UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Jorge Guzman

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials: J. M.

Age: 70

Gender:

Marital Status: Widowed

Female

Primary Language: English

Level of Education: Quit school in 8th grade

Assignment Date: 21 June 2016

Agency: Lakeland Regional Medical

Center
Admission Date: 5/23/2016
Primary Medical Diagnosis: Hypotension with
sepsis
Other Medical Diagnoses: (new on this admission)

Occupation : Unemployed, disabled, previously worked for Texas

Instrument Company in a factory assembling electronics
Number/ages children/siblings: Unable to obtain however,
according to staff patient has daughter come visit occasionally
Served/Veteran: Unable to obtain
If yes: Ever deployed? Yes or No

Code Status: Full Code

Living Arrangements: Patient was widowed and lives at home with

her friend

Advanced Directives: None

If no, do they want to fill them out?
Surgery Date:
Procedure:

Culture/ Ethnicity /Nationality: White/ American

Religion: N/A

Type of Insurance: Medicare

1 CHIEF COMPLAINT: According to the patients medical record, the patient was complaining of
abdominal pain after a fall.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) According to the medical record
Patient is a 70 year old Caucasian female with a history of Paroxysmal Atrial Fibrillation, not on any chronic
anticoagulants, HTN, HLD, DVT, multiple TIAs, osteoarthritis, anxiety, COPD, current tobacco user, and former heavy
alcohol drinker, who came into the Emergency Department with abdominal pain. Patient stated she has been having left
sided abdominal pain for many months but since yesterday she has severe abdominal pain with nausea and vomiting.
Patient denied any diarrhea but has constipation. Patient complained of chronic constipation and stated not having a BM
in at least 7 days. Patient stated no alleviating or aggravating factors. Patient denied having a fever, chills, or night sweats.
Patient presented with hypotension (61/36) in the Emergency Department. Patient was given 2 liters of Normal Saline via
IV and blood pressure did not improve much. Currently, the patient is intubated and mechanically ventilated for
respiratory support.

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
7/8/2015
Not documented
Not documented
Not documented
Not documented

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
)

Alcoholism

SGI Colonoscopy
Abdominal hysterectomy
Cesarean section
Pacemaker
Pacemaker removal

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness

Father
Mother
Brother
Sister
relationship
relationship
relationship

Comments:

1 IMMUNIZATION HISTORY: UNABLE TO OBTAIN

(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS
Medications

NAME of
Causative Agent

NO

Type of Reaction (describe explicitly)

NKDA

University of South Florida College of Nursing Revision September 2014

Other (food, tape,

latex, dye, etc.)

