UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student:ASHLEY KAVUMKAL

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

BB
F

Assignment Date:02/13/2015
Agency:SMH

Age: 72

Admission Date:02/12/2015

Marital Status: SINGLE

Primary Medical Diagnosis: possible

Cerebrovascular accident ICD9: 434.91

Primary Language: ENGLISH

Level of Education: REAL ESTATE LICENSE

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): REALTOR

Number/ages children/siblings: 2 CHILDREN (43,45), 6
SIBLINGS
Served/Veteran:
If yes: Ever deployed? Yes or No

Code Status: FULL CODE

Living Arrangements: HOUSE NEAR SARASOTA MALL WITH

DAUGHTER

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

Culture/ Ethnicity /Nationality: ENGLAND

Religion: BAPTIST

Type of Insurance: MEDICARE, MEDICAID

1 CHIEF COMPLAINT:
Patient stated that her chief complaint for today is pain in the IV site (right forearm) and numbness in lower extremities
bilaterally.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient was brought to the ER yesterday (02/11/15) for having left face, arm and leg numbness at around 9:30 am. Patient
stated that she had tingling and discomfort mainly in left foot which disappeared after a few minutes but then came back
and became persistent since then. Patient also stated that she had head pain of 6 and nausea but, did not vomit. Patient
denied having weakness or difficulty walking. Patient had a blood pressure of 173/95 upon arrival and received labetelol
which made her feel better. MRI and CT of head results were normal. Physician suspected TIA vs Anxiety and favored the
latter.

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

Operation or Illness

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

cancer

Arthritis

Brother

Father

Anemia

Mother

Cause
of
Death
(if
applicable
)
pneumoni
a
cancer

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Age (in years)

7/20/2007

Alcoholism

Diabetes (diet controlled)

GI bleeding
incontinence
Rotator cuff repair

Sister
relationship
relationship
relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(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
University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
IVP dye
Hydrocodone

Type of Reaction (describe explicitly)

anaphylaxis
GI distress

Medications

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Cerebrovascular accident is a sudden loss of neurological function, caused by vascular injury to an area of the brain.
Causes include emboli from other organs, cerebrovascular disease, trauma, hypercoagulable states etc. Risk factors
include advanced age (65 and above),atherosclerosis of the aortic arch, atrial fibrillation, coronary artery disease,
smoking, alcohol, heart failure, hyperlipidemia, hypertension, history of myocardial infarction, diabetes mellitus, male
gender, non-white race, peripheral vascular disease, physical inactivity, obesity, pregnancy etc. Signs and symptoms
include sudden weakness/ numbness of the face, arm or leg, sudden loss of vision, double vision, difficulty in speaking,
sudden severe headache, sudden falling, gait disturbance or dizziness. Diagnosis requires physical examination,
neurological examination, CT, MRI, Doppler ultrasound or arteriography. Treatment includes recombinant tissue
plasminogen activator (rt-PA) if recognized by the first 90 to 180 min.

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

Concentration 325mg/ tab

Route: PO

Dosage Amount 325mg (1 tab)

Frequency: ONCE DAILY

Pharmaceutical class: SALICYLATES

Home

Hospital

or

Both

Indication: pain, fever, prophylaxis for TIA and MI,

Adverse/ Side effects: GI BLEEDING, ANAPHYLAXIS, LARYNGEAL EDEMA
Nursing considerations/ Patient Teaching: take with full glass of water, remain upright for 15-30 min, avoid alcohol, acetaminophen or NSAIDS unless
prescribed
Name: Atorvastatin

Concentration 20mg/tab

Route: PO

Dosage Amount 20mg (1 tab)

Frequency: once daily

Pharmaceutical class: hmg coa reductase inhibitor

Home

Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Indication: management of hyperlipidemia, prevention of CAD, stroke

Adverse/ Side effects: abdominal cramps, constipation, diarrhea, heartburn, rashes, rhabdomyolysis, angioneurotic edema,
Nursing considerations/ Patient Teaching: notify provider if unexplained muscle pain, tenderness if accompanied by fever or malaise
Name: sodium chloride

