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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Natalie Drass

MSI & MSII PATIENT ASSESSMENT TOOL .


1 PATIENT INFORMATION

Assignment Date: January 26, 2016


Agency: Florida Hospital Tampa

Patient Initials: B.W.

Age: 67

Admission Date: January 20, 2016

Gender: Female

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Pleural effusion, J90

Level of Education: Associates Degree

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired from criminal justice

N18.3 Chronic kidney disease, stage 3

Number/ages children/siblings:
Brother-64 Sister-60 Daughter-39 Son-41
Served/Veteran: No

Code Status: Full

Living Arrangements: Lives with husband in a one story house

Advanced Directives: Yes


If no, do they want to fill them out?
Surgery Date: Unknown
Procedure: Possible
Transjugular Intrahepatic Portosystemic Shunt

Culture/ Ethnicity /Nationality: American


Religion: Baptist

Type of Insurance: Medicare

1 CHIEF COMPLAINT:
Patient came to the ER on 1/20/16 with shortness of breath. Patient had fluid drained from her lungs via thoracentesis last
month at Florida Hospital Wesley Chapel. Four liters of fluid were removed. Patient states I had trouble breathing last
month and there was fluid in my lungs. I knew that the same thing was happening because I had the exact same
symptoms. The patient reported that her chest had felt tight and that she could not stop coughing.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The shortness of breath started a week prior to admission
The shortness of breath is affected the lungs
Shortness of breath was constant
Patient states when I had trouble breathing my whole chest felt tight
Patient says nothing really makes it worse
The chest tube has alleviated some of the discomfort, sitting up in bed
Treatment is insertion of a chest tube to drain fluid

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

Operation or Illness

Father

47

Mother

91

Brother

64

Sister
Daughter

60

Son

41

Birth defect, hole in diaphragm


Measles
Hypertension
Hysterectomy

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

Cause
of
Death
(if
applicable
)
Heart
attack

Environmental
Allergies

Type II diabetes
Hypercholesterolemia

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Birth
Childhood
Patient says ~ age 40
Patient says age 36
or 37
Patient says ~ age 40
Patient says ~ age 40

39

Comments: Include age of onset


Neither patient or husband remember the date of onset for any family member

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
U
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Date) Patient went to a free flu shot drive in fall, U
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
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NO

occupational purposes? Please List


1 ALLERGIES
OR ADVERSE
REACTIONS

Medications

Other (food, tape,


latex, dye, etc.)

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Codeine
Erythromycin
Penicillin
Keflex
Floxin
Atarax
Environmental/seasonal
allergies

Nausea
Nausea
Hives
Nausea
Patient says she feels very sleepy
Nausea
Itchy nose, watery eyes, headaches

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)
Accumulation of fluid within the pleural space is considered a pleural effusion. Fluid buildup impairs the lungs
ability to fully expand. Dyspnea and chest pain are the most common symptoms with a pleural effusion. A
cough may sometimes be present with a pleural effusion but not always. Disease in any organ system can result
in a pleural effusion. For this patient, the liver caused the pleural effusion. This patient has cirrhosis of her liver
and a hole in her diaphragm. Fluid is backing up from her liver and spleen into her chest. Pleural effusions can
be detected with a chest x-ray or physical examination. It is important to distinguish if the pleural fluid is
exudative or transudative. An exudative effusion will be due to inflammatory conditions or underlying health
problems that need to be evaluated. Transudative effusions do not require further clinical evaluation because
these types of effusions are associated with clinically apparent conditions (Bouros, 2004).
If the liver causes the pleural effusion, the patient may have ascites. Transudative effusions form due to the
movement of fluid along a pressure gradient from the peritoneal space into the pleural space. The development
of hepatic hydrothorax in a patient with cirrhosis and ascites is the movement of ascetic fluid from the
peritoneal space to the pleural cavity through a defect in the diaphragm. A transjugular intrahepatic portalsystemic shunt (TIPS) may effectively manage hepatic hydrothorax (Bouros, 2004). TIPS is a procedure by
which communication between the portal and the hepatic vein is created. A stent connects hepatic and portal
systems. Blood will be shunted to the hepatic vein to decompress the portal venous system (Gins, Arroyo,
Rods, & Schrier, 2005). A pleural effusion can be treated with thoracentesis, chest tube drainage, or a
pleurectomy.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
(Zyrtec)