NKA

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)
According to (2012) Huether, sepsis is defined as, the bodys response to infection which progresses to
bacteremia, then systemic inflammatory response syndrome. Severe sepsis may lead to septic shock which
ultimately leads to multiple organ dysfunction syndrome and death.
Mechanics of disease:
Septic shock happens when an infection is introduced to the body and causes decreased systemic vascular resistance
which leads to inadequate tissue perfusion which can progress to multiple organ failure and hypotension that does not
respond to the usual medical management. Cardiac output is decreased therefore putting the patient in a hypotensive state.
Patient will present hypoxemic and may present with altered mental status secondary to inadequate cerebral perfusion.
Impaired tissue perfusion leads to electrolyte imbalances leading to lactic acidosis because the body is metabolizing
anaerobically. Systemically, the body begins to decompensate because it is not receiving the adequate amount of oxygen
or glucose it needs to function properly. Furthermore, the patient may present hyperglycemic and insulin resistant due to a
glucose metabolism impairment. The patients temperature may fluctuate from hyperthermia to hypothermia. Sodium
shifts into the cell where water follows and results in decreased urinary output (Huether, 2012, pp. 632-634).
Risk factors:
Bacterial infections, viral infections, immunosuppression, technology such as indwelling urinary catheters, feeding tubes
or IVs, and misuse of antibiotics may cause nosocomial infections and lead to the patient becoming septic.
How to diagnose:
According to (2012) Huether, sepsis is diagnosed by the patient presenting with 2 or more of the systemic inflammatory
response syndrome (SIRS) which are as follows:
Temperature>38 C or <36 C
Heart Rate > 90 beats/min
Respiratory rate >20 breaths/min or arterial blood carbon dioxide level < 32 mm Hg
White blood cell count > 12,000 cells/mm^3, < 4,000 cells/mm^3, or containing < 10% immature forms (bands)
Severe sepsis is sepsis with organ dysfunction and septic shock is sever sepsis with persistent hypotension refractory to
early fluid therapy (Huether, 2012, pp. 632-634).
How to treat:
The best treatment for sepsis is early recognition and early intervention (Huether, 2012, pp.634).
100% oxygen via NRB or mechanical ventilation via endotracheal intubation if needed. Before antibiotics are
administered one must obtain 2 separate blood cultures, after blood cultures are obtained antibiotic therapy and fluids are
initiated. If patient presents with profound hypotension, intravenous vasopressors may be administered as well as
corticosteroids to reduce the inflammation. Monitoring blood pressure and blood glucose levels closely is crucial.
Administer insulin as needed to control hyperglycemia. Measuring the patients lactate and hemoglobin-A lactate levels is
essential to determine liver function and anaerobic glucose metabolism. Last but not least, one would insert a Foley
urinary catheter to strictly monitor urine output hourly, to determine if the kidneys are being perfused adequately
(Huether, 2012, pp.634).
Prognosis:
The disease has a poor prognosis. Septic shock is the most common cause of death in ICUs in the U.S., with an overall
mortality rate of 28% to 60% and may be caused by any class of microorganism including bacterial, fungal or viral
(Huether, 2012, pp. 632-634).
Genetic factors impacting the diagnosis:
No genetic factors are known to impact the diagnosis of sepsis.

University of South Florida College of Nursing Revision September 2014

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

Concentration: 4mg/ 250 mL D5W

Route: IV

Dosage Amount: 4 mg

Frequency: One time dose

Pharmaceutical class: peripheral vasoconstrictor (alpha-adrenergic

action) and as an inotropic stimulator of the heart and dilator of
coronary arteries (beta-adrenergic action)
Indication: Profound hypotension

Home

Hospital

or

Both

Adverse/ Side effects: Possibility of allergic reaction including hives; difficult breathing; swelling of your face, lips, tongue, or throat
Nursing considerations/ Patient Teaching: Monitor for signs of an allergic reaction
Name: metronidazole (Flagyl)

Concentration: 500 mg/ 100 mL

Route: IVPB

Dosage Amount: 500 mg

Frequency: one time dose

Pharmaceutical class: synthetic nitroimidazole antimicrobial

Home

Hospital

or

Both

Indication: used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria
Adverse/ Side effects:
numbness or tingling in your hands or feet;
white patches or sores inside your mouth or on your lips;
pain or burning when you urinate;
diarrhea that is watery or bloody;
vision problems, pain behind your eyes;
trouble concentrating, slurred speech, mood or behavior changes
Nursing considerations/ Patient Teaching:
Monitor for signs of an allergic reaction including hives; difficult breathing; swelling of your face, lips, tongue, or throat
Avoid alcoholic beverages while taking this medication and for at least 1 day (3 days if you are taking the oral capsules) after finishing this medicine because
drinking alcohol may result in severe stomach upset/cramps, nausea, vomiting, headache and flushing.
Name: metoprolol (Lopressor)

