Final Pat 5

UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
Student: Nicole Mercedes
MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Assignment Date: 04/07/2016

Agency: St. Josephs Hospital
Patient Initials: MB
Age: 83
Admission Date: 04/05/2016
Gender:
Marital Status: Married
Primary Medical Diagnosis Cellulitis
Female
Primary Language: English

Level of Education: College
Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired; Elementary School

Teacher, Social Worker
Number/ages children/siblings: 2 Daughters and 1 son.
Served/Veteran: No
If yes: Ever deployed? Yes or No N/A
Code Status: Full Code
Living Arrangements: Lives home with husband and dog.
Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: N/A
Procedure: N/A
Culture/ Ethnicity /Nationality: English, Scottish, and Irish.

Religion: Episcopal
Type of Insurance: Medicare
1 CHIEF COMPLAINT:
I went to the clinic I have been going to, to get my check-ups after surgery and they suggested I put a compression bandage on my leg because it was swollen. Its been swollen for a while. I put it on, and somehow I started getting blisters
on my leg that then opened and turned into ulcers. Then Tuesday it advanced and started getting infected and
spreading fast the pain was unbearable so I came in.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient is an 83 Y/O female admitted 4/05/16 with redness, swelling, temperature increase of the anterior fibula/tibia
portion of the right leg. These symptoms developed after applying a tight fitting bandage for edema shes had for 2
months on this leg. She has a history of intermittent dependent edema of both legs after removal of tumor in left leg.
After applying the bandage, the patient began to develop blisters which opened and turned into ulcers that led to the
symptoms patient was admitted with. Admitting diagnosis for the patient is cellulitis. Patient had (-)venous Doppler done
in the ER. Current plan is to treat the cellulitis with vancomycin and third generation cephalosporins, DVT
prophylaxis, leg elevation, and to monitor to see if it spreads along the leg. There is also plans to do an arterial Doppler,
and to get CPK as well as BNP levels to evaluate cardiac function and chronic edema.
OLDCARTS for Cellulitis SX.
Fever, redness, swelling, bruising and throbbing pain of the anterior tibia/fibula of the R. Leg began on Tuesday 4/5/16,
these symptoms have lasted for three days at time of interview. Patient indicated that pain is aggravated when standing up.
Patient indicated that she didnt try anything at home to relieve pain, she came straight to ER when symptoms got worse.
University of South Florida College of Nursing Revision September 2014
At time of interview patient indicated that while laying down her pain was a 0/10 but that standing up on the leg,
increased the pain to an 8/10 throbbing pain.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Father
87
Mother
88
Brother
80
Tumor
Stroke
Stomach Ulcers
Seizures
Kidney
Problems
Mental Health
Problems
Hypertension
(angina, MI, DVT etc.)
Heart Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Cause
of
Death
(if
applicable)
Kidney
disease
Colon
Cancer
Environmental
Allergies
Operation or Illness
Partial hysterectomy
Hypertension treated with Diovan (valsartan)
Hyperlipidemia treated with Zocor (simvastatin)
Hypothyroidism treated with Synthroid (levothyroxine)
Arthritis
Osteoporosis
Intermittent dependent edema
Patient had resection of tumor in left anterior fibula/tibia. forgot to get the exact name of procedure
Alcoholism
2
FAMILY
MEDICAL
HISTORY
Age (in years)
Date
Unknown date
Unknown date
Unknown date
Unknown date
Unknown date
Unknown date
Unknown date
December 2015
Alive
Sister
relationship
relationship
relationship
Comments Pt. did not recall age of onset for mother and father. Pt indicated that brother had melanoma and prostate cancer
around six years ago.
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) Pt. indicated within the past 5 years.
Adult Tetanus (Date) Is within 10 years? Past 5 years.
Influenza (flu) (Date) Is within 1 years? November 2015.
Pneumococcal (pneumonia) (Date) Is within 5 years? Past 5 years.
Have you had any other vaccines given for international travel or
occupational purposes? Please List
YES
NO
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS
NAME of
Causative Agent
Type of Reaction (describe explicitly)
NKA
Medications
Other (food, tape,