Name Cetirizine

Concentration

Dosage Amount 10mg

Route PO

Frequency daily

Pharmaceutical class antihistamines,

piperazines

Home

Hospital

or

Both

Indication allergies
Adverse/ Side effects Dizziness,

drowsiness, fatigue, pharyngitis, dry mouth


driving until medication response is known, avoid alcohol and other CNS depressants with

Nursing considerations/ Patient Teaching Avoid

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this drug, good oral hygiene


Name Valsartan

Concentration

(Diovan)

Dosage Amount 160mg

Route PO

Frequency daily

Pharmaceutical class angiotensin

II receptor antagonists

Home

Hospital

or

Both

Indication high

blood pressure
fatigue, headache, edema, hypotension, hyperkalemia, angioedema, back pain, abdominal pain, diarrhea,
nausea, sinusitis
Nursing considerations/ Patient Teaching Take at the same time each day, take missed doses as soon as possible, avoid salt substitutes, get up
slowly to avoid orthostatic hypotension, avoid driving until medication response is known, notify health care professional if swelling
occurs
Adverse/ Side effects dizziness,

Name Simvastatin

Concentration

(Zocor)

Dosage Amount 40mg

Route PO

Frequency QHS

Pharmaceutical class hmg coa reductase inhibitor

Home

Hospital

or

Both

Indication hypercholesterolemia
Adverse/ Side effects abdominal

cramps, constipation, diarrhea, heartburn, nausea, rashes, hyperglycemia, rhabdomyolysis, dizziness,


confusion, headache, weakness
Nursing considerations/ Patient Teaching Avoid drinking more than 1 qt of grapefruit juice a day, exercise and diet changes, notify health care
professional if unexplained muscle pain, wear sunscreen
Name Ondansetron
Route IV

Concentration

(Zofran)

Dosage Amount 4mg

push

Frequency Q6H

Pharmaceutical class antiemetics

Home

Hospital

or

Both

Indication nausea
Adverse/ Side effects headache,

dizziness, drowsiness, fatigue, weakness, constipation, diarrhea, dry mouth, abdominal pain,

extrapyramidal reactions
Nursing considerations/ Patient Teaching Take
Name Acetaminophen
Route

(Tylenlol)

as directed, notify health care professional of involuntary movement of eyes, face, or limbs
Concentration

Dosage Amount 650mg

PO

Frequency Q4H

Pharmaceutical class nonopiod


Indication mild

analgesics

Home

Hospital

or

Both

pain

Adverse/ Side effects renal

failure, neutropenia, rash, urticarial, toxic epidermal necrolysis


Nursing considerations/ Patient Teaching Do not take more than the recommended dose, discontinue if rash develops, may alter blood glucose
in diabetic patients
Name Albuterol
Route

ipratropium (Duoneb)

Concentration

Dosage Amount 3

Inhalation

ml

Frequency Q4

Pharmaceutical class bronchodilators

Home

Hospital

or

Both

Indication Dyspnea
Adverse/ Side effects dizziness,

headache, nervousness, bronchospasm, cough, hypotension, nausea, rash


Nursing considerations/ Patient Teaching Instruct patient in proper use of nebulizer, rinse mouth after using
Name Insulin

lispro (Humalog)

Concentration

Dosage Amount sliding

Route SubQ

Frequency A.C.

Pharmaceutical class pancreatics


Indication Type

Home

Hospital

or

scale

(before meals)
Both

II diabetes

Adverse/ Side effects hypoglycemia,

pruritis, erythema, swelling anaphylaxis


Nursing considerations/ Patient Teaching Instruct proper technique for administering insulin, rotate sites, insulin is not a cure, teach signs and

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symptoms of hypoglycemia and hyperglycemia, carry source of sugar, proper testing glucose