Concentration: 1 mg/mL

Route: INJ, IV push

Dosage Amount: 2.5 mg

Frequency: q6h

Pharmaceutical class: beta-adrenergic receptor blocking agent

Home

Hospital

or

Both

Indication: Metoprolol is used to treat angina (chest pain) and hypertension (high blood pressure). It is also used to treat or prevent heart attack.
Adverse/ Side effects:
chest pain, pounding heartbeats or fluttering in your chest;
feeling light-headed, fainting;
feeling short of breath, even with mild exertion;
swelling of your hands or feet;
nausea, upper stomach pain, itching, loss of appetite, dark urine
Nursing considerations/ Patient Teaching:
Hold if HR < 55 or SBP < 100 per EMR reference manual protocol
Monitor for signs of an allergic reaction including hives; difficult breathing; swelling of your face, lips, tongue, or throat
Do not stop taking metoprolol without first talking to your doctor. Stopping suddenly may make your condition worse.
Metoprolol is only part of a complete program of treatment for hypertension that may also include diet, exercise, and weight control. Follow your diet,
medication, and exercise routines very closely if you are being treated for hypertension.
Name: ceftriaxone sodium (Rocephin)

Concentration: 2000 mg/ 100 mL

Route: IVPB

Dosage Amount: 200 mL/hr

Frequency: q24h

Pharmaceutical class: broad-spectrum cephalosporin antibiotic

Home

Hospital

or

Both

Indication: used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria such as bacterial septicemia
Adverse/ Side effects: generally well tolerated
Be aware of possible signs of an allergic reaction including hives; difficult breathing; swelling of your face, lips, tongue, or throat
Nursing considerations/ Patient Teaching:
use this medication until the full prescribed treatment period is finished, even if symptoms disappear after a few days
Name: levothyroxine sodium (Synthroid)

Concentration:

Route: IV push, INJ

Dosage Amount: 25 mcg

Frequency: Daily

Pharmaceutical class: Thyrotropin-releasing hormone (TRH)

replacement
Indication: used to treat hypothyroidism

Home

Hospital

or

Both

Adverse/ Side effects:

fever, hot flashes, sensitivity to heat, sweating, headache, nervousness, irritability, nausea, sleep problems (insomnia), changes in appetite or changes in weight,

University of South Florida College of Nursing Revision September 2014

and transient hair loss. Some women experience menstrual changes.

Nursing considerations/ Patient Teaching:
Notify your doctor immediately if you experience serious side effects of Synthroid including rapid heartbeat or chest pain
If you have diabetes, monitor your blood and/or urinary glucose levels as directed by your physician and immediately report any changes to your physician

Name: enoxaparin (Lovenox)

Concentration: 40 mg/ 0.4 mL

Route: Subcutaneous Injection

Pharmaceutical class: Anticoagulant

Dosage Amount: 40 mg

Frequency: daily
Home

Hospital

or

Both

Indication:
Prevents blood clots from forming and is used for prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE)
Adverse/ Side effects:
Bleeding gums, coughing up blood, difficulty with breathing or swallowing, dizziness, headache, increased menstrual flow or vaginal bleeding, nosebleeds,
prolonged bleeding from cuts, red or black, tarry stools, red or dark brown urine, shortness of breath
Nursing considerations/ Patient Teaching:
Stop using enoxaparin and call your doctor if you have a serious side effect such as:
unusual bleeding (nose, mouth, vagina, or rectum), bleeding from wounds or needle injections, any bleeding that will not stop, easy bruising, purple or red
pinpoint spots under your skin, pale skin, feeling light-headed or short of breath, rapid heart rate, black or bloody stools, coughing up blood or vomit that looks
like coffee grounds
Name
Concentration
Dosage Amount
Insulin glargine (Lantus)
25 units/ 0.25 mL
10 units
Route
Frequency
Subcutaneous Injection
Twice a day (bid)
Pharmaceutical class
Home
Hospital
or
Both
long-acting type of insulin that works slowly
Indication
long-acting insulin used to treat adults with type 1 Diabetes
Adverse/ Side effects
Hypoglycemia, Hypersensitivity and allergic reactions, Renal impairment, Hepatic impairment,
Nursing considerations/ Patient Teaching
Do not administer Lantus if blood glucose levels are low. Headache, hunger, weakness, sweating, tremors, irritability, or trouble concentrating can be signs of
hypoglycemia. Avoid alcohol consumption. Follow recommended diet, medication, and exercise routines to avoid hyper/hypoglycemia.
Name: insulin lispro (Humalog)

