UNIVERSITY OF SOUTH FLORIDA COLLEGE OF NURSING 5) MSI & MSII PATIENT ASSESSMENT TOOL D> [lola01S +1 PATH (ORMATION Patient Initials: ‘Age: ‘Admission Date: Ac. JANN Als lao\s Gender: rE Marital Status: Se Primary Medical Diagnosis Primary Language: 7 a ad Engtishh Podomina| GAA é ‘evel of Education: ven sce | | Other Medical Diagnoses: (new on this admission) ecupation rect what owe Cg Proc SS anno S ‘Number/ages children/siblings: (siskee Beni toler? Served/Veteran: Ge Code Status: If yes: Ever deployed? ‘yes: Ever deployed? Yes d¢No >) Eu Living Arrangements: \ Advanced Directives: Avi Wd] Pacts If'no, do they want to fill them out? Surgery Date: Procedure: OSV OH Bois ination a clescricuandt Culture/ Ethnicity (Nationality: zs o Qa Cosi Bodoni Religion: Type of Insurance: ; Divan Bir cass | blue site £1. CHIER COMPLAINT: ures t £3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay) Ay |o Toncate mired QZ lacit AD SC. Lod, complain of eAwninal mary 7 Reavis a uMichy 4 F nD \4 Sw nal i eny pip broker Dede Wo. So Ker k 1S Snare GUAds Con HOF WNW OS “VER O00 power University of South Florida College of Nursing — Revision September 2014 1£2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation: include treatment/management of disease Date ‘Operation or Hiness C NS Aigecal 4S, Del os Aetonite nh fez ] 7 6 lnisrory |= | 1%, glesie|2|elals 8) jcz/£/esles} €/ 2) 2 | = & Ge | S/E8/2)2)e] 28) = S/S E2/S/E2/8215) 2/2) 5 2 | sptanin| = [F=|2| =| 2/e| 5] 4] 5 (elf e/Zlees| 3/3) 5 | 2 [Father 4 O[ojojojo/olololojo eo efololojo/oso [Mother | Ofo[o/o/o/ofolefololofololofolololo [Brother D/O |jo/o/olololofoole ole lolojo[olo sister ES O[o [olojofolelololojo ofa lololofolo ee Fo Ofo [o/o/olofolofololo ole solojo[olo fear [mal O[o jojojojolerolololo lofolololofolo a cal O[o jo/ofo[ole@felolofo oyoolelofole ‘Comment: Include age of onset Meter Loos ackpleel #1 IMMUNIZATION HISTORY (May state “U” for unknown, except for Tetanus, Flu, and Pna) Routine childhood vaccinations ines given for international travel or upational purposes? Please List If yes: give date, can state University of South Florida College of Nursing — Revision September 2014 2mu Abs amin vs Yedlucticn 14 SM cirelosti Cersifind Wy ARE Changer Ati by emNthraceptes, fusrnia is ose eo tke uAhrocyte By pki. Shape Mat, OF \nsi My SE OyGen Conny - BEC 40 i ae Cal educa Corhawcs MPT Reco MOL PemNaUnced and Corntenseetin cgraraliig nvelues He (Spwrating, Cardovaculer 4 Vemedolegic Sympn ns Aieductiony jn~te number cf tolbod iit vn Hie, load cacy Q veduction inthe jnsimncey Avorn OF Llaod. Rig eters 2 Wuche inergasel eoee volume and hart (att whict el lead to Nart-Falure Huortor AS MeCrence,303). Qhagnees CraicCrations “Far Bord dete and clinical mane hicne, “RL: praqnosis olepencls Fo) ry Under lgirey Cute of he Gary We Og2 GK the Perth # qd Oke, comorbid coviitions unftuance We bbe. TWeacwort we Ble Worapnc iNew e WON AS Tansfusion, died ccntidercehkn, LN Bam nictrearher, OF Supplemtertal vdamin* or icin Cauainera Bak (ance, sdla), ‘college of Ni \yen's_Dissodt. i 3 ARO CNL IK TAMM CHEM, Ai Suirder Hack Offers laity lege ancl Sol) WAMAHADS. TRL WeMaMmedia: Process Notre WwW RE inchita | SWOMUCOReL Gnd sereads Bard and LUdtwWere FO NVElUE fee prrce’ Bnd Serosa. fetvolea Ruvtiaris ane macwehayes Pere mfrangatic Gd CORE AISUD nun, CSIC fabs clase Fan vitu hich, of Tors) ASSenv and the ciseace 1s MeO Pala amenp HhHe outed Bn, Whore \S Ory Oldered immune response TO vor ue | flora Cevsthge M Wrens) srr), DraqQnorrs WC bare ON ALL rooti col et S wigtey, an Mricol mankesteryns, Parium PREM a, Somoicloscoeg panel ¥ra Ams art vasa 1 adeiticn to labsratery colada. © ic Suolias Cy Niviliene Qiclonce Loikn “the pinnoste VEE See yone INALOES Susy, Oo Menrane complications Geonas Fishule ,absss, WY dlosmuehen , Coutine endoscary Abr Cancer Scresnwy Sheutel be Nirformod (Hreettus MeCraice, 3 ola).