latex, dye, etc.)
Pt. indicated envirnmental allergies

during spring and
fall.
Runny nose, itching, sneezing.
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)
The patients diagnosis on this admission was cellulitis. As the suffix of the word cellulitis suggests, this is a type of
infection/inflammation that involves both skin and subcutaneous tissue, without involving any muscle tissue (Osborn,
Wraa, Watson & Holleran, 2014). Risk factors or in other words, people more susceptible to acquiring this infection are
those with any type of openings in the skin through which organisms like staphylococcus aureus or streptococcus can
gain entry. Examples include people with lacerations, insect bites, surgical wounds, and trauma wounds (Osborn et al.,
2014). People with decreased immunity, such as those receiving chemotherapy, as well as people who have venous
insufficiency or obesity are also at risk for acquiring this type of infection (Osborn et al., 2014). Some of the following
symptoms are usually noted at location of the cellulitis: erythema, swelling, tenderness, vesicles, blisters, warmness, and
tightness. Along with these symptoms the patient can have a systemic fever. In order to diagnose this condition, white
blood cell counts and wound cultures are taken and looked at in combination with the symptoms. Treatment involves
elevation of the location where the cellulitis is, antibiotics specific to the causative organism (determined by wound
culture), and wound care. According to Osborn et al., use of cool Burrows solution in wound treatment can be helpful in
alleviating tension and pain when blisters have developed (2014). If patient is treated for cellulitis, the prognosis is good
but if the cellulitis is left untreated the infection can travel to the bloodstream and cause sepsis. There are no genetic
factors associated with this condition.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name
Concentration
Dosage Amount
Vancocin (vancomycin)
750 mg = 250 mL/hr
750 mg
Route
Frequency
IVPB
Q24 hr., infused over 1 hour.
Pharmaceutical class
Home
Hospital
or
Both
Anti-infective (Therapeutic class)
Indication
Indicated in my patient for cellulitis skin infection, that seemed to be spreading along her leg rapidly from the time of symptom onset. According to nursing central, its
used to treat potentially life threatening infections that cant be controlled with less toxic medications. This medication is broad-spectrum, and may explain why the
patient was on it before the wound culture results came back. She was subsequently taken off when the results came in.
Adverse/ Side effects
The common side effects of vancomycin include nephrotoxicity, and phlebitis. It can also cause hypotension, ototoxicity (noted by ringing ears, vertigo, or hearing loss)
as well as neck and back pain. More severe, life-threatening symptoms include: anaphylaxis, chills, and fever (red man syndrome).
Nursing considerations/ Patient Teaching
As far as nursing considerations, its important to double check infusion times, and the patient during the infusion since infusing too fast can cause red man syndrome.
Patient teaching should warn of hypersensitivity signs to report such as tinnitus, vertigo and hearing loss. Since the drug can cause nephrotoxicity its important to stay up
to date with kidney function tests such as BUN, creatinine and GFR especially if the patient is on it for a few days. In assessment close attention should be paid to IVs for
signs of phlebitis (redness, swelling, and pain).
Name
Concentration
Dosage Amount
Zosyn Dextrose 5% in 50mL (piperacillin/tazobactam)
3.375g = 50 mL (given over 30 minutes or 100mL/hr.) 3.375g
Route
Frequency
IVPB
Q6 hr.
Home
Hospital
or
Both
Extended Spectrum Penicillin
Indication
This medication can be used for appendicitis, peritonitis, gynecologic infections, and community acquired/nosocomial pneumonia. In my patient it was indicated for a her
cellulitis (skin infection), which is the second listed use for this medication.
Common symptoms include diarrhea, rashes, pain, and phlebitis at the IV site. Blood dyscrasias and drug-induced hepatitis can also occur. Some life threatening