Concentration: 50 units= 0.5 mL

Route: Subcutaneous injection

Pharmaceutical class: rapid acting insulin

Dosage Amount: corrective scale med

Frequency: give immediately before meals

Home

Hospital

or

Both

Indication: used to treat hyperglycemia in diabetics

Adverse/ Side effects: hypoglycemia which may include headache, nausea, hunger, confusion, drowsiness, weakness, dizziness, blurred vision, fast heartbeat,
sweating, tremor, trouble concentrating, confusion, or seizure . Hypokalemia
Nursing considerations/ Patient Teaching: Monitor blood glucose levels closely. Check blood glucose before administering. Ensure food is readily available to
avoid hypoglycemic episode. Make sure patient eats meal within 15 minutes after administration. Check allergies before administration. Never share an injection
or needle with another person. Show the patient how to check their sugar if they do not know how to.

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? NPO
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? None
Consider co-morbidities and cultural considerations):
24 HR average home diet: Unable to obtain secondary to
the patient being sedated and intubated.
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids (include alcohol):
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.

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

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
N/A

+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? _Unable to obtain secondary to patient being intubate and sedated
Have you ever been talked down to?_____ N/A __________ Have you ever been hit punched or slapped? N/A
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
____________ N/A ______________________________ If yes, have you sought help for this? N/A
Are you currently in a safe relationship? N/A

University of South Florida College of Nursing Revision September 2014

 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: 65+ years
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is 70 years wise and is in the Ego integrity vs. Despair of Eriksons stage of psychosocial development which
deals with the acceptance of ones life, accomplishments and inevitably death (Treas, 2014, p. 164). From my
understanding of Eriksons ego integrity vs. despair, this stage gives the individual the opportunity to reflect on what they
have accomplished throughout their life and is the time when the individual may label their lives as successful or
unsuccessful. It gives the patient a moment to dwell on their past and what they have done in their lives. At this age, it is
considered successful if the person feels a sense of fulfillment and achievement and unsuccessful if they have feelings of
regret. Due to the patient being sedated and intubated, feedback was limited. However, putting myself in that patients
shoes, I would have to ask myself a few questions. If I were to die today, would I be proud of my accomplishments? Have
I established a strong relationship with god? If god is ready to take me then I am ready to go. Am I content with what I
have done in my life? What legacy will I leave behind? What lessons have I taught others? Is my family going to be well
taken care of once my time is up? Have I allocated the finances my family needs to support themselves once I pass? Will
my family know how to invest what they will inherit? Am I ready to die? Did I reach my full potential? Did I get the
opportunity to travel and see the world? What memories will I leave behind? What bonds have I made with friends and
families? Am I able to donate any resources to a particular organization? It is difficult to get an answer from reading body
language of a bed ridden patient. However, I prefer quality of life over quantity of life. Due to her extensive history of
alcoholism I would assume she was in the despair phase of Eriksons final stage. Based off of the atmosphere and the
absence of family I could assume that the patient may have been in the despair stage.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

Although I must admit, I did not have the opportunity to have a conversation with my patient, I can only imagine what she
was going through. I cannot begin to imagine how life would be with a tube down my throat and a machine breathing for
me. I cannot picture life without having the energy to move and perform my activities of daily living on my own. As a
very independent person which I would label myself as, I would not want to be kept alive in this manner. It would be
devastating to me to have to go in this fashion. I would feel hopeless and somewhat depressed if I was in these conditions.
Although, I could not interact with the patient much I explained to her what procedure I was assisting her nurse with. For
example oral care, rotating the patient, and cleaning her up.

+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
Unable to Obtain
Have you ever been sexually active?____________________________________________________________________
Do you prefer women, men or both genders? _____________________________________________________________
Are you aware of ever having a sexually transmitted infection? _______________________________________________
Have you or a partner ever had an abnormal pap smear?_____________________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___________________________________________
Are you currently sexually active? ___________________________ 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? __________________________________
How long have you been with your current partner?________________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ___________________________

University of South Florida College of Nursing Revision September 2014

Do you have 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

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

What importance does religion or spirituality have in your life?
Unable to obtain
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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)
Cigarettes
20 cigarettes/day according to chart

Yes
No
For how many years? X years
(age

thru

Not documented
If applicable, when did the
patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much?