+1 ALLERGIES | OR ADVERSE | eee ‘Type of Reaction (describe explicitly) REACTIONS | WKOR Medications Other (food, tape, latex, dye, ete.) £5 PATHOPHYSIOLOGY: (include APA reference and intext citations) (Mechanics of discase, risk factors, how to diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or treatment) £5 MEDICATIONS: [include both prescription and OTC; hospital (include IVF), home (reconciliation), routine, and PRN medication . Give trade and generic name.] fie oe Sulfncien ya oa Doser feo ——\O]p py dawn Woe ere | iammowneates SE ae ome eaten : aac [tvere/SidFemees “Lirming., Chine Suey “KOWng a= Qyndome Tede epider imal worry’ Rrimcmtirir rentals GE Oca uf cc Bees ive as eed flame a yuan) concen BasgeAmeant OS p.c, eae Aen] Freer Suny values (aya doan Fiemeesitet eis Py op lid | AoE S [Home glopital) or Both = frsteaion Ve enmycct \Gkectices Caused By Vanya = easter Errol Ieee eects Sr adomanroncss as Fees Meera 1A AON OreUrt ge + dinahkees abrlominl Cfempny ever \ Sols o ane ic ance Damas Amount Fluroogzels jpPucan [enn : Domes, Rowe val [Preaveney Adu ly [Pharmaceutical ess 1 [Home CHospital> or Both” University of South Florida College of Nursing — Revision September 2014 3[indieaton Too | eS ax SULPOnE oraonisms era EN coche Aizeness Sots opin NV, Sewn Semnuns Sybase hy RaPiRSErE Perel ain oafaor 8 Slun Yan ahdAiminal pean Over oc dire an tal [pig Plonacn [boven any So [Posse Roun Rowe Sent Freaweney Jai [Pharmacewent cls Ui ono, jap lanes tome aglaS o ton Peaterln Uncomelicoted A Complicated SIA ASA Sache. 1akchent Adverse’ Side effet A zngss Atoeinass Woaclagis » NIV, 4 10 Lrepestc ty, Seven Nansens Wh Nentes consideration Patent TesttteToyy Weds as dialed maou had fare of ot Last Iephd TAP pane CoStar Nea, orp cue 1 Ter are Alevelup ‘Name, [Concentration Borage Amount SuvCodore Geom cag AE + 6-33Sme, Rowe Frequency ; xX otal Bers Avours Br moctoccte |, Lo pA ic [Flare agen [Home A C i Kinder ws Onaga Gua via, Ontma! Snacks: CANS (Pound aerasiry > leoo t Liquids (include alcohol): CST | cVC2 lomenadel Nor in Prmtan a¥igags “NSH 0 = Chosrmnand = — 6 Ta ne ‘Use this link for the nutritional analysis by comparing the patients = | 21m avemge home dt oth rexommenied ports an se AC | hg Pinte" arene teed J Onder ABI = Write jogo Cremmencls eps £1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide vour discussion) ‘Who helps you when you are ill? (We Onda Ser How do you generally cope with stress? or What do you do when you are upset? < < OS u ‘oluon t an reat? Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) No. +2 DOMESTIC VIOLENCE ASSESS! 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. Iam going to ask some questions that help me to make sure that you are safe." Have you ever felt unsafe in a close relationship? _( YO. Have you ever been talked down to?