Concentration: 0.9%

Route IV

Dosage Amount: 1000ml

Frequency: 75ml/hr

Pharmaceutical class

Home

Hospital

or

Both

Indication: management of hypovolmia, dehydration

Adverse/ Side effects: edema, hypertension
Nursing considerations/ Patient Teaching: monitor VS, intake and output, watch for fluid overload, edema
Name: Lovenox

Concentration 40mg/0.4mL

Route: SQ

Dosage Amount 40mg

Frequency Q24H

Pharmaceutical class: antithrombotic

Home

Hospital

or

Both

Indication: prevention of VTE /DVT,

Adverse/ Side effects: bleeding, anemia
Nursing considerations/ Patient Teaching: report any unusual bleeding, itching, rash, fever, swelling, difficulty breathing
Name: Lisinopril

Concentration 5mg/tab

Route:PO

Dosage Amount 5mg (1tab)

Frequency once daily

Pharmaceutical class: ace inhibitors

Home

Hospital

or

Both

Indication: management of hypertension, heart failure, MI

Adverse/ Side effects: dizziness, cough, hypotension, angioedema
Nursing considerations/ Patient Teaching: notify rash, sore throat, fever, swelling, irregular heart beat, chest pain, difficulty swallowing or breathing
Name: acetaminophen

Concentration 325mg/tab

Route : PO

Dosage Amount : 625mg (2tab)

Frequency: PRN

Pharmaceutical class: antipyretic, nonopioid analgesics

Home

Hospital

or

Both

Indication: treatment of pain, fever

Adverse/ Side effects: hepatoxicity, acute generalized exanthematouspustulosis, stevens-johnson syndrome
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

University of South Florida College of Nursing Revision September 2014

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

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? regular
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: egg, cap n crunch sweet corn and oat cereal with The patients diet consists of mainly proteins and fiber
milk
which is good. However her fuit and vegetable intake is
less than 50%. She should add more of these into her diet.
Also she could incorporate more milk or yogurt into her
diet as her diet now only consist of less than 25% of those.
Her sodium intake exceeds the daily limit by 700mg which
should be cut down. Instead of chips and crackers she could
incorporate yogurt or fruits as snack.
Lunch: Hamburger, potato, small unsweet tea
Dinner: mushroom soup, baked fish
Snacks: cheese crackers, unsalted peanuts, chips
Liquids (include alcohol): coffee with half n half
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?
daugter
How do you generally cope with stress? or What do you do when you are upset? Patient stated that she practices deep
breathing to cope with stress. Also, she talks with her daughter or friends when upset.

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

+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.

University of South Florida College of Nursing Revision September 2014

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?
_no_____________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
______________no____________________________ If yes, have you sought help for this? ______________________
Are you currently in a safe relationship? yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
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: The patient is in her late adulthood with an integrity stage. When reflecting on his or her life, the older adult may
feel a sense of satisfaction (integrity) or failure (despair) (Myers, 2008, p.87).
Reference:
Myers, D. G., (2008). Development through the life span: Psychology in everyday life (pp. 78) New York, Worth Publishers.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

Patient seems content about her life. She mentioned that her daughter is taking care of her very well and she is the one
who brought her to the hospital this time.

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

The disease did not seem to affect the patients developmental stage that much. She is very positive about recovering. She
is very thankful that her daughter brought her in on time to the hospital.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Anxiety
What does your illness mean to you?
Slowing down- in term of doing daily activities

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?
_______yes_____________________________________________________________
Do you prefer women, men or both genders?
______men_______________________________________________________
Are you aware of ever having a sexually transmitted
infection? __once_____________________________________________

University of South Florida College of Nursing Revision September 2014

Have you or a partner ever had an abnormal pap smear? Yes, long time
ago_____________________________________________________
Have you or your partner received the Gardasil (HPV) vaccination?
__________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?
__N/A______________________________________________________
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?
__patient does not follow any religion. She only believes in being a good person and in doing good to people
around.___________________________________________________________________________________________________
______________________________________________________________________________________________________
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)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much? no

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?
Yes
No
What?
How much? A glass of wine
Volume:
Frequency: occasionally, during
family gatherings
If applicable, when did the patient quit?

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?
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?
no

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 : 2 years
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?
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
incontinence

3/day

x/day
x/year

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
Type: 2
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?