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?
What? Unable to obtain the details
however, patient has liver cirrhosis which is
How much?
indicative of an extensive history of
alcoholism.
Volume:
Frequency:
If applicable, when did the patient quit?

Yes

No
For how many years?
(age

thru

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
Unable to obtain
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
Unable to obtain
5. For Veterans: Have you had any kind of service related exposure?
Unable to obtain

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:
Other:

Be sure to answer the highlighted area

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
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? 7/8/2015
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:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
x/day
x/year

Diabetes
Type: 1
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

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

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

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?
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
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision September 2014

10

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health? Unable to obtain

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Unable to obtain

Any other questions or comments that your patient would like you to know?
Unable to obtain

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11

10 PHYSICAL EXAMINATION:
General Survey: Pt is
severely ill
Temperature: (route
taken?)35.9 axillary

Height
Pulse 95
Respirations 23
SpO2
96%

Weight
BMI
Blood Pressure: (include location)
87/72
Is the patient on Room Air or O2

Pain: (include rating and

location)
Unable to obtain

Pt is mechanically ventilated

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

clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
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?

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 / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
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: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: faint crackles
RUL
CL
LUL CL
RML CL
LLL CR
RLL
CR

Chest expansion

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

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12

Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
Carotid:
Brachial:
Radial:
Femoral:
Popliteal:
DP:
PT:
No temporal or carotid bruits
Edema: +1
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: Lower extremities bilaterally
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
GI
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Last BM: (date 5 / 28
/ 2016 )
Formed
Semi-formed
Unformed
Soft X Hard
Liquid X
Watery X
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe: Pt has suspected UTI and has a foley catheter inserted.
GU
Urine output:
Clear
Cloudy
Color:
Foley Catheter and rectal tube
Urinal or Bedpan
CVA punch without rebound tenderness

Previous 24 hour output: 1300 mLs N/A

Bathroom Privileges without assistance or with assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ___3____ RUE ____3___ LUE ____2___ RLE

& ___2____ in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

Biceps: 1

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive

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
UA:
Blood 1+
Protein 2+
Bili 1+
WBC= 13.2 High

Dates

Trend
5/23/16

5/23/16

5/31/16

5/31/16
Decreased to 12.4 still
high
5/31/16
Decreased to 24.8 low

Analysis
Possibe UTI and kidneys
are not filtering
adequately

Elevated WBC count is

indicative of a bacterial
infection
Hct = 49.2 High
5/23/16
Patient has become
anemic throughout her
hospitalization. Possible
bleed
PT= 14 secs High
5/23/16
5/31/16
This lab is indicative of
Increased to 19
an increased risk for
bleed due to the clotting
time increasing
Albumin= 3.1 Low
5/23/16
5/31/16
This lab is indicative of
persistent diarrhea and
malnutrition
Cr= 1.3 High
5/23/16
5/31/16
Increase in Cr is
Increased to 1.4
indicative of renal
insufficiency and patient
may progress to complete
renal failure
K= 3.3 Low
5/23/16
5/31/16
Hypokalemia may lead to
Slightly increased to 3.4
cardiac arrhythmias,
respiratory alkalosis,
patients need to be
monitored closely on
cardiac monitor
Glucose= 180 High
5/23/16
5/31/16
Although the Accuchecks
Decreased to 105
do fluctuate. Blood
glucose seems to be well
managed in the hospital
Hgb= 15.2 normal
5/23/16
5/31/16
Do the significant drop in
Severely decreased to 8.0 Hgb the patient will need
a blood transfusion. This
progressive drop in Hgb
is indicative of bleed
possibly a GI bleed. Stool
sample was sent to lab for
occult blood test and C.
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diff.
+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.)
CT abdomen/ pelvis without contrast revealed, atelectasis which may indicate possible pneumonia, liver
cirrhosis, atrophic pancreas, large amount of retained fecal material throughout the colon possibly related to the
constipation, colitis, and a small stable pericardial effusion. Chest X-ray revealed placement of a right sided
jugular central venous catheter with tip inserted into the superior vena cava, no pneumothorax Patient is NPO and
being fed TPN via OG tube. Dietician was called for a consult to determine adequate caloric intake for a complex
recovery.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Ineffective tissue perfusion related to alterations in circulating volume secondary to sepsis as evidenced by thready pulses
and hypotension
2. Fluid volume deficit related to alterations in circulating volume secondary to sepsis as evidenced by persistent
hypotension
3. Decreased cardiac output related to alterations in circulating volume and cardiac pump function as evidenced by
tachycardia and hypotension
4. Ineffective airway clearance related to altered level of consciousness secondary to sepsis as evidenced by aspiration of
foreign matter
5. Ineffective glucose metabolism related to insulin resistance secondary to sepsis as evidenced by multiple hyperglycemic
blood glucose levels.
6. At risk for nutrition imbalance related to decreased appetite secondary to treatment and fatigue
7. Readiness coping for enhanced grieving related to imminent death of loved one secondary to septic shock as evidenced
by the patient gradually decompensating