_\J<9- Have you ever been hit punched or slapped? _(\© Haye you been emotionally or physically harmed in other ways by a person in a close relationship with you? aD Ifyes, have you sought help for this? __ yw | Are you curently ina sa relationship? _._ | OS University of South Florida College of Nursing — Revision September 2014 5«) +4 DEVELOPMENTAL CONSIDERATIONS: (Halee 204) Erikson’s slage of psychosocial development: Gtx: iss” Hauowony vs bai & Sane Gave Galt Cindi va Cinferorcy (denity vs. Role ConfisionDifusion Cinimacy vs Csoation CiGeneratvty vs, Se absortion/Sagnaton CJEgoInegry vs. CIDespair ‘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: (Q- BOC ; Mo\wy svc From chanidViend 48 ada l4noorl deve lopre Ke ot icoyity scosshul VeSclidion - Si gorsenal ident ( escful= (okies Abye Describe the slage your patient is in and give the characteristics that the patient exhibits that led you to your determination: =" \ She Seomoct Any Uncloistarcl ys 5 fetaYS duo AD Wor maolical Sonditicn jab She is than, tp Pict wars¥i® and way ay Describe what impact of disease’condition or hospitalization has had on your patient's developmental stage of Hie Bowe, 19 and mire wtp wolutthnood | Wate Sis yao he fad - Sec a8 mere Fd hor Koattin 1s +3 CULTURAL ASSESSMENT: “What do you think is the cause of your iliness?™ Dy staves Covigther is abopked |S Cott be BRUNO What does your illness mean to you? ee Vane er ables Us shat normal Stop are A ladet yt +3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) Consider beginning with: “Tam 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. Alll of these questions are confidential and protected in your medical record” Fiave you ever been sexually active?_(\Q Do you prefer women, men or both genders K Are you aware of ever having a sexually transmitted infection? _ (XC) Have you or a partner ever had an abnormal pap smear?_ 17. Have you or your partner received the Gardasil (HPV) vaccination? (DS Are you currently sexually active? tio Ifyes, 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? SUA How long have you been with your current partner?_C> Have any medical or surgical conditions changed your ability to have sexual activity? LQ Do you Ee any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? University of South Florida College of Nursing — Revision September 2014 6+1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions) 3 importance ‘or spirituality have in your lie? Oa (0ok _apracciyot hur Os. oly wip Cwrcln and Alot of At ol Cond. Fim wor FF Do your religious beliefs influence your eurrent condition? Nh +3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES: 1. Does the patient currently, or has he/she ever smoked or used chewing tobscve? Yes. (Wo If so, what? How much?(specify daily amount) _| For how many years? _X years (age thru ) Pack Years: If applicable, when did the patient quit? Does anyone in the patient's household smoke tobacco? IF | Has the patient ever tried to quit? ‘so, what, and how much? No If yes, what did they use to try to quit? 2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes _ No What? How much? For how many years? ae Volume: (aoe thre D Frequency: Ifapplicable, when did the patient quit? 3, Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes Crna) If so, what? How much? For how many years? age thru y 15 tis pant ‘currently using these drugs? Yes Ifnot, when did he/she quit? 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? TI University of South Florida College of Nursing — Revision September 2014 7£10 REVIEW OF SYSTEMS NARRATIVE Gastrointestinal Immunologie ‘Nausea, vomiting, or diarrhea TI Chills with severe shaking Integumentary Constipation] Irritable Bowel CUNight sweats i Changes in appearance oF GERD Cholecystitis | E] Fever Problems with nails Indigestion (Gastritis ‘Ulcers | T] HIV or AIDS: Dandruff Hemorrhoids [7] Blood in the stool | T] Lupus Psoriasis TL Yellow jaundice C] Hepatitis (Rheumatoid Anis (Hives or rashes [Pancreatitis ‘Sarcoidosis [2'skin infections Colitis ‘Tumor. (Use ofsunscreen SPF Diverticulitis [Life threatening allergic reaction Bathing routine: Sys sa, ROT] CJAppendicitis