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5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Analysis of home diet (Compare to My Plate and
Diet patient follows at home?
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patient has hypertension so she should control the
amount of sodium she consumes. Patient is diabetic and
needs to check blood sugar throughout the day.
Breakfast: Kelloggs Raisin Bran Cereal, 1 banana
The 24-hour average home diet is 1933 calories. The limit
is 2000 calories. The patient is very close to going over the
2000 calorie limit.
Patient consumes 75 grams of sugar with a daily limit of 50
grams. Soda has sugar and adds extra calories. Switching to
water or tea will lower calorie intake and lower sugar
intake.
Lunch: Ham and cheese sandwich with white bread, 1
Patient went over daily sodium limit of 2300 milligrams by
serving size bag of potato chips
1000 milligrams. It is important for the patient to lower her
sodium intake. Switching potato chips for carrots or another
type of vegetable will lower sodium intake and increase
vegetable intake.
2 ounces over protein limit. The patient should avoid eating
anymore protein. Too much protein can negatively affect
the kidneys and cause weight gain. This patients BMI is in
the overweight range so she shouldnt gain more weight.
The patients kidneys are already unhealthy (GFR 38.9).
Dinner: Grilled steak, 1 cup of asparagus
Meets fruit requirement for the day.
1 cup under for vegetables. Eating vegetables with lunch is
a healthier choice than potato chips. Adding lettuce and
tomato onto the sandwich at lunchtime will increase
vegetable intake.
Snacks: Large scoop of chocolate ice cream
2 ounces under daily requirement for grains. It would be a
good idea to use whole wheat bread for her sandwich at
lunch.
2 cups under dairy limit. 80% of daily limit for cheese is
consumed. 20% of daily limit for milk and yogurt is
consumed. Adding yogurt to the diet will increase the
amount of dairy eaten.
Liquids (include alcohol): 1 cup of apple juice, 1 can of
Pepsi, 1 bottle of beer
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?
How do you generally cope with stress? or What do you do when you are upset?

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When I am stressed I like to color and snuggle with my pets. I have a few coloring books with me right now.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I have been anxious. I want to go home.

+2 DOMESTIC VIOLENCE ASSESSMENT


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

Integrity is a sense of integrity and fulfillment; willingness to face death; wisdom and despair is the
dissatisfaction with life; denial of or despair over prospect of death (Halter, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is in the ego integrity stage. The patient had a successful career. The patient states I loved my job
and I am happy that I was able to help people. The patient enjoys talking about her family. The patient states I
have the smartest grandkids. I teach them to put school first and they are doing very well. I got to be a mother
and a grandmother. That is all I ever wanted.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The patients condition has had no impact on the patients developmental stage of life.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The doctor says that my birth defect caused it. Fluid from my liver is going into my lungs or something.
What does your illness mean to you?
It means that I cant be home. I miss my pets.

+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

University of South Florida College of Nursing Revision September 2014

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? ________No_______________________________________
Have you or a partner ever had an abnormal pap smear?
__________No___________________________________________ Have you or your partner received the Gardasil
(HPV) vaccination? ___________No________________________________
Are you currently sexually active? ___Yes________________________ If yes, are you in a monogamous relationship?
________Yes____________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _____Nothing_____________________________
How long have you been with your current partner? Since I was 20.___________________________________
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? _Religion is everything to me. I pray every day
and I go to church every Sunday. God has given me a beautiful family and amazing doctors to take care of
me.____________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?

___I wish I could go to church. My faith keeps me strong and I will get over all of these health issues. I have a
lot of people praying for
me.___________________________________________________________________________________________________
______________________________________________________________________________________________________

+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
2 packs a day
Pack Years: 74
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Yes
No
For how many years? 37 years
(age 30

thru 67

If applicable, when did the


patient quit?
4 months ago
Has the patient ever tried to quit? Yes, nothing
If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What?
How much? 1 bottle
Beer
Volume: 24 fluid ounces
Frequency: every few days
If applicable, when did the patient quit?

No
For how many years? 42
(age 25

thru 67

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

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: 30
Bathing routine: regularly
Other:

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 3
x/day
Routine dentist visits
1 x/year
Vision screening
Other: Patient states that she hasnt had a
vision screening in a while, I have great
vision!

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: nausea when taking medication
without nausea medication, patient has
never had a colonoscopy, edema on
abdomen, hepatomegaly, splenomegaly

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: A+
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 4
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
Type: 2
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Other: Chronic kidney disease, stage 3
(GFR 38.9)

Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 1/21/16
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? 3 years ago
menstrual cycle
regular
irregular
menarche
14
age
menopause around 50 age
Date of last Mammogram &Result: a few
years ago, normal
Date of DEXA Bone Density & Result:

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

Patient states that she has never had an


infection of her genitalia, patient does not
have a menstrual cycle, patient has never
had a bone density test

Cardiovascular
Hypertension
Hyperlipidemia

MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?

Mental Illness
Depression
Schizophrenia

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10

Chest pain / Angina


Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 1/20/16
Other:

Date of last prostate exam?


BPH
Urinary Retention

Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
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?
No

Any other questions or comments that your patient would like you to know?
The patient has two cats, two dogs, and a bird that she misses very much

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11

10 PHYSICAL EXAMINATION:
General Survey:
Height 167.64 cm
Weight 81.9 kg
BMI 29
Pain: (include rating and
Patient is a welllocation)
Pulse 64
Blood Pressure: (include location)
developed 67 y.o. female Respirations
128/59 Left arm
who is alert & oriented x 18
5/10, right side where the
3
chest tube is inserted
2/10 breathing (upon
Temperature: (route
SpO2 98%
Is the patient on Room Air or O2 No
inhalation)
taken?)
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
Central access device Type: Midline
Location: cephalic vein right upper
Date inserted: 2/21/16
Fluids infusing?
no
yes - what?
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 / 3 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
Comments: No whisper test done, patient can hear
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:
RUL: D
LUL: CL
RML: CR
LLL: CL
RLL: CR

Chest expansion

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

Comments: Left side expands more than right side, fremitus over right lung decreased, percussion dull over right side, no
sputum production, slight difficulty breathing, patient describes painful inhalations 2/10
Chest tube inserted 1/21/16 right lateral, fluid is yellow and cloudy, output 600cc

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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)
Normal sinus rhythm

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: 3
Femoral:
Popliteal:
DP: 3
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: abdomen
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
Only radial and dorsalis pedis pulses assessed
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 1
/ 25 16
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red

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13

Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe: Hepatomegaly and splenomegaly present

Not assessed, patient alert, oriented, denies problems

GU
Urine output:
Clear
Cloudy
Color: yellow
Previous 24 hour output: 550
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness CVA punch not performed
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at ____5___ RUE ___5____ LUE ____5___ RLE

mLs N/A

& ____5___ in LLE

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

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

Romberg not performed, stereognosis not performed, graphesthesia not performed, proprioception not performed, Babinski not performed, ankle clonus
not performed, DTR not performed

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):

Lab
Chest X-ray

Dates
1/20/16 1/ 21/16 1/23/16

NM liver/spleen planar
within spleen

1/21/16

Glomerular filtration rate

Trend
Fluid in lungs, chest tube
placed correctly, less
fluid in lungs
Hepatomegaly,
splenomegaly,
homogenous increased
uptake throughout the
liver, increased uptake
The GFR is consistently ~
38.9

Analysis
To check for fluid
Visualize changes to liver
and spleen

The glomerular filtration


rate is a test used to check
38.9 mL/min 38 mL/min 1/26/16 1/23/16 1/20/16
kidney function.
38.9 mL/min
Chronic kidney disease
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14

Glucose
101 91 120
Total protein
5.9 g/dL 5.7 g/dL 5.9g/dL

1/26/16 1/23/16 1/20/16

Normal (6-8) g/dL

Creatinine
1.4 mg/dL 1.6 mg/dL 1.6 mg/dL

Normal (0.6-1.3 mg/dL)


1/26/16 1/23/16 1/20/16

BUN

Patients BUN levels


have been high. BUN
levels are increased in
patients with diabetes.

23 mg/dL 26 mg/dL 23 mg/dL

Normal (6-20mg/dL)

Patients glucose levels


are normal for her
baseline glucose levels
The total protein levels
are close to the normal
range. Decreased total
protein levels occur with
cirrhosis related to a
damaged liver that cannot
synthesize adequate
amount of protein.
The patients creatinine
levels are a little high.
The values are close to
the normal range.
Creatinine levels increase
with renal disease.

1/26/16 1/23/16 1/20/16

stage 3 (GFR 30-59


mL/min per 1.73 m2)
Patient is Type II diabetic
and the glucose level
needs to be monitored.
Total protein measures
the amount of protein in
the blood. Albumin and
globulin are included.
The liver produces
albumin.
Creatinine is used to
assess renal function.
Creatine is from the
skeletal muscle, where it
participates in metabolic
reactions. A small amount
of creatine is converted to
creatinine and is excreted
in the kidneys. This level
determines the rate at
which the kidneys are
clearing creatinine from
the blood.
BUN is used to assess
renal function. Urea is
formed in the liver from
ammonia and excreted by
the kidneys as an end
product of protein
metabolism. Blood urea
nitrogen levels reflect the
balance of nitrogen
ingested and excreted.

+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.)
Respiratory therapy to improve breathing pattern, heart healthy diet, accu check Q4, surgery consult for possible
TIPS procedure, gastroenterologist consult to evaluate liver, chest tube
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Ineffective breathing pattern r/t pain as evidenced by patient stating that is hurts to breath
2. Excess fluid volume r/t compromised regulatory mechanisms of liver as evidenced by fluid in the lungs

University of South Florida College of Nursing Revision September 2014

15

3. Impaired gas exchange r/t respiratory fatigue secondary to pleural effusion as evidenced by patient stating that is difficult
to breath
4. Acute pain r/t chest tube and excess fluid volume as evidenced by patient stating pain 5/10 at her chest tube site and 2/10
upon inhalation
5. Disturbed body image r/t chest tube as evidenced by patients stating, I am embarrassed that I have a tube coming out of
my chest.

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16

15 CARE PLAN
Nursing Diagnosis: Ineffective breathing pattern r/t pain as evidenced by patient stating that is hurts to breathe
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions
Evaluation of Goal on Day
Achieve Goal
Provide References
Care is Provided
By end of hospitalization
Monitor vital signs
To evaluate patients baseline
Vital signs consistent
patient will report ability to
compared to new data, how is
throughout shift, dyspnea
breathe comfortably
dyspnea affecting vital signs
causes tachycardia for a few
minutes and then resolves
Monitor respiratory rate, depth, To evaluate changes compared
and ease of respirations
to patients baseline
Respiratory rate consistently
18, ease of respirations
Auscultate breath sounds
Abnormal breath sounds
increased throughout day
(absent, crackles, and wheezes) Crackles on right side didnt
indicate respiratory pathology
resolve by the end of the day
associated with an altered
breathing pattern
Relaxing environment
Decrease anxiety associated
Light turned off in room,
with acute dyspneic state
patient colored pictures in her
coloring books, breathing
Elevate head of patients bed
comfortably
An upright position facilitates
lung expansion
Patient reported breathing is
Consult respiratory therapy
easier in the Fowlers position
Breathing treatments can
relieve dyspnea
Patient reported dyspnea
resolved after breathing
treatment
Identify and avoid factors that
exacerbate episodes of

Administer medication*

Prescribed medications might


prevent episodes of ineffective

Patient felt that she could


breathe better after having pain

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17

ineffective breathing pattern by


end of shift

breathing pattern
Elevate head of patients bed

Demonstrate ability to perform


pursed-lip breathing and
controlled breathing

Teach patient how to perform


pursed-lip breathing

Maintain normal oxygen


saturation level throughout shift

Administer supplemental
oxygen as needed
Consult respiratory therapy
Monitor respiratory rate, depth,
and ease of respirations
Pursed lip-breathing

Demonstrate a breathing pattern


that supports blood gas results
within the clients normal
parameters

Monitor respiratory rate, depth,


and ease of respirations
Elevate head of patients bed

An upright position facilitates


lung expansion

Pursed-lip breathing results in


increased use of intercostal
muscles, decreased respiratory
rate, increased tidal volume,
and improved oxygen
saturation level
Supplemental oxygen can assist
in raising O2 saturation if it
lowers <95%
Breathing treatments can
relieve dyspnea and improve
oxygen saturation
To evaluate changes compared
to patients baseline
Pursed-lip breathing results in
increased use of intercostal
muscles, decreased respiratory
rate, increased tidal volume,
and improved oxygen
saturation level
To evaluate changes compared
to patients baseline
An upright position facilitates
lung expansion