symptoms include seizures (when given in high doses), clostridium difficile, anaphylaxis, serum sickness (cause skin rash, stiff joints, and fever), Stevens Johnson
syndrome, and toxic epidermal necrolysis.
Patient teaching should advice patient to report any rashes or signs of superinfection like black furry tongue, diarrhea or foul smelling stool, vaginal discharge and itching.
Patient/nurse should also check stool for any color change, blood, pus or mucus which can indicate clostridium dificile. In assessment, Id pay close attention to IV sites,
skin. As far as lab tests CBC would be important to look at it since this medication can cause decreasing WBC and platelets, and Id also look at liver function tests such
as ALT and AST.
Name
Concentration
Dosage Amount
Zocor (simvastatin)
40 mg
40 mg =1 tab
Route
Frequency
PO; by mouth
1x daily h.s (at night)
Home
Hospital
or
Both
Hmg coa reductase inhibitors (statin)
Indication
In my patient, this medication is indicated for hyperlipidemia.
Common side effects include abdominal cramps, constipations, diarrhea, flatus, heartburn, and rashes. This medication can also cause itching, and hyperglycemia. The
only listed adverse side effect is rhabdomyolysis.
For this medication Id monitor hyperglycemia, and monitor bowel movements closely. Id probably check if I had other PRN medications to deal with symptoms such
constipation or heartburn. For patient teaching, Id advise the patient to take the medication as prescribed, to avoid grapefruit juice since this may increase toxicity, to
continue other diet regimens to help with hyperlipidemia, to use SPF and protective clothes in sunlight, and to let HCP know of any OTC medications theyre taking. Id
also warn my patient to immediately seek HCP if they develop symptoms of rhabdomyolysis such as muscle aches, tenderness or weakness along with decreased urination
and pinkish urine.
Name
Concentration
Dosage Amount
Synthroid (levothyroxine)
25 mg
25 = 1 tab
Route
Frequency
PO
1x daily
Home
Hospital
or
Both
Thyroid preparations
Indication
This medication is indicated for thyroid supplementation in hypothyroidism, which my patient has.
Nursing central notes that side effects for this medication only occur when excessive doses cause iatrogenic hyperthyroidism. Some side effects include headache,
tachycardia, sweating, heat intolerance, weight loss, tachycardia, arrhythmias, and angina pectoris.
For this medication its important to teach the patient to take it at the same time every day. Forgotten doses should be taken as soon as remembered unless its almost time
for the next one. If 2-3 doses are missed, the patient needs to tell the HCP. This medication should never be discontinued without first talking to HCP. Patient should be
warned that this medication is a life-long treatment, it does not cure hypothyroidism. Hyperthyroidism symptoms like headache, nervousness, tachycardia, weight loss,
palpitations, excessive sweating and diarrhea should be reported because they can be indicative of over dosing. Patient teaching should also caution patient to not take
this medication within four-hours of antacids, iron or calcium supplements since they may inhibit absorption. Finally patients should let all HCP that theyre on this
medication, and yearly follow-up appointment to check for the effectiveness of this medication should be emphasized.
Name
Concentration
Dosage Amount
Lovenox (enoxaparin)
40 mg = 0.4 mL
40 mg
Route
Frequency
Subcutaneous Injection
1x daily
Home
Hospital
or
Both
Anti-thrombotics// Low molecular weight heparins
Indication
For my patient this medication was used as prophylaxis for deep venous thrombosis (DVT). It can also be indicated for venous thromboembolism (VTE) and pulmonary
embolism (PE) in surgical/medical patients. Its not only used for prophylaxis of DVT/PE but also for the treatment of these conditions. Additionally, Lovenox is used in
prevention of ischemic complication from unstable and angina and non ST-segment elevation MI, as well as treatment of acute- ST segment elevation MI.
Common side effects for this medication include bleeding and anemia. Some other side effects are constipation, itching, rash, hematomas at injection site, hyperkalemia,
urinary retention and edema.