C7 Enlarged lymph nodes Others AT ‘Abdominal Abscess ther: Be sure to answer the highlighted area_{ [J Last colonoscopy? HEENT Other: Hematologie/Oneologic | C1 Ditticulty seeing Genitourinary ‘emia Camraces o Clair Ty nocturia Di Bleeds east Difficulty hearin; -dysuria, [ZyBruises easily (lear infections hematuria FSinus pain or infections polyuria | EiNose bleeds ‘kidney stones ‘Blood type if known: Post-nasal drip ‘Normal frequency of urination’ —__xiday | Other: ‘Oralipharyngeal infection [Bladder or kidney infections [een I problems Metabolic/Endocrine [Routine brushing of teeth | ida L1Diabetes Type: Routine dentist visits [_wyear, C1 Hypothyroid /Hyperthyroid Vision sereenins ‘1 Intolerance to hot or cold ther: —_ Thosteoporosis Other: Pulmonary Difficulty Breathing Central Nervous System Cough = dry or productive WOMEN ONLY Dicva ‘Asthma [Infection of the female genitalia Dizziness [Cl Bronchitis (i Monthly sel breast exam [Severe Headaches | ET Emphysema () Frequency of pap/pelvie exam CO Migraines Pneumonia Date of last gyn exam?” Cl Seizures Tuberculosis TXfmenstrual cycle regular Cigar) | 7] Ticks or Tremors [ F1Environmental allergies ‘menarche age? ‘Encephalitis [Dist CXR? menopause ase? Meningitis ‘Other: ‘Date of last Mammogram Result Ciher: Date of DEXA Bone Density & Result: Cardiovascular ‘MeN ONLY Mental Miness [Hypertension [infection of male genitaliajprosiais? | L] Depression Hyperlipidemia Cl Frequeney of prostate exam? Di Schizophrenia ‘Chest pain T Angin Duty of iat rosie exam? Thame [Myocardial Infarction Lerx CBipolar CCcADPvb Clrinary Retention ‘Giher: (CHF ‘Musculoskeletal {DoMarmur: Injuries or Fractures. Childhood Diseases (Di Thrombus ‘Weakness Di Measles Rheumatic Fever Pain (Mumps: Myocarditis Gout Polio tess come Seni Far Last EKG sereening, when? TAnthritis (Chicken Pox iter: ier: ‘Other: University of South Florida College of Nursing — Revision September 2014General Constitution {, | C] Recent weight loss or gain AY | How many Ibs? ! | Time fame? Intentional? How do you view your overall health? Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No Any other questions or comments that your patient would like you to know? No University of South Florida College of Nursing — Revision September 2014£10 PHYSICAL EXAMINATION: | General Survey: S\= Height (od Weight \\i\\cs [BMI Pain: (include rating and AY lo Whe tS ec Yo an Pulse & Blood Pressure: (inside locaon) | location) / jc) eevenneh KEh Respirations, (ce |\O\ INF (acer antec u- gledomo} ‘Temperature: (route ‘SpO, \ 9) Is the patient on Room Air or O, si taken?) 8--) “ee. \ \o0"lo Gene ee (Overall Appearance: [Dress/grooming/physical handicaps/eye contact] lean, hair combed, dress appropriate for setting and temperature, malnlains Gye ‘contact, no obj jus handicaps Overall Behavior: [e.g appropriate/restlesslodd mannerisms/agitated/lethargic/other] Gfawake, calm, relaxed, interacts well with others, judgment intact Speesh [e.g clear/mumbles /rapid /slurred/silenvother] [aelear, crisp diction Mood and Affect: feasant | J RLE & in LLE (ting seal: absent [ce 2-to aps gravy, agains gravy bl pans sae, against some Teistane,S-against fl resistence] [Greprebral column without kyphosis or scoliosis jeurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia Neurological: [Patient awake, alert. oriented to person, place, time, and date _[_JConfused; if confused attach mini mental exam N2-12 grossly intact ~ [28éhsation intact to touch, pain, and vibration _[[fRomberg’s Negative [ZStereognosis, graphesthesia, and proprioception intact [Z}Gait smooth, regular with symmetric length of the stride