new medications.
Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.
Advise patient to notify health care professional if pregnancy is planned or suspected, or if breast feeding.
Patient Teaching
Instruct patient on how and when to ask for and take pain medication.
Advise patient that oxycodone is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the individual for whom it was
prescribed.
Medication may cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving and other
activities requiring alertness until response to medication is known.
Advise patients taking Oxycontin tablets that empty matrix tablets may appear in stool.
Advise patient to make position changes slowly to minimize orthostatic hypotension.
Advise patient to avoid concurrent use of alcohol or other CNS depressants with this medication.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional
before taking any new medications.
Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.
Advise patient to notify health care professional if pregnancy is planned or suspected, or if breast feeding.
Name Dextrose 5% / NS with KCl Concentration 150 ml/hr Dosage Amount 20 mEq KCl/1000 ml
Patient Teaching
Explain the purpose of dextrose administration to patient.
Instruct diabetic patient on the correct method for self–blood glucose monitoring.
Advise patient on when and how to administer dextrose products for hypoglycemia.
How do you generally cope with stress? or What do you do when you are upset?
Patient reported, “Badly. I lose my temper, then calm down, and sort things out, figure out what I have to do.”
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient said none of these were applicable to him.
Have you ever been talked down to? Patient said, “No.” Have you ever been hit punched or slapped? Patient said, “No.”
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? Patient said,
“No.” If yes, have you sought help for this? N/A ________
Are you currently in a safe relationship? Patient said, “Yes. I love my wife.”
4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self-absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your
patient’s age group:
The definition of “generativity” according to Miriam-Webster’s Medical Dictionary is, “a concern for people besides
self and family that usually develops during middle age; especially: a need to nurture and guide younger people and
contribute to the next generation” (Generativity, 2017).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
Mr. MM is in the “generativity” stage of Erikson’s stages of psychosocial development. The patient is in his late 50’s,
and though he is married, has four children with one still living at home, is still working, he showed great interest in my
education and enjoyed talking with me. He also enjoyed explaining his views on culture and his religion to me and his
nurse, exhibiting the desire to teach the next generation.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
Mr. MM’s condition may impact his quality of life, and therefore his ability to reach out into younger people’s lives. If
not treated properly, he would not be able to help others very much because of the need to attend to his own needs, which
in his condition would be having to manage his pain and constipation.
+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
The patient replied, “over-eating, gluttony, an absolutely pathetic lifestyle. I’m a work-a-holic, and have a weakness of
not being able to learn how to relax.”
+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? Patient replied, “Yes.” ________________________________________________
Do you prefer women, men or both genders? Patient replied, “Women,” and gestured to his wife. ______________
Are you aware of ever having a sexually transmitted infection? Patient replied, “No.” __________________________
Have you or a partner ever had an abnormal pap smear? Patient replied, “No.”_______________________________
Have you or your partner received the Gardasil (HPV) vaccination? Patient replied, “No.”________________________
How long have you been with your current partner? Patient replied, “Thirty-five years.” ________________________
Have any medical or surgical conditions changed your ability to have sexual activity? Patient replied, “No.”___________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
Patient replied, “No.”
Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? No If yes, what did they use to try to quit? Did not ask
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? N/A How much? N/A For how many years?
Volume: (age thru )
Frequency: Patient said, “Never.”
If applicable, when did the patient quit?
N/A
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
N/A How much? N/A For how many years? N/A
(age thru )
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient replied, “No.”
5. For Veterans: Have you had any kind of service related exposure?
N/A
Gastrointestinal Immunologic
Chills with severe shaking (with
Nausea, vomiting, or diarrhea
diverticulitis)
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever (with diverticulitis)
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen yes SPF: 50 Diverticulitis Life threatening allergic reaction
Bathing routine: shower 2 times a day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy? (4/2015)
HEENT Other: Hematologic/Oncologic
Difficulty seeing (Glasses; far-sighted) Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing (Left ear) dysuria Bruises easily
Ear infections (Left ear) hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known:
Post-nasal drip Normal frequency of urination: 3 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 1 x/day Diabetes Type:
Routine dentist visits 1 x/year Hypothyroid /Hyperthyroid
Vision screening (1 x a year) Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? menopause age? Meningitis (as a child, 4 years old)
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression (during 1999-2000)
Hyperlipidemia Frequency of prostate exam? 1x/yr Schizophrenia
Chest pain / Angina Date of last prostate exam? 1/2017 Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures (torn meniscus) Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 2/13 Arthritis Chicken Pox
University of South Florida College of Nursing – Revision September 2014 12
Other: Other: Other:
General Constitution
Recent weight loss or gain
How many lbs? Gained 5 lbs, lost 6 lbs
Time frame? Last 6 months
Intentional? Yes
How do you view your overall health? Patient replied, “Not ill, but I’m not happy with my health. I want to be fitter.”
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient replied, “No.”
Any other questions or comments that your patient would like you to know?
Patient replied, “No.”
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
Patient had dark spots on his pelvic, pubic, and lower back regions. He said he thought they might have resulted from an
allergic reaction to shrimp. The spots were originally raised and filled with clear fluid, but then healed into dark spots.
Peripheral IV site Type: 20 gauge Location: Left AC joint Date inserted: 2/13/2017
no redness, edema, or discharge
Fluids infusing? no yes – what? 5% Dextrose with KCl 20 mEq/1000 mL; NS with Zosyn IVPB
Central access device Type: Location: Date inserted:
Fluids infusing? no yes - what?
HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 6 inches & left ear- 6 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments: palpable submandibular lymph nodes; discharge for 32 years in left ear, perforated, finally has appointment with
doctor in April – amount of discharge 8 on a 0-10 scale – keeps it clean, keeps it covered when showering or swimming – hot
environment, tiredness, and stress aggravate it
Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: all fields clear, no adventitious breath sounds
RUL: CL LUL: CL
RML: CL LLL: CL
RLL: CL
N/A
Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: X Carotid: X Brachial: X Radial: X Femoral: Popliteal: DP: X PT:
No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: N/A pitting non-pitting
Extremities warm with capillary refill less than 3 seconds
GU Urine output: Clear Cloudy Color: dull yellow/straw Previous 24 hour output: 700 mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness – patient declined
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 Romberg’s Negative (not assessed)
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: Biceps: Brachioradial: Patellar: X Achilles: Ankle clonus: positive negative Babinski: positive negative
Axis
P: 36
QRS: 1
T: -4
3. Deficient knowledge related to diet needed to control disease as evidenced by acute inflammation of the bowel
Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: an evidence-based guide to planning care
(9th ed.). St. Louis: Elsevier Inc.
Generativity. (2017). Retrieved from Miriam-Webster : https://www.merriam-webster.com/medical/generativity
Hinchey , E., Schaal , P., & Richards , G. (1978). Treatment of perforated diverticular disease of the colon.
Retrieved from PubMed.gov: https://www.ncbi.nlm.nih.gov/pubmed/735943
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (5th ed.). St. Louis: Elsevier Inc.hhh
Lal, S. K. (2016, 5 11). Gastrointestinal perforation. Retrieved from MedlinePlus:
https://medlineplus.gov/ency/article/000235.htm
Up-to-date drug information. (2017). Retrieved from Davis'sDrugGuide.com: http://www.drugguide.com/ddo