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 15 CARE PLAN
Nursing Diagnosis: Readiness coping for enhanced grieving related to imminent death of loved one secondary to septic shock as evidenced by the
patient gradually decompensating
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient and/or family are able to
Provide the patient and the family
Assist the patient and family with
Family verbalize realistic
make decisions about care
with information about their illness
grieving
perception of the patients
or injury
condition and chances of survival.
Nursing Diagnosis: Ineffective airway clearance related to altered level of consciousness secondary to sepsis as evidenced by aspiration of foreign
matter
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will maintain a patent
Open and clear the airway.
Patient may have secretions in
Patient was intubated for airway
airway
mouth
protection due to decreased level of
consciousness and aspiration
Nursing Diagnosis: At risk for nutrition imbalance related to decreased appetite secondary to treatment and fatigue
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will ingest daily nutritional
Consult with the nutritionist to
Consult helps to ensure optimal
Patient maintains adequate caloric
requirements for activity level and
establish appropriate daily caloric
intake
intake
metabolic needs
requirements
Nursing Diagnosis: Ineffective tissue perfusion related to alterations in circulating volume secondary to sepsis as evidenced by thready pulses and
hypotension
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Improve tissue perfusion
Assess peripheral pulses and
A decrease in or loss of peripheral
Central pulses were significantly
compare to central pulses
pulses indicates decreased tissue
stronger. Peripheral pulses were
perfusion
fainter. Pedal pulses were present
but not palpable bilaterally.
Doppler was required to assess for
pedal pulses.
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Improve mental status

Monitor restlessness and confusion

Confusion and restlessness are

indicative of decreased cerebral
perfusion and worsening shock

Control of blood and fluid loss

Assess for obvious signs of

bleeding

Both blood and/or fluid loss will

alter circulating volume

Capillary refill < 3 seconds

Assess capillary refill, skin color

and temperature

Patient was not oriented to place.

Patient was able to squeeze on my
fingers and follow that verbal
command.
No obvious signs of blood loss
were found. Patients feces was
obtained for a stool culture to rule
out occult blood and C. diff.
Capillary refill was sluggish

Capillary refill indicates bodys

attempt to compensate for
decreased perfusion by diverting
blood flow from the periphery to
the central circulation
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
*Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
*Palliative Care

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Reference
Ackley, B. (2010). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). Maryland
Heights, Mo.: Mosby.
Huether, S. (2012). Alterations of Cardiovascular Function. In Understanding pathophysiology (5th ed., pp.
632-634). St. Louis, Mo: Elsevier.
Kee, J., & Hayes, E. (n.d.). Pharmacology: A patient-centered nursing process approach (8th ed.).
Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning (p. 164). Philadelphia, PA:
F.A.Davis Company.

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