UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student:Kayleigh Shelton

MSI & MSII PATIENT ASSESSMENT TOOL .

Assignment Date: 11/13/2015

Patient Initials:

J.W

Age: 63

Agency: James A Haley Veterans

Hospital
Admission Date: 09/15/2015

Gender:

Male

Marital Status: Single

Primary Medical Diagnosis : Bacterial Infection

1 PATIENT INFORMATION

Primary Language: English

Level of Education: High school

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Handy man

N/A

Number/ages children/siblings: 1 child 40 year old son and no

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

Code Status: Full

Living Arrangements: Trailer with girlfriend

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: none
Procedure: none

Culture/ Ethnicity /Nationality: Caucasian

Religion: Christian

Type of Insurance: VA

1 CHIEF COMPLAINT:
I got some dirty water in a cut on my foot and now its infected.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient presented to the James A Haley Veterans Hospital 09/15/2015 with complaints of a contaminated cut on his
foot. The patient claims he was walking barefoot in dirty water overflowing from the water drains in the street. The
patient complains of pain, mild fever, hyperglycemia, swelling, and impeded healing of the ulcer. The patient has a history
of DM II, HTN, hyperlipidemia, and CAD. The ulcer was about two inches in length and less than a quarter of an

inch in width. The drainage was bloody and yellow, but has dried up and is becoming less purulent. The
patients CBC showed elevated WBCs. He was tachycardic, slightly hypertensive, SPO2 was 98%, slight fever of 101
degrees Fahrenheit, RR were 19, and pain was rated as a 3 when ambulating. The patient was started on IV vancomyocin.
His glucose was normal at 109 and is on metformin. Patient denies nausea and vomiting, loss of sensation in lower
extremities, no peripheral neuropathies present, alert and oriented X 3, appropriate expression and behavior, and
has orders to ambulate Ad LIB. There are also orders for accu check Q1hr, Tylenol for pain PRN, and to change the
dressing.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
06/2005
03/2001
03/2001

Father

88

Mother

82
N/
A
N/
A

Brother
Sister

stroke

X
X

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
)
natural

Alcoholism

DM II
HTN
Hyperlipidemia

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness

X
X

N/A
N/A

relationship
relationship
relationship

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
X
Routine childhood vaccinations
X
Routine adult vaccinations for military or federal service
Adult Diphtheria
UNKNOWN
X
Adult Tetanus (UNKNOWN DATE) Is within 10 years? YES
Influenza (flu) (UKNOWN) Is within 1 years? NO
X
Pneumococcal (pneumonia) (UNKNOWN) Is within 5 years? YES
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKA
Medications

NKA
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)
Diabetes Mellitus type two occurs when the patients pancreas is unable to produce or use an efficient amount of insulin
for the body to properly break down glucose (Nursing, 2014). For this reason, these patients suffer from hyperglycemia if
untreated with insulin or oral medications such as metformin (Nursing, 2014). Long term effects of living with diabetes
is the body has increased healing time, risk of peripheral neuropathies, and other atherosclerotic changes (Nursing, 2014).
It is important for these patients to monitor their blood sugar and participate in good foot care due to the risk
of peripheral neuropathies and increased healing time (Nursing, 2014). In this case the patient acquired an infected cut on
his foot, which is being treated with antibiotics. There was no sign of loss of sensation in his lower extremities, so the
antibiotics and proper foot care offer a good prognosis. The doctor ordered a follow up with podiatrist because of the
potential complications.

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

Concentration 1mg

Route oral

Dosage Amount 1mg

Frequency once a day

Pharmaceutical class Calcium Channel Blockers

Both

Indication HTN
Adverse/ Side effects hypotension chest pain, swelling, lightheadedness, unusual sweating
Nursing considerations/ Patient Teaching Take even if BP is normal. Do not take if hypotensive.
Name Metformin

Concentration 500

Route oral

Dosage Amount 750

Frequency BID

Pharmaceutical class biguanides

Both

Indication hyperglycemia/ DM type two

Adverse/ Side effects hypoglycemia, dizziness, weakness, increased hunger, or confusion
Nursing considerations/ Patient Teaching Take medication even when not eating because of illness, dont skip doses, and check blood sugar before and after exercise.
Name Lovastatin
Route oral

Concentration 40 mg

Dosage Amount 40 mg
Frequency QID

University of South Florida College of Nursing Revision September 2014

Pharmaceutical class HMG-CoA reductase inhibitors

Both

Indication high cholesterol

Adverse/ Side effects muscle pain, lethargy, rash, swelling, jaundice, and nausea
Nursing considerations/ Patient Teaching do not drink with grape fruit juice and do not skip or double up doses
Name Atenolol

Concentration 25

Route oral

Dosage Amount 25
Frequency BID

Pharmaceutical class Beta blocker

Both

Indication HTN
Adverse/ Side effects bleeding, bruising, chest pain, hypoglycemia, and hyperglycemia
Nursing considerations/ Patient Teaching take dose at same time every day, dont skip or double doses, and stand up slowly
Name Vancomyocin

Concentration 500 mg

Route IV

Dosage Amount 500 mg

Frequency One time administration

Pharmaceutical class anti infective

Hospital

Indication infection
Adverse/ Side effects photo toxicity, phlebitis, nephrotoxicity, tinnitus
Nursing considerations/ Patient Teaching report signs of rash, tinnitus, and dont double or skip doses
Name Augmentin

Concentration 500 mg

Route oral

Dosage Amount 500 mg

Frequency Q12 hr

Pharmaceutical class anti infective

Home

Indication infection
Adverse/ Side effects rash, nausea, omitting, pseudomembranous colitis
Nursing considerations/ Patient Teaching call MD id diarrhea, abdominal cramping, fever, or bloody stools occur. Finish pills completely and take as directed.

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?
Healthy
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? healthy
consider co-morbidities and cultural considerations):
24 HR average home diet:
Overall his typical meal is pretty well balanced. He could
Breakfast: oatmeal and a banana with coffee
Incorporate more milk, yogurt, and fruit. Id really focus
on cutting down on the beer. The chocolate cake is okay
Lunch: turkey sandwich with lettuce tomato and onion
occasionally if his sugar isnt high, but I would recommend
against having it every night. His calorie intake is pretty
Dinner: shepherds pie
good, but if he cut out the cake and beer he might be a little
under the 2000 calorie diet.
Snacks: chips and salsa, chocolate cake
Liquids (include alcohol): 36 oz of beer every night
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.

Total Percentage of Target

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My girlfriend.
How do you generally cope with stress? or What do you do when you are upset?
I watch TV.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I dont have any.

+2 DOMESTIC VIOLENCE ASSESSMENT

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

University of South Florida College of Nursing Revision September 2014

Have you ever been talked down to? Not really. Maybe by my dad when I was bad as a kid._____________ 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? N/A ______________________
Are you currently in a safe relationship?
Yes.

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 X Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:generativity vs Self absorption/stagnation
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

Generativity VS. self absorption/stagnation occurs between 40 and 65 (Eriksons, 2011). At this time the individual
reflects on their accomplishments in life and decide if they are satisfied with their contributions and accomplishments in
life (Eriksons, 2011). My patient is a very happy easy-going man. He is content with what he has.
He lives in a trailer instead of a house but is very happy there. He describes himself as Blessed to have
the neighbors and community that he has. He also is not married but loves his son and his girlfriend who
take care of him. He had nothing negative to say about anyone or anything.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

Living with diabetes doesnt seem to have much of an effect on his life. He doesnt let it keep him from doing
anything. Unfortunately he seems to not take his disease too seriously. Although it is good that the patient is not
put down or affected negatively by his disease, he may encounter future complications due to the lack of importance he
places on his care.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I forgot my shoes and cut my foot and never cleaned it.
What does your illness mean to you?
I guess I need to be more careful.

+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? I didnt think
so.___________________________________________________ Have you or your partner received the Gardasil
(HPV) vaccination? Im not sure. I know I havent________________________________________

University of South Florida College of Nursing Revision September 2014

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 pregnancy? ______Condoms ____________________________
How long have you been with your current partner? Six
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?
Nope.

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? Im not very religious, but my girlfriend is.
___________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition? Not too much.
______________________________________________________________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?

How much?(specify daily amount)

N/A

N/A

Yes
No
For how many years? N/A X
years
(age

thru

N/A

If applicable, when did the

patient quit? N/A

Pack Years: N/A

Does anyone in the patients household smoke tobacco? If
so, what, and how much? Yes his girlfriend smokes a pack of
cigarettes everyday.

Has the patient ever tried to quit?

If yes, what did they use to try to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? Beer
How much? 2-3
Volume: 12 oz
Frequency:every night
If applicable, when did the patient quit?
N/A

No
For how many years?
(age

18 thru

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
N/A
How much?
For how many years?
(age
thru N/A
N/A
Is the patient currently using these drugs?
Yes No

63

If not, when did he/she quit?

N/A

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No.
5. For Veterans: Have you had any kind of service related exposure?
No.

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
X Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
X Skin infections
X Use of sunscreen
SPF: 50
Bathing routine: QID
Other: N/A

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
X Routine brushing of teeth
2x/day
X Routine dentist visits
1x/year
X Vision screening once a year
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
X Last colonoscopy? 2014
Other:

Chills with severe shaking

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

Genitourinary

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

nocturia
dysuria
hematuria
X polyuria
kidney stones
Normal frequency of urination: 12
x/day
Bladder or kidney infections

Hematologic/Oncologic

Other: N/A

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

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis

Central Nervous System

WOMEN ONLY
Infection of the female genitalia N/A
Monthly self breast exam N/A
Frequency of pap/pelvic exam N/A
Date of last gyn exam? N/A
menstrual cycle N/A regular
irregular

Environmental allergies
X Last CXR? Unknown
Other:

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

menarche N/A
age?
menopause N/A
age?
Date of last Mammogram &Result: N/A
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Occasionally
Date of last prostate exam? 2012
BPH
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other: N/A

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout

Childhood Diseases
Measles
Mumps
Polio

University of South Florida College of Nursing Revision September 2014

Arrhythmias
X Last EKG screening, when? Unknown
Other: N/A

Osteomyelitis
Arthritis
Other:

Scarlet Fever
X Chicken Pox
Other:

General Constitution
Recent weight loss or gain
How many lbs? N/A
Time frame? N/A
Intentional? N/A
How do you view your overall health? Pretty good.

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?
When will I be discharged?

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10

10 PHYSICAL EXAMINATION:
General Survey: calm
and pleasant

Height 510
Pulse 78
Respirations 20
SpO2 98%

Weight 185
BMI 26.5
Blood Pressure: (include location)
Left arm 130/78
Is the patient on Room Air or O2

Pain: (include rating and

location) 3/10 when
ambulating
1/10 when resting

Temperature: (route
RA
taken?) 100.2 F oral
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
X 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]
X awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
X clear, crisp diction

Mood and Affect: X pleasant X cooperative X cheerful

X talkative
quiet
boisterous
flat
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
loud
Other:
Integumentary
X Skin is warm, dry, and intact X Skin turgor elastic
No rashes, lesions, or deformities (Infected lesion on his right
lateral foot. Upon admission it was hot to the touch, with inflammation about an inch around the wound, about two inches in length and
less than a quarter of an inch in width. The drainage was bloody and yellow, but has dried up and is becoming less purulent.)

X Nails without clubbing X Capillary refill < 3 seconds X 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?
HEENT: X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ X Trachea midline
X Thyroid not enlarged
X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge
X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
X PERRLA pupil size 3mm / 3 mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmus
X Ears symmetric without lesions or discharge X Whisper test heard: right ear- 6 inches & left ear- 6 inches
X Nose without lesions or discharge X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:
Pulmonary/Thorax: X Respirations regular and unlabored X Transverse to AP ratio 2:1 X Chest expansion symmetric
X Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: N/A thick thin
Amount: scant small moderate large N/A
Color: white pale yellow yellow dark yellow green gray light tan brown red N/A
Lung sounds:
RUL clear
LUL clear
RML
clear
LLL clear
RLLclear
CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent

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11

Cardiovascular: X No lifts, heaves, or thrills

Heart sounds: X S1 S2 audible X Regular
Irregular X No murmurs, clicks, or adventitious heart sounds X No JVD

X Calf pain bilaterally negative

Apical pulse: 3 Carotid: 3
PT: 3
X No temporal or carotid bruits
6mm),

X Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Brachial: 3
Radial:
3
Femoral: 3
Popliteal: 3
DP:
Edema:

1 (just around injury)

[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-

+4(7-8mm) ]

Location of edema: right lateral foot pitting non-pitting

X Extremities warm with capillary refill less than 3 seconds
GI
X Bowel sounds active x 4 quadrants; no bruits auscultated
X No organomegaly
X Percussion dull over liver and spleen and tympanic over stomach and intestine
X Abdomen non-tender to palpation
Last BM: (date 09 / 15 / 2015 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
X Nausea
emesis Describe if present: N/A
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe: N/A

X Not assessed, patient alert, oriented, denies problems

GU
Urine output: X Clear
Cloudy
Color:
yellow
Previous 24 hour output:
mLs
Foley Catheter
Urinal or Bedpan X Bathroom Privileges without assistance or with assistance
X CVA punch without rebound tenderness

1000

Musculoskeletal: X Full ROM intact in all extremities without crepitus

X 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]

X vertebral column without kyphosis or scoliosis

X Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Neurological: X Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
X CN 2-12 grossly intact
X Sensation intact to touch, pain, and vibration
X Rombergs Negative
X Stereognosis, graphesthesia, and proprioception intact X 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:
positive

2+

Biceps:

2+

Brachioradial:

2+

Patellar:

2+

Achilles: 2+

Ankle clonus: positive negative Babinski:

negative

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

Dates
09/15/2015
09-16-2015

Trend
WBC count is decreasing
12000 (high)
11000 (high)

Glucose

09/15/2015
09/16/2015

109
106

Neutrophil

09/15/2015
09/16/2015

7.5 (slightly high)

6 (normal)

Monocyte

09/15/2015
09/16/2015

15 (decreasing)
13

Basophils

09/15/2015
09/16/2015

2 (normal)
2

Analysis
When the patient came in
his WBC count was high
due to the infection in his
foot. The antibiotics are
lowering the WBC count
as they get rid of the
infection.
When a patient is sick the
body gets stressed out and
it is harder for the body to
keep up with the
breakdown of glucose. It
is important to monitor
this in diabetics, who
already have trouble
breaking down glucose.
Neutrophils indicate
inflammation and often
indicate a bacterial
infection.
Increased monocytes
indicate an infection that
is commonly bacterial.
Basophils also indicate an
infection.

+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 being treated with antibiotics, glucose control, and wound care. The patient was started on IV
Vancomyocin with normal saline. The patient also receives routine accu checks because of his diabetes. Lastly,
his wound was cleaned with antibacterial cream, warm water, and soap. The wound was covered with a clean
dressing and ice was applied over the dressing.

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13

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

1. Impaired skin integrity r/t mechanical damage AEB drainage and redness of the skin.
2. Impaired mobility r/t pain and discomfort AEB unsteady gait (limping) while walking.
3. Acute pain r/t impaired skin integrity AEB rating pain as 3/10.
4. Risk for infection r/t tissue destruction and increased exposure to environmental pathogens.
5. Impaired healing r/t high glucose levels.

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14

 15 CARE PLAN
Nursing Diagnosis:
1. Impaired skin integrity r/t mechanical damage AEB drainage and redness of the skin.
2. Impaired mobility r/t pain and discomfort AEB unsteady gait (limping) while walking.

Patient Goals/Outcomes
1. Patients wound will show signs
of healing (decreased warmth
around site, decreased redness,
decreased purulent drainage, and
decreased pain) before discharge.

1. Pt will verbalize understanding

on how to care for his wound
(proper cleaning, proper glucose
control, proper use of antibiotics,
and proper foot care) before
discharge.

Nursing Interventions to Achieve

Goal
Keep wound clean with
antibacterial cream and clean
dressing.
Administer antibiotics.
Elevate foot with ice.

Rationale for Interventions

Provide References
The antibacterial cream helps
decrease infection and keeping the
wound clean keeps new bacteria
from impairing the healing process.
Antibiotics help the body fight the
infection.
Elevation and ice help with blood
flow and inflammation.

Evaluation of Goal on Day Care

is Provided
Assess wound every day for
decreased inflammation and
drainage.
Assess pain level.
Assess labs such as WBC count
and glucose level.

Teach the patient how to clean his

wound, what symptoms to report
(fever, increased pain, increased
inflammation, signs of
hyperglycemia or hypoglycemia, or
excessive purulent drainage), how
glucose maintenance effects
healing and when to check his
blood sugar, when to take his
antibiotics and not to stop taking
them until theyre done, and how to
take care of his feet with his
diabetes.

Keeping the wound clean is

important to avoid additional
pathogen entry.
The risk of impaired healing with
diabetic patients can cause many
more complications, so it is
important to make sure the patient
understands what signs and
symptoms to look for so he can
obtain additional treatment.
Maintaining normal glucose levels
help avoid complications in healing
caused by hyperglycemia.
It is important to teach patients to
take their antibiotics all the way
through to avoid superinfections.
Diabetic education is important

Assess the dressing and wound

every day.
Have the patient verbalize back the
signs and symptom of
hypoglycemia and hyperglycemia.
Have the patient verbalize normal
glucose levels and demonstrate
how to check his blood sugar
before discharge. Also make sure
he has enough metformin when he
leaves.
Have patient verbalize
understanding of how and when to
take his antibiotic and the
contraindications with
discontinuing them early.
Have patient verbalize the

University of South Florida College of Nursing Revision September 2014

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because they are high risk of

peripheral neuropathy.

components of diabetic foot care,

the components of diabetic
neuropathy, and identify a
podiatrist he can see regularly.

1. Patient will demonstrate a

normal WBC count after a few
days of antibiotic administration.

Give patient antibiotics.

Control blood glucose.

The antibiotics will help the body

fight the infection, which will
decrease the need of the leukocytes
to be in the blood fighting the
infection.
Controlling the blood glucose will
lower the stress of the body to fight
the infection allowing the WBC
count to decrease faster.

Check CBC and UA.

2. Patient will demonstrate safe

ambulation before discharge.

Teach patient how to distribute

weight to not aggravate injury.
Give patient assistive device if
needed.
Give pain medication if needed.
Assess home and hospital
environmental safety.

It is important to distribute his

weight evenly in order not to stress
another part of his body and to
have a steady gait.
If the patient cannot distribute
weight appropriately on his own an
assistive device such as a cane may
be needed to keep balance and
ensure safe ambulation.
Pain medication may be needed to
help control the pain.
It is important to make sure the
patients environment is free of
clutter, dim lighting, or anything
that may impair his ambulation
causing him to fall and create more
injury.

Have patient demonstrate steady

gait and safe ambulation.
Have patient try ambulating with or
without a cane or crutches so he
can decide what is the most
comfortable for him.
Assess pain level before, during,
and after ambulation.
Have patient help identify possible
obstacles or safety hazards at
home, and assess his room for any
hazards.

2. Patient will rate pain as less than

3 with or without medication
before discharge.

Administer NSAIDs for pain 6 and

under.
Administer narcotic pain

It is important to control the

patients pain with medication with
the least possible complications as

Assess pain level before, during,

and after ambulation.

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medication if indicated with a pain

level 7 or higher.

possible first. NSAIDs are cheaper,

more easily available, and have
less side effects than narcotics.
The patients pain is the primary
priority and if NSAIDs do not help
his pain and it gets severe enough
narcotics may be indicated.

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
Pastoral Care
Durable Medical Needs
X F/U appointments
X Med Instruction/Prescription
X are any of the patients medications available at a discount pharmacy? X Yes No
Rehab/ HH
Palliative Care

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References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
(10th ed., pp. 119-529). United States: Mosby, an imprint of Elsevier Inc.
Choose My Plate. Retrieved September 30, 2015, from
www.choosemyplate.gov
Davis's Drug Guide for Nurses (Thirteenth edition), (2014). F.A. Davis Company
Eriksons Stages of Psychosocial Development. (2011, November 29). Retrieved November 10, 2015, from
http://allpsych.com/psychology101/social_development.html
Nursing Central by Unbound Medicine: Diabetes. (2014). (ver. 1.610.627) [Mobile Application Software]
Retrieved from http://nursing.unboundmedicine.com/nursingcentral/

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