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? 52
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

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox

University of South Florida College of Nursing Revision September 2014

10

Other:

Other:

Other:

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
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? none

Any other questions or comments that your patient would like you to know? none

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11

10 PHYSICAL EXAMINATION:
General Survey:

Height: 165.1cm
Pulse: 85
Respirations: 18
SpO2 99

Weight 170lb
BMI: 28.28
Blood Pressure: 160/85

Pain: 0

Temperature: (route
Is the patient on Room Air or O2
taken?) 98.7
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
flat
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
loud
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
numbness in left foot, weak pedal pulse, got better with SCDs
was not WNL (within normal limits)
Central access device Type: peripheral
Location:
right forearm
Date inserted: 02/12/2015
Fluids infusing?
no
yes - what? NS 0.9%
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: all clear
RUL
LUL
RML
LLL
RLL

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: left,
2
No temporal or carotid bruits
Edema:
[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
/
/
)
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:

Not assessed, patient alert, oriented, denies problems

GU
Urine output:
Clear
Cloudy
Color: yellow
Previous 24 hour output:
N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
voids: pt reported clear and yellow with no pain
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at _______ RUE _______ LUE _______ RLE

mLs

& _______ 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:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

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13

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
Glucose POCT

Dates

Chem. 12
PTT activated
Prothrombin time w/
INR
CT head

MRI

12/02/15
12/02/15
12/02/15
12/02/15
12/02/15

12/02/15

Trend
244 high

Analysis
Type 2 diabetes

Normal values
25.2 seconds -normal
12.7 normal
0.91 normal
Low-attenuation
periventricular white
matter compatible w/
small vessel ischemic
changes. No
hemorrhage
mass/edema, ventricles
normal size, mastoid air
cells and paranasal
sinuses clear
No abnormal diffusion
is noted

normal
normal
normal
Small vessel ischemic
changes in both cerebral
hemispheres. No
intracranial
hemorrhage or acute
intracranial
abnormality seen

normal

+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.)
Vitals Q4H, ambulate with assistance,
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
_________________________________________________________________________________________________
Risk for Ineffective Cerebral Tissue Perfusion
risk for fall
risk for DVT- DVT score of 7
risk for peripheral neurovascular dysfunction

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14

 15 CARE PLAN
Patient Goals/Outcomes
Patient will maintain level of
consciousness, cognition, and
motor/sensory function with stable
vital signs and absence of signs of
increased ICP.

Safety-Patient will remain free

from falls

Patient will be free from potential

DVT risk factors

risk for peripheral neurovascular

dysfunction

Nursing Diagnosis: Nursing Diagnosis goes here

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Assess factors related to decreased If the stroke is evolving, patient
cerebral perfusion and potential for can deteriorate quickly and require
increased ICP. Closely assess and
repeated assessment and
monitor neurological status
progressive treatment.
frequently and compare with
baseline. Monitor vital signs,
changes in blood pressure, compare
BP readings in both arms. Heart
rate and rhythm, respiration,pupils
equal size shape equality and light
reactivity, report changes in vision.
Located near nurses station, call
To make sure patient does not
light in place and educated to use,
move out of bed without assistance
bed alarm, non-skid socks, fall risk to avoid risk of fall
arm band, top side rails up, bed
positioned in the lowest possible
height , hourly rounds, monitor VS,
monitor BP for orthostatic
hypotension
Encourage ambulation with
To make sure circulation to the
assistance, put SCDs while in bed, extremities are intact and does not
administer Lovenox as ordered,
form any clots
change position, move extremities,
toe exercises in bed, assess
extremities for edema, capillary
refill, numbness, tingling, pain,
swelling
Encourage ambulation with
assistance, put SCDs while in bed,

To make sure circulation to the

extremeties are intact and does not

University of South Florida College of Nursing Revision September 2014

Evaluation of Goal on Day Care

is Provided
Patient reported numbness in lower
extremities. Sensation is intact.
LOC is intact, no signs of increased
ICP present.
Unresolved

All interventions are done

unresolved

All interventions are done

unresolved

All interventions are done

unresolved
15

change position, move extremities,

toe exercises in bed, assess
extremeties for edema, capillary
refill, numbness, tingling, pain,
swelling,

form any clotts

Include a minimum of one

Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
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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References
Myers, D. G., (2008). Development through the life span: Psychology in everyday life (pp. 78) New York, Worth
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Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software]. Retrieved from
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