DIR: (rang scale: absent, +1 siuggishdiminhed, +2 acive/exposed, OF sligyhyperstive, + Hyperactive, with stent or niet clon] Troeps: Biceps Brishioradil: (a. Patellar bj Aciles:~{ Anil clon posing” waatnd abi psve GSN, Las Decks Fond U-aO en = ales open admission Gy = ans Lope Wand Kava q ale 's Yimewnad lod ett we alas Years, “Wand wodioks aa aliolts Vridwy dsues. folZ onesie \ Spon ed ites Se TRE uss Was Wok MDD x OFMe 1 May BECOME eves) £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): University of South Florida College of Nursing — Revision September 2014 MPertinent includes labs that are checked when on certain medications, monitored for the disease proces prior to and afier surgery, and pertinent to hospital Do not forget to include diagnostic tests, « Ultrasounds, X-rays, CT, MRI, HIDA, etc, Ia lab or lest is not ip the cl ade why you expect it to be done and what results you expect fo see. Lab Dates ‘Trend Analy: 2s-Nd ae ey PE] alu apialeaaale re It Rmownsd_qyymel nacmal c-5 fRimssii0n o.3.959,4.05) Cornancd Ror me’ nor ira.| ted [Caleeasa A Bee ie Romawmed Amal nym! ioe» ALSeICLS. Wyte, {5,105 orwied Oma Oma | Stew algaoe chow. fy poses dimer aloSESS ps0 Pale Le 243.93, 298,207 Drowned yell Aornnwl Led = & Lemearnal puma! AgrMe } #2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include ail 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.) 48 NURSING DIAGNOSES (actual and potential - listed in order of priority) 1. Vist fev v nucle andumin Surcgar fre eoatito fi {cutie ee © xl Gost a e PECK ae Ne ole von ect Lind: u TDstie Leto, wi rousoo! lay {hee Gincbdhat eee evel S e eI Rist tor ney Qoticn Ble npvid AES ard Soll 4. AS Por ns good St ynkay au Cle immdintitehen AES aby Oni Labs Cond 3.07 ae RUBAWALE UWTYBNO pon qdyniesion & tod EBL indi totes aoe +") pon OBC Herding, Noo ov By \ dooniwerd yndicahny age 3c a lon CBHeant 0 al aut Ke Deak missun a vos Yay! Lead Hyfo dicoes x \ eee wo ceegoretel i oe Wevels axe tvencliney clucryderell 0 e wa & Pay Sayin veses ‘ porfisy fer ans \ admission & NU Het Low or indica oo | WUE aye te entaerd RRA ane am akc \ MUG Os Aveahinsy Suuenlacr ee Sol vy Sue e University of South Florida College of Nursing — Revision September 2014 12+15 CARE PLAN Nursing Diagno: goes here Patient Goals/Outeomes Nursing Interventions to Achieve ationale for Interventions | Evaluation of Goal on Day Care Goal Provide References is Provided 9 Palate, Tolan 8 Baiy | patient oWlOrCi [Promoulased ioefeee Kafery jwnct LS oxen oN OA Salerl pai WMondeion loo Gain Level [Nudse aillotue farcoret Ose Stebel Alin Poin Hee conid Lead Promote Sun wndeaycha Nurse cel Leet packer Be miecekh wil anc Dur tes diy chenee: Sig OS Gb iftoric . disemleronin acd [uti rdecpde, pt oun Deve Groeten Ottis arch Ieee Sb eluat Pastoral Care caDurable Medical Needs oF/U appointments oMed Instruction/Preseri DRehab/ HH Palliative Care £2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would iad for discharge teaching) seahhy = care any of the patient’s medications available at a discount pharmacy? aYes 0 No University of South Florida College of Nursing — Revision September 2014 Cictrley + Lady, 2011) 1BReferences “fel book Achiy, 6.3. 8 Laclusig,, ®. (ati). Alessi C4igd.) Sk (acis, Mo. Mosey messy Ms I ol N. “8 Orton, Coat, . wine Pactrioplays tofoy sproen (H#Magl.). Syeniatnc prerrtel healt Halles m5, Gow). Vareshé Rundanirs MutSerg AClinictel Apne an ( cate), St: (axis (NO. E (devi te Halo, SE. 4 PleCrarce itol. Gow), clerdenatrrs Ato 2lg Siolesu (SMeol.). St laris, nd: Masiay : , University of South Florida College of Nursing ~ Revision September 2014