Patient should be taught to report signs of unusual bleeding, bruising, dizziness, itching, fever, swelling or difficulty breathing immediately. Patients should also be
warned to not take aspirin, naproxen or ibuprofen without first talking to HCP while on this medication. As a nurse, Id check the potassium levels for my patient while on
theyre on this medication and make sure to do a thorough GI and GU assessment as always. Since this medication can cause anemia I could also do something teaching
on high iron foods to combat any possibility of anemia.
Name
Concentration
Dosage Amount
Cymbalta (DUloxetine)
30mg
30 mg = 1 capsule
Route
Frequency
PO
1x daily
Home
Hospital
or
Both
Selective serotonin and norepinephrine reuptake inhibitors (SSNRI)
Indication
This medication is indicated for major depressive disorder, diabetic peripheral neuropathic pain, generalized anxiety disorder, fibromyalgia, and chronic musculoskeletal
pain. My patient had neuropathic pain listed in her past medical history even though she does not have diabetes, so I assume that is why she is on this medication.
The common symptoms for this medication include fatigue, drowsiness, insomnia, decreased appetite, constipation, dry mouth, dysuria, and increased sweating. Some of
the more adverse effects include neuroleptic malignant syndrome (high fever, irregular pulse, tachycardia, tachypnea, altered mental status, and unstable BP), seizures,
suicidal thoughts, hepatotoxicity, serotonin syndrome, erythema multiforme and Stevens Johnson syndrome.
Patient teaching should instruct patient to take medication at same time every day, and to never abruptly discontinue the medication since stopping it can cause symptoms
such as headache, dizziness, paresthesia, etc. This medication should always be titrated down by HCP when going of it. Patient family should be part of teaching, and
should be taught to look out for anxiety, agitation, panic attacks, akathisia, mania, and suicidal thoughts. If any of these occur, they should be reported to HCP. This
medication by itself and in combination with blood pressure medications can cause orthostatic hypotension so patient should be taught to get up slowly. Patients/nurse
should look out for symptoms of serotonin syndrome such as mental status changes, tachycardia, labile BP, hyperthermia, hyperreflexia, incoordination, as well as n/v/d.
With serotonin syndrome, liver damage can also occur so patient and nurse should also look for any pruritus, dark urine, jaundice, right upper quadrant pain, and
unexplained flu-like symptoms. Any of these should be reported to HCP immediately. Along with these patient should be warned not to drink or drive while taking this
medication.
Name
Concentration
Dosage Amount
Zyrtec (cetirizine)
10 mg
10 mg = 1 tab
Route
Frequency
PO
1x daily
Home
Hospital
or
Both
Piperazines (peripherally selective)
Indication
This medication is used for relief of allergic symptoms caused by histamine release. In my patient this medication is indicated for season (spring/fall time) allergies.
This medication can cause dizziness, drowsiness, fatigue, pharyngitis, and dry mouth.
This medication can cause drowsiness so patient should avoid driving until they know what effect it has on them. Patient should also avoid use of alcohol with this
medication. If dizziness occurs for more than two weeks, patient should contact HCP. As a nurse, Id encourage oral hygiene, frequent water rinses, lip moisturizer, and
sugarless gum to help combat the dry mouth symptoms.
Name
Concentration
Dosage Amount
Pulmicort Flexhaler (budesonide)
180 mcg
180 mcg = 2 inhalations
Route
Frequency
Inhaler
2x daily
Home
Hospital
or
Both
Corticosteroids
Indication
This medication is used for chronic control of persistent bronchial asthma. Patient has history of asthma.
The common side effects for this medication include headache, and otitis media. Other symptoms include oropharyngeal fungal infections, cough, bronchospasms, weight
gain and back pain. The only adverse effect listed in anaphylaxis.
As the nurse, since this a corticosteroid Id monitor glucose closely since these kinds of medication can cause hyperglycemia. Id then teach the patient to take this
medication as instructed, and to not discontinue use without contacting the HCP. If patient is on a bronchodilator while on this medication, the bronchodilator should be
used five minutes prior to this medication to open the airway up so that the corticosteroids can get to where they need to go and function. Patient should be cautioned that
this medication (corticosteroid) is not meant for treatment of acute asthma attacks. As far as patient teaching with use of the inhaler, the patient should be taught to rinse
their mouth after each use to avoid candidiasis. Proper prepping and use of the device should also be demonstrated to the patient. For example, patient should be taught to
never shake the inhaler to prep it. Finally, patient should be aware of and report signs of anaphylaxis such as rash, severe itching, swelling of face, mouth, or tongue and
trouble with breathing, chest pain and anxiety.
Name
Concentration
Dosage Amount
Diovan (Valsartan)
320 mg
320 mg = tab
Route
Frequency
PO
1x daily
Home
Hospital
or
Both
Angiotensin II receptor antagonists
Indication
Indicated for management of hypertension and treatment of heart failure. My patient had hypertension, and according to BNP results, on this admission, mild heart
failure.
The common side effect for this medication is dizziness. Some other side effects include hyperkalemia, hypotension, impaired renal function and pharyngitis. The only
adverse side effect listed is angioedema.
As with all medications, patient should be instructed to take as directed and never abruptly stop a medication without consulting the HCP. For this medication patient
should avoid salt substitutes containing sodium or foods with high level of potassium, sudden position changes (orthostatic hypotension), and activities such as alcohol
drinking, standing for long periods of time and hot weather which can also influence orthostatic hypotension. Pt. should warn HCP of any OTC medication theyre taking
when this medication is prescribed and should also be advised to keep up with follow up appointments to monitor whether or not the medication is having intended
effects. Since angioedema is an adverse side effect patient and nurse should know the symptoms for it such as swelling of face, eyes, lips, tongue or difficulty
swallowing/breathing. Lifestyle modification and diet change should also always be mentioned to patients with hypertension as adjunctive therapy to the blood pressure
management.
Name
Concentration
Dosage Amount
Xopenex HFA (levalbuterol)
Not mentioned in the home medication section.
Not mentioned in the home medication section.
Route
Frequency
Inhaler
Q6 PRN
Home
Hospital
or
Both
Adrenergic (therapeutic class: bronchodilator)
Indication
Indicated for bronchospasm due to reversible airway disease. So this medication would probably be used for an acute asthma attack.
Some of the listed symptoms for this medication include tachycardia, hyperglycemia, hypokalemia, tremor, dizziness, headache and increased couch. The only adverse
effect listed is paradoxical bronchospasms.
Monitoring of glucose and potassium are both important for this medication. In terms of teaching for this medication, patient should be instructed on proper use and
preparation of a metered dose inhaler. