UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Amanda Seeds

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 02/17/2015

Agency: MPM

Patient Initials: P. F. B.

Age: 69

Admission Date: 02/16/2015

Gender: Female

Marital Status: Married

Primary Medical Diagnosis: Cervical stenosis and

myelopathy/ cervical spondylotic cord
compression

Primary Language: English

Level of Education: High school

Other Medical Diagnoses: (new on this admission):

NA

Occupation: Retired
Number/ages children/siblings: 2 daughters/51, 46/2 brothers
Served/Veteran:
If yes: Ever deployed? Yes or No
Living Arrangements: Lives with her husband in a house, only has
2 stairs.

Code Status: Full code

Advanced Directives: Yes
If no, do they want to fill them out?
Surgery Date: 02/16/2015 Procedure:
Laminectomy- C3-C7

Culture/ Ethnicity /Nationality: Caucasian

Religion: Christian

Type of Insurance: UHC AARP-Medicare

advantage plan

1 CHIEF COMPLAINT:
Numbing of fingers and feet and chronic neck pain.

3 HISTORY OF PRESENT ILLNESS:

The patient stated that she had neck pain, and bilateral finger and bilateral foot paresthesia that began two years ago. The
pain was roughly a 4 on a 0-10 scale; both the pain and paresthesia were constant and worsened over time, there were no
relieving factors. The patient stated that she saw her primary care physician who then referred her to a neurologist. She
was tested for neuropathy and that was found to be negative. She then had magnetic resonance imaging; this is when it
was found that cervical spine 3 through cervical spine 7 had no fluid, due to bone spurs and arthritis, per patient. The
neurologist then referred her to Dr. Gobo, a neurosurgeon. The patient had a laminectomy of C3-C7 on 02/16/2015. On
02/17/2015 the patient reported no lower extremity paresthesia, bilateral upper extremity paresthesia in fingers, and rated
her posterior neck pain, at the surgical site, as a 2 on a 0-10 scale.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY

GERD: pantoprazole (Protonix) 40 mg 1xdaily

Hyperlipidemia: ezetimibe (Zetia) 10 mg, 1xdaily
Skin cancer: under left eye, removed. Resolved
Back pain: acetaminophen-oxycodone (Percocet 5 mg/ 325 mg) q4hr
Bruises easily
Neck pain: acetaminophen-oxycodone (Percocet 5 mg/ 325 mg) q4hr

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

Gout

(angina,
MI, DVT
etc.)
Heart
Trouble

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

65 Lung cancer

Arthritis

Brother

Father

Anemia

Mother

Cause
of
Death
(if applicable)
Huntingtons
65
chorea
85 Stroke

Environmental
Allergies

Asthma- resolved

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Hypertension: Amlodipine (Norvasc) 10 mg, 1xdaily; benazepril (Lotensin) 20 mg, 1xdaily

Age (in years)

Date
Unknown by
patient/ not in
electronic medical
record
Unknown by
patient/ not in
EMR
Unknown by
patient/ not in
EMR
Unknown by
patient/ not in
EMR
Unknown by
patient/ not in
EMR
Unknown by
patient/ not in
EMR
Unknown by
patient/ not in
EMR
Unknown by
patient/ not in
EMR

Sister
relationship
relationship
relationship

Comments:
The patients father died in his 60s, the onset of the disease was in his late 30s, per patient.
The patient stated that her brother smoked for years before he died from lung cancer.
The patient had another brother; he died in a car accident at the age of 19.

University of South Florida College of Nursing Revision September 2014

 1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations U.
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U.
Adult Tetanus (Date) Is within 10 years? No.
Influenza (flu) (Date) Is within 1 years? No.
Pneumococcal (pneumonia) (Date) Is within 5 years? Yes, 3 years ago.
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
statins

YES

NO

Type of Reaction (describe explicitly)

Muscle pain.

Medications

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY:
The patient had cervical spondylotic cord compression, cervical stenosis and myelopathy. Spondylolysis is a defect o the
spines structure, concerning the lamina or neural arch of the vertebra. Heredity plays a large role, and spondylolysis is
linked to an elevated frequency of other congenital spinal defects. Symptoms include pain in the back and lower limbs.
Spinal stenosis is a narrowing of the spinal canal, which causes pressure on the spinal cord or nerves. This can be
congenital or acquired and related to arthritis or trauma. The areas of the spine that are most often involved are the
cervical and lumbar regions. Acquired spinal stenosis can include facet hypertrophy, a bulging disc, or a thick ossified
posterior longitudinal ligament. Pain, numbness and tingling in the legs are symptoms. For those who do not respond to
medical management or who have chronic symptoms, surgical decompression is recommended (Huether & McCance,
2012). The conditions can be diagnosed via an MRI. The treatment used for this patient was a laminectomy. This surgical
procedure decompresses the spinal canal. The laminectomy is performed via a posterior approach and involves removing
the lamina and ligament from the back of the spinal column. Disc fragments, bone fragments, tumor, or hematoma that
result in the spinal cord being compressed will also be removed, when indicated. If the spine is unstable, spinal
instrumentation with fusion is performed to reestablish stability and spinal alignment. Spinal fusion involves placement of
a combination of titanium screws, rods, wires, or intervertebral cages and bone (Osborn, Wraa, Watson, & Holleran,
2014).

University of South Florida College of Nursing Revision September 2014

 5 MEDICATIONS:
Name Amlodipine (Norvasc)

Concentration

Dosage Amount 10 mg

Route PO

Frequency 1xdaily

Pharmaceutical class Calcium channel blockers ( Deglin., Mansell,

Home
Hospital
or
Sanoski, & Vallerand , 2015).
Indication Hypertension. Systemic vasodilation decreases blood pressure (BP) (Deglin et al., 2015).

Both

Adverse/ Side effects Dizziness, fatigue, peripheral edema, angina, bradycardia, hypotension, palpitations, gingival hyperplasia, nausea, flushing (Deglin et al., 2015).
Nursing considerations/ Patient Teaching Do not take with grapefruit juice, monitor BP and heart rate before and after medication given, teach patient to change
positions slowly, avoid salt substitutes, take medication as prescribed (Deglin et al., 2015).
Name benazepril (Lotensin)

Concentration

Dosage Amount 20 mg

Route PO

Frequency 1xdaily

Pharmaceutical class Angiotensin converting enzyme inhibitor (Deglin et

Home
Hospital
or
Both
al., 2015).
Indication Hypertension. Blocks the conversion of angiotensin I to angiotensin II (a vasoconstrictor) and decreases aldosterone levels. Systemic vasodilation (Deglin et
al., 2015).
Adverse/ Side effects Dizziness, drowsiness, fatigue, headache, cough, hypotension, nausea, impaired renal function, rash, hyperkalemia, angioedema (Deglin et al.,
2015).
Nursing considerations/ Patient Teaching Monitor BP and heart rate before and after medication given, teach patient to change positions slowly, avoid salt substitutes,
take medication as prescribed; assess patient for signs of angioedema such as facial swelling and dyspnea (Deglin et al., 2015).
Name celecoxib (Celebrex)

Concentration

Dosage Amount 200 mg

Route PO

Frequency q12hr

Pharmaceutical class COX 2 inhibitor. (Deglin et al., 2015).

Home

Hospital

or

Both

Indication Relief of the signs and symptoms of arthritis and spondylitis; has anti-inflammatory and analgesic properties; the enzyme COX-2, which is required for the
synthesis of prostaglandin, is inhibited (Deglin et al., 2015).
Adverse/ Side effects Dizziness, headache, insomnia, myocardial infarction, stroke, thrombosis, edema, gastrointestinal bleeding, abdominal pain, diarrhea, dyspepsia,
flatulence, nausea, exfoliative dermatitis, stevens-johnson syndrome, toxic epidermal necrolysis, rash (Deglin et al., 2015).
Nursing considerations/ Patient Teaching May increase the risk of bleeding with aspirin and warfarin; assess range of motion, pain and swelling in joints; assess for
skin rash; advise patient to contact health care professional immediately if signs or symptoms of gastrointestinal toxicity (such as abdominal pain or black stools), skin
rash, edema, chest pain or unexplained weight gain; take medication as prescribed (Deglin et al., 2015).
Name dexamethasone (Decadron)

Concentration 4 mg / 1 mL

Route IV push

Dosage Amount 4 mg

Frequency q6hr

Pharmaceutical class Steroidal anti-inflammatory (Deglin et al., 2015).

Home

Hospital

or

Both

Indication Suppresses inflammation (Deglin et al., 2015).

Adverse/ Side effects Depression, euphoria, headache, insomnia, psychoses, restlessness, cataracts, hypertension, edema, peptic ulceration, anorexia, nausea, increased
appetite, acne, slow wound healing, ecchymoses, hirsutism, petechiae, adrenal suppression, hypokalemia, thromboembolism, muscle wasting, osteoporosis, cushingoid
appearance (Deglin et al., 2015).
Nursing considerations/ Patient Teaching Asses for signs of adrenal insufficiency, monitor intake and output ratios and daily weights, assess for changes in level of
consciousness (for cerebral edema),Guaiac test stools, teach patient not to suddenly stop medication as it may lead to adrenal insufficiency, take medication as prescribed
(Deglin et al., 2015).
Name docusate (Colace)

Concentration

Dosage Amount 100 mg

Route PO

Frequency 2xdaily

Pharmaceutical class Stool softener (Deglin et al., 2015).

Home

Hospital

or

Both

Indication Constipation prevention, promotes water incorporation into the stool (Deglin et al., 2015).
Adverse/ Side effects Throat irritation, mild cramps, diarrhea, rashes (Deglin et al., 2015).
Nursing considerations/ Patient Teaching Assess for abdominal distention, presence of bowel sounds and typical bowel function pattern, advise patient that Colace
should be used for short-term therapy only, take medication as prescribed (Deglin et al., 2015).
Name ezetimibe (Zetia)
Route PO

Concentration

Dosage Amount 10 mg
Frequency 1xdaily

Pharmaceutical class Cholesterol absorption inhibitors (Deglin et al.,

Home
Hospital
or
Both
2015).
Indication For the management of dyslipidemias; cholesterol absorption is inhibited in the small intestine (Deglin et al., 2015).
Adverse/ Side effects Cholecystitis, increases liver enzymes, nausea, pancreatitis, angioedema (Deglin et al., 2015).

University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching Obtain a diet history, specifically regarding fat intake, advise patient that this medication should be used in addition to a
reduced fat diet, take medication as prescribed (Deglin et al., 2015).
Name ketorolac (Toradol)

Concentration 15 mg / .5 mL

Route IV push

Dosage Amount 15 mg

Frequency q6hr

Pharmaceutical class Pyrroziline carboxylic acid (Deglin et al., 2015).

Home

Hospital

or

Both

Indication Management of pain, short-term. Inhibits prostaglandin synthesis (Deglin et al., 2015).
Adverse/ Side effects Stroke, drowsiness, throat irritation, asthma, dyspnea, myocardial infarction, vasodilation, edema, gastrointestinal bleeding, diarrhea, dyspepsia,
increased liver enzymes, oliguria, renal toxicity, exfoliative dermatitis, stevens-johnson syndrome, toxic epidermal necrolysis, prolonged bleeding time, anaphylaxis
(Deglin et al., 2015).
Nursing considerations/ Patient Teaching May decrease effectiveness of diuretics or antihypertensives, assess for rash periodically, assess pain, teach patient to avoid
driving until know how react to medication, take medication as prescribed (Deglin et al., 2015).
Name pantoprazole (Protonix)

Concentration

Dosage Amount 40 mg

Route PO

Frequency 1xdaily

Pharmaceutical class Proton pump inhibitors (Deglin et al., 2015).

Home

Hospital

or

Both

Indication Erosive esophagitis associated with gastroesophageal reflux disease. Binds to an enzyme while in acidic gastric pH, this prevents the final transport of
hydrogen ions to the gastric lumen (Deglin et al., 2015).
Adverse/ Side effects headache, pseudomembranous colitis, abdominal pain, diarrhea, flatulence, hyperglycemia, hypomagnesemia, bone fracture (Deglin et al., 2015).
Nursing considerations/ Patient Teaching Asses for abdominal or epigastric pain and occult or frank blood in stool, teach patient to avoid alcohol and notify health care
professional right away if rash, diarrhea, abdominal cramping, fever or bloody stools occur; take medication as prescribed (Deglin et al., 2015).
Name acetaminophen-oxycodone (Percocet 5/325)

Concentration

Dosage Amount 5 mg/ 325 mg

Route PO

Frequency PRN, q4hr

Pharmaceutical class Opioid agonists nonopioid analgesic combinations

Home
Hospital
or
Both
(Deglin et al., 2015).
Indication Moderate to severe pain. Alters perception of and response to pain; inhibits synthesis of prostaglandins (Deglin et al., 2015).
Adverse/ Side effects Confusion, sedation, dizziness, euphoria, dysphoria, blurred vision, respiratory depression, orthostatic hypotension, constipation, dry mouth,
urinary retention, flushing, sweating, physical or psychological dependence, tolerance; hepatotoxicity, acute generalized exanthematous pustulosis, stevens-johnson
syndrome, toxic epidermal necrolysis (Deglin et al., 2015).
Nursing considerations/ Patient Teaching Asses pain, blood pressure, pulse and respirations prior to and periodically during administration, advice patient that drug has
a known abuse potential, avoid driving until reaction to medication is known; assess alcohol use, teach patient to avoid alcohol and notify provider/discontinue medication
if develop a rash; take medication as prescribed (Deglin et al., 2015).

Name diazepam (Valium)

Concentration

Dosage Amount 5 mg

Route PO

Frequency PRN, 3xdaily

Pharmaceutical class Benzodiazepines (Deglin et al., 2015).

Home

Hospital

or

Both

Indication skeletal muscle relaxant; inhibits spinal polysynaptic afferent pathways (Deglin et al., 2015).
Adverse/ Side effects Dizziness, drowsiness, lethargy, depression, ataxia, blurred vision, respiratory depression, constipation, nausea, vomiting, weight gain, rashes,
physical or psychological dependence, tolerance (Deglin et al., 2015).
Nursing considerations/ Patient Teaching Monitor blood pressure, respiratory rate and pulse prior to and throughout therapy, assess muscle spasms, teach patient to
avoid taking with alcohol, go to follow-up exams to determine medication effectiveness; take medication as prescribed (Deglin et al., 2015).

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION:
Diet ordered in hospital?
Regular
Diet patient follows at home? Regular
24 HR average home diet:

Analysis of home diet (Compare to My Plate and

Consider co-morbidities and cultural considerations):
The patient is only consuming 44% of the recommended
refined grains, 27% of daily recommended fruits, only 23%
of the target dairy and 92% of the target protein. However,
she is consuming more than the target for daily intake of
vegetables. The patient consumes too much sodium; she
eats over 1,000 mg more than is recommended. She intakes
less saturated fat than is allowed for, which is a positive for
her hyperlipidemia, and has consumed only 2 tsp of the
allowed 6 tsp of oils. The patients total calorie intake was
1492 with 489 of that being considered empty calories
(SuperTracker).
I would recommend that the patient replace some of the
empty calories with healthier choices and eat more refined
grains, fruit, low-fat dairy, and that she reduce the amount
of sodium she intakes. I would advise her that with the
extra sodium that she is consuming, she may retain water
and this may worsen her hypertension. I would also
mention that the acid content in the tomato soup may affect
the gastroesophageal reflux disease negatively.
Additionally, I would recommend that she speak with a
dietician and/or her primary care physician regarding
healthy ways to lose weight, so her body mass index is
brought down to a healthy level.

Breakfast: Peach Greek yogurt, 6 ounces

Lunch: Canned tomato soup, 10 saltine crackers.
Dinner: Medium chicken breast, baked potato with butter,
cup of broccoli
Snacks: 1 ounce of salted peanuts
Liquids (include alcohol): 4 ounce orange juice, 12 ounce
7-up, 12 ounces of water, 6 ounces of red wine

1 COPING ASSESSMENT/SUPPORT SYSTEM:

Who helps you when you are ill? Husband and daughter.
How do you generally cope with stress? or What do you do when you are upset?

University of South Florida College of Nursing Revision September 2014

The patient stated she copes well, she talks with friends.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The patient said she has anxiety regarding her husband; he is experiencing health problems and she said she does not have
support in dealing with his health issues.

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? __No.___________________________________________________
Have you ever been talked down to?_No.__________ Have you ever been hit punched or slapped? Yes. ____________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
______________No.______________________ If yes, have you sought help for this? ______________________
Are you currently in a safe relationship?
Yes.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Intimacy vs. Isolation

Autonomy vs. Doubt & Shame

Initiative vs. Guilt
Industry
Generativity vs. Self absorption/Stagnation
Ego Integrity vs.

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:

This patient is in Eriksons integrity vs. despair stage, for ages 65 years and older. In this stage elderly adults must come to
see their lives as meaningful in order to face death without regrets or worries; this would be the integrity stage, which is
also related to an elevated sense of psychological well-being and minimal levels of despair or depression. However, if the
patient does not yet view their life as meaningful and know that in death they will have no regrets or worries (they may
worry about unsettled regrets), the patient would be considered to be in the despair stage (Sigelman & Rider, 2012).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

This patient is in the integrity stage of life. She was able to matter-of-factly answer questions regarding her life history
and spoke proudly of her daughters, husband and the life she has had up to this point. The patient is comfortable with her
lifes work and mentioned no worries, regrets or depression. The only sign the may not be consistent with integrity versus
being in despair is the fact that she said she has some anxiety related to her husband being ill, but she did say that her
husbands primary care physician did say that everything should clear up in a couple of months.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The patient did not view her condition and the subsequent surgery in a manner that negatively affected her mood or
thought process, if anything the fact that she was able to have the procedure and immediately felt relief in the numbness in
her feet and the pain level decreasing in her neck, made her more content with life. She also was encouraged that the
doctor told her the numbness in her fingers would subside within a couple of months.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Arthritis and bone spurs.

University of South Florida College of Nursing Revision September 2014

What does your illness mean to you?

The patient stated that her illness meant she had limited movement and activities. She also said she had a difficult time
with completing household chores. The patient did also mention that her physician told her she should feel improvement
in her symptoms every couple of days, post-operatively.

+3 SEXUALITY ASSESSMENT:
Have you ever been sexually active?__Yes.______________________________________________________________
Do you prefer women, men or both genders? __Men.______________________________________________________
Are you aware of ever having a sexually transmitted infection? ___No.________________________________________
Have you or a partner ever had an abnormal pap smear?_Yes, pre-cancer, patient had a hysterectomy due to fibroids at the
age of 50 years old.__
Have you or your partner received the Gardasil (HPV) vaccination? __No. No.__________________________________
Are you currently sexually active? ____No.____________________ 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?____30 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?
No.

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?
The patient said she does not attend church but does believe in God.
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_No.___________________________________________________________________________________________________
______________________________________________________________________________________________________

+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)
The patient has a history of smoking
40 cigarettes per day; 2 packs.
cigarettes.

Yes
No
For how many years? 25 years
(age 17 through 42)

If applicable, when did the

patient quit? 1990.

Pack Years: 50

Does anyone in the patients household smoke tobacco? If

Has the patient ever tried to quit? Yes.
so, what, and how much?
If yes, what did they use to try to quit? Nicorette gum.
Yes. The patients husband smokes half of a pack of cigarettes a day, outside.
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Red wine.
How much? 1 glass.
For how many years? 6 weeks.
(age 69 through 69)
Volume: 6 ounces.
Frequency: Nightly.
If applicable, when did the patient quit?
The patient said prior to 6 weeks ago, she drank 3 glasses of white wine a night for 25 years.
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

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

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen: No
SPF:
Bathing routine: daily
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis: appendix removed 13
years ago.
Abdominal Abscess
Last colonoscopy?
2013
Other:

Genitourinary
nocturia
dysuria
hematuria

Sinus pain or infections

Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
1 x/day
Routine dentist visits
1 x/year
Vision screening
1 year ago
Other: Wears glasses at night to drive.

polyuria
kidney stones
Normal frequency of urination:8-10 x/day
Bladder or kidney infections

Immunologic
Chills with severe shaking
Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Hematologic/Oncologic
Anemia
Bleeds easily
Bruises easily
Cancer: skin, under left eye, roughly 20
years ago.
Blood Transfusions
Blood type if known:
Other:

Metabolic/Endocrine
Diabetes
Type:
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?
02/16/2015
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? At age 50 years.
menstrual cycle
regular
irregular
menarche
age 13
menopause
age 50
Date of last Mammogram &Result: 5 years
ago, negative.
Date of DEXA Bone Density & Result:
2000, patient said height from 56 to 55.
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: left foot bone,
age 45 years

Childhood Diseases

University of South Florida College of Nursing Revision September 2014

Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
02/10/2015, not in chart.
Other:

Weakness: right arm

Pain: intermittent, at surgical site.
Gout
Osteomyelitis

Measles
Mumps
Polio
Scarlet Fever

Arthritis

Chicken Pox

Other:

Other: Patient said she had all of these

diseases and the vaccines.