medication, pain aggravated


dyspnea
Patient reported that she
becomes short of breath laying
down, elevating head of bed
increased ease of respirations
Patient was able to demonstrate
pursed-lip breathing and
controlled breathing, patient
reported that it helped with her
dyspnea
Patient did not require any
supplemental oxygen, O2
saturation 98% throughout shift
Breathing treatments resolved
dyspnea, O2 remained 98%
Oxygen saturation did not
change, ease of respirations
improved throughout shift
Patient was able to demonstrate
pursed-lip breathing and
controlled breathing, patient
reported that it helped with her
dyspnea
Respiratory rate consistently
18, ease of respirations
increased throughout day
Patient reported breathing is
easier in the Fowlers position

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18

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
Nursing Diagnosis: Excess fluid volume r/t compromised regulatory mechanisms of liver as evidenced by fluid in the lungs
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions
Evaluation of Goal on Day
Achieve Goal
Provide References
Care is Provided
Patient maintains clear lung
Listen to lung sounds for
Abnormal breath sounds
Patient breathing easier
sounds by end of shift
crackles, monitor respirations for (absent, crackles, and wheezes) throughout the day, crackles
effort, and determine the
indicate respiratory pathology
on right side do not resolve by
presence and severity of
associated with an altered
end of shift
orthopnea
breathing pattern
Maintain body weight
appropriate for the client by
end of hospitalization

Monitor intake and output


Monitor daily weight for sudden
increases; use same scale and
type of clothing at same time

Accurately measuring intake


and output is important for the
client with fluid volume
overload
It is important to weigh patient
with fluid overload to ensure

University of South Florida College of Nursing Revision September 2014

Patient had 300ml urine output


in 10 hours, normal output
Patient weight has not changed
since 1/20/16

19

each day

that fluid is not being retained

Restrict fluid intake

Fluid restriction may decrease


intravascular volume
Educate patient and their
family to contact a health care
professional if fluid excess
returns

Patient and family will describe


signs and symptoms of excess
fluid volume and actions to
take if they occur by end of
shift

Patient education about fluid


excess

Explain actions that that are


needed to treat or prevent
excess fluid volume including
fluid and dietary restrictions,
and medications by end of shift

Provide a restricted-sodium diet


as appropriate if ordered*

Effusion resolves by end of


hospitalization

Monitor for the development of


conditions that increase the
clients risk for excess fluid
volume

Many clients with fluid


overload have acute kidney
disease, and fluid balance is an
important indicator of
outcomes, with increased
morbidity and mortality in
clients with fluid overload

Monitor chest tube

Record chest tube output to


ensure that is it working
efficiently

Restrict fluid intake

Restricting sodium in the diet


will favor the renal excretion
of excess fluid
Fluid restriction may decrease
intravascular volume

Patient is compliant to
restricting her fluid intake
Patient and family know to
contact health care
professional if weight
increases by 2 pounds in a day
and if shortness of breath
comes back
Patient started on heart healthy
diet
Patient is compliant to
restricting her fluid intake
Patient has chronic kidney
disease and cirrhosis of her
liver

600cc output from chest tube

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
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20

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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21

References
Ackley, B. (2010). Nursing Diagnosis Handbook: An Evidence-based Guide to Planning Care (9th Ed). Maryland Heights, Missouri:
Mosby.
Bouros, D. (2004). Pleural disease. New York: Marcel Dekker, Inc.
Food Tracker. (n.d.). Retrieved November 4, 2015, from https://www.supertracker.usda.gov/foodtracker.aspx
Gins, P., Arroyo, V., Rods, J., & Schrier, R. (2005). Ascites and Renal Dysfunction in Liver Disease: Pathogenesis, Diagnosis, and
Treatment, Second Edition. Malden, MA: Blackwell Publishing.
Halter, M. (2014). Varcarolis' foundations of psychiatric mental health nursing: A clinical approach. (7th ed., p. 23). St. Louis,
Missouri: Elsevier.
Unbound Medicine. (2014). Nursing Central (Version 1.24 (414)) [Mobile application software]. Retrieved
from: http://nursing.unboundmedicine.com/nursingcentral

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