General Constitution
Recent weight loss or gain
How many lbs? 8
Time frame? 5 weeks
Intentional? Yes.
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?
Patient stated she was ill in 2006, she was in the hospital for 16 days, was out of work for three months. Signs and
symptoms were headache, lethargy and fever. The patient also stated that her cells (red blood cells and white blood cells)
were off. She saw an oncologist however, she was never diagnosed with an illness; she said it went away on its own.

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: Patient
is a well-developed 69
year old who is
overweight, showing no
visible signs of distress.
Temperature: 98.1, oral

Height: 55
Pulse: 75
Respirations: 18

Weight: 164 lbs

BMI: 27.3
Blood Pressure:
145/79, right upper arm

Pain: 2; posterior neck, at

surgical site.

SpO2: 93

Is the patient on Room Air or O2:

Room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
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

flat
loud

Incision on posterior neck (surgical site): clean and dry. Patient has a Jackson-Pratt drain.
Peripheral IV site Type: 22 gauge
Location: left, dorsal hand
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Fluids infusing?
no
yes - what?

Location:

Date inserted: 02/16/2015

Date inserted:

HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 12 inches & left ear- 12 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: upper dentures.
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
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: Clear throughout.
RUL: CL
LUL: CL
RML: CL
LLL: CL
RLL: CL

Chest expansion symmetric

University of South Florida College of Nursing Revision September 2014

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

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)
Patient did not have ECG tracing.

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 75 bpm Carotid: 3
Brachial: 3 Radial: 3 Femoral: 3
Popliteal: 2
DP: 3 PT: 3
No temporal or carotid bruits
Edema:
0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
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 02 / 16 / 2015 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
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
Other Describe: Bowel sounds were hyperactive x4quadrants.

Not assessed, patient alert, oriented, denies problems

GU
Urine output:
Clear
Cloudy
Color: clear
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Previous 24 hour output:

without assistance

or

mLs

N/A

with assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ___ RUE __4___ LUE __4__ RLE __5__ LLE__5__
[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- did not
test, patient said she was too tired; she was with the physical therapist beforehand.
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: +2

Biceps: +2

Brachioradial: +2

Patellar: +2 Achilles:

+2

Ankle clonus: positive negative Babinski: positive negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS:

Lab
WBC

Dates

Trend
The white blood cell
count in trending
upwards. This may
indicate an inflammatory
process.

Analysis
The trending upwards of
5.4
(02/09/2015)
the WBC may be due to
8.9
(02/17/2015)
the patient having a
surgical procedure on
Normal (4.5-11)
02/16/2016. The patients
body is likely somewhat
inflamed at the surgical
site and is fighting to
make sure infection does
University of South Florida College of Nursing Revision September 2014

RBC
5.24
4.75

(02/09/2015)
(02/17/2015)

The red blood cells have

been within the normal
range, although slightly
decreased since surgery.

(02/09/2015)
(02/17/2015)

The hemoglobin is within

the normal range,
although slightly
decreased since surgery.

(02/09/2015)
(02/17/2015)

The hematocrit was high

pre-operatively but has
since come down to a
normal level.

Normal (3.6-5.4)

HGB
16.0
14.4
Normal (12-16)

HCT
47.9 H
43.2
Normal (37-47)

not occur.
This indicates that the
patients body is properly
producing RBCs before
and after surgery. Being
that the patient had a
normal level of RBCs
prior to surgery was
important; in case of
bleeding. Postoperatively, a normal
level of RBCs is
important in the delivery
of oxygen and nutrients to
the body, and surgical
site, to promote adequate
healing.
HGB being in the normal
range is important for the
oxygen carrying capacity
of the RBCs, to aid in the
healing process at the
surgical site and in
maintaining cell life.
Being that the RBCs have
slightly decreased, it is
logical that the HGB has
also slightly decreased, as
HGB is on RBCs.
However, as previously
mentioned they are both
within normal ranges.
The HCT being elevated
pre-operatively may have
been an indication of
hypovolemia; the patient
may have been slightly
dehydrated, leading to
this result. Being that her
RBC count is within
normal range and that
there is no other
information in the chat or
mentioned by the patient
that suggested there is
any health issue causing
the elevated pre-op HCT,
this is not cause for
concern.

University of South Florida College of Nursing Revision September 2014

PLT
296
253

(02/09/2015)
(02/17/2015)

Normal (140-450)
Segs
91.1 H

(02/17/2015)

Normal (45-75)

Lymphs
5.8 L

(02/17/2015)

Normal (24-44)

Potassium
4.0

(02/09/2015)

Normal (3.5-5.1)

The platelets are within

The PLTs being in normal
normal range, slight
range is important for the
decrease post-operatively. clotting at the surgical
site to aid in ensuring that
there was not abnormal
bleeding.
The segmented
The Segs are elevated
neutrophils are elevated,
post-operatively which
there is no trend as this
could be an indication of
was the only result for
infection/or
Segs.
inflammation. The body
was put through trauma
from the surgical
procedure on 02/16/2015
and is in the process of
healing, inflammation
may be present. Tracking
the patients temperature
is important to aid in
observing for infection.
Currently, the patients
temperature is within
normal limits, so an
infection is not of concern
at the moment.
The lymphocytes are low. This result could be
There was no previous
indicative of lymph
result to generate a trend. changes due to surgery or
due to the amount of
alcohol the patient
consumed, until 6 weeks
ago. Having previous
lymph lab results would
be beneficial in
determining the cause of
low lymphs.
Unfortunately, they are
not available. The patient
should continue to be
monitored.
The potassium is within
Some of the patients
normal limits. There was medication can interfere
no previous result to
with the potassium level.
generate a trend.
Potassium plays a pivotal
role in maintaining
electrical conduction of
the heart. So, it is
important to monitor this
electrolyte.

University of South Florida College of Nursing Revision September 2014

Carbon dioxide
25

(02/09/2015)

Within normal range.

There was no previous
result to generate a trend.

Normal (21-32)

Glucose
100 H

(02/09/2015)

Normal (70-99)

Calcium
9.4

(02/09/2015)

Normal (8.5-10.1)

The glucose level is

elevated. There was no
previous result to
generate a trend.

The calcium is within

normal range. There was
no previous result to
generate a trend.

MRI of C spine.

Date and results not in

chart, this was done preoperatively.

Cervical spine 3 through

cervical spine 7 had no
fluid, due to bone spurs and
arthritis, per patient.

X-ray cervical spine

post 2+ levels implants

02/16/2015

Findings were normal.

The patients CO2 level

being within normal
range, along with the
oxygen saturation of
93%, is indicative of
proper ventilation and
breathing pattern.
Tight glycemic control is
important in proper
healing. This is important
after a surgical procedure.
However, the patients
glucose in only slightly
elevated. Encouraging the
patient to consume a
slightly smaller amount
of glucose would be
sufficient in maintaining
proper glucose levels, as
the patient is not diabetic.
The patient had a
laminectomy, being that
bone was involved in the
surgery it is especially
important that she have
adequate calcium, which
she does, for bone health.
The patient is also a postmenopausal woman so
having normal calcium
levels is important overall
for her bone health and
aids in blood clotting;
necessary for a surgical
procedure.
This finding is lead to the
patient having the
laminectomy of C3-C7 on
02/16/2015.

The instrumentation and

fusion are in the correct
locations.

University of South Florida College of Nursing Revision September 2014

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

The patient is on a regular diet; activity is up with assist, activities of daily living and she is to reposition every 2
hours, to aid in pressure sore prevention and venous thromboembolism (VTE) formation. The patient walks with
the physical therapists daily to aid circulation, promote healing and help prevent VTE formation. A soft collar neck
brace was ordered for the patient to aid in stabilizing her head and neck muscles and in alleviating pain.
8 NURSING DIAGNOSES
1. Impaired skin integrity related to disturbance of skin tissue as a result of surgical procedure as evidenced by incision.
2. Activity intolerance r/t pain and imposed activity restriction aeb facial grimacing and limited mobility.
3. At risk for VTE r/t decreased activity.
4. Posterior neck pain r/t medical treatment aeb patient report of pain and facial grimacing.
5. At risk for infection r/t invasive procedure.
6. Fall risk r/t pain medication.

University of South Florida College of Nursing Revision September 2014

 15 CARE PLAN
Nursing Diagnosis: Impaired skin integrity r/t disturbance of skin tissue as a result of surgical procedure aeb incision.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Report pain or altered sensation at
Instruct the patient to notify nurse
Early identification of pain or
Goal was met. The patient notified
skin impairment site within 15
of any pain or altered sensation at
altered sensation can identify
the nurse of pain at the incision site
minutes of onset.
incision site.
looming problems early and aid in within 15 minutes of onset.
preventing complications (Ackley
& Ladwig, 2011).
Demonstrate comprehension of the
plan to heal skin by verbally
reciting understanding, and
describe measures to protect the
skin and care for the incision site as
well as assessment for infection by
1200.

Implement a written and verbal

plan of treatment/care and
assessment for the site of skin
impairment.

A written plan safeguards

consistency in care, as well as
documentation. Early assessment
accompanied by intervention aid in
prevention of serious problems
from evolving (Ackley & Ladwig,
2011).

Goal was met. The patient was able

to recite that she was to keep the
site clean and dry and that the
silverlon bandage was not to be
removed for 7 days. She also
expressed knowledge of signs and
symptoms of infection such as
rubor, swelling and calor.

Long term goal: Regain skin

integrity within 2 weeks of
procedure.

Asses skin for any signs and

symptoms of infection while
patient at hospital. Encourage
ambulation to increase circulation
to the site of skin impairment.

Early assessment along with

intervention aids in prevention of
serious problems from developing.
(Ackley & Ladwig, 2011). Activity
promotes circulation and improves
oxygenation and healing at the site
of impaired skin integrity.

Regain of skin integrity will be

evaluated by provider after
discharge.

Nursing Diagnosis: Activity intolerance r/t pain and imposed activity restriction aeb facial grimacing and limited mobility.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Walk 250 feet with physical
The ambulation was carried out by Ambulating assists in the
Goal met. Patient walked 250 feet
therapy by 1000 without an
the physical therapy team.
prevention of VTE formation. Pain with the physical therapist by 1000
elevation in pain level/keep pain
However, nurse to notify and
restricts the patient from reaching
without elevation of pain or facial
University of South Florida College of Nursing Revision September 2014

managed.

encouraged the patient prior to

ambulating. Nurse assessment of
pain prior to, during and after
ambulation. Management of pain
with medication. Monitor blood
pressure and heart rate as well.

maximum activity goal and often is grimacing. Pain managed.

intensified by movement so
assessing and addressing pain
level, specifically prior to
ambulation, is vital to goal being
met(Ackley & Ladwig, 2011). The
activity is restricted by physician as
well, to ensure that the incision site
does not open.

Verbalize an understanding of the

need to gradually increase activity
level as permitted by provider by
0930.

Provide written and verbal

explanation to patient of the
importance of increasing activity
steadily. Answer any questions the
patient has regarding activity and
healing process.

A written plan maintains

consistency in care, as well as
documentation (Ackley & Ladwig,
2011). Patient understanding of
health improvement and healing is
pivotal in the recovery process.
Patient understanding aids in
compliance.

Goal met. Patient verbalized

understanding of need to
progressively increase activity by
repeating information back by
0930.

Long term goal: demonstrate

increased activity tolerance without
signs of pain within 2 weeks of
surgery.

Aid the patient in ambulation in

between physical therapy sessions
and assess pain level while still in
the hospital.

Increased activity is important in

maintaining overall health and to
aid in the healing process, and with
pain management is more
achievable (Ackley & Ladwig,
2011).

Goal to be assessed by nurse and/or

provider as healing progresses.

2 DISCHARGE PLANNING:
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
University of South Florida College of Nursing Revision September 2014

Rehab/ HH
Palliative Care
The patient will be discharged to home with orders for follow up appointments with the surgeon and her primary care physician. The patient will also
have a referral to continue physical therapy after discharge.

University of South Florida College of Nursing Revision September 2014

References
Ackley, B.J. & Ladwig, G.B. (2011). Nursing diagnosis handbook (9th ed.). St. Louis, MO: Mosby.
Deglin, J. H., Mansell, H. G., Sanoski, C. A., & Vallerand, A. H. (2015). Daviss drug guide for nurses (14th ed.). Philadelphia, PA: F.A. Davis
Company.
Huether, S. & McCance, K. (2012). Understanding pathophysiology (5th ed.). St Louis, MO: Elsevier Saunders.
Osborn, K., Wraa, C., Watson, A., & Holleran, R. (Eds.). (2014). Medical-surgical nursing: Preparation for practice (2nd ed.). Upper Saddle River,
New Jersey: Pearson.
Sigelam, C. & Rider, E. (2012). Life span: Human development (7th ed.). Belmont, CA: Wadsworth Cengage Learning.
SuperTracker. (n.d.). supertracker.usda.gov. Retrieved February 28, 2015, from https://www.supertracker.usda.gov/foodtracker.aspx

University of South Florida College of Nursing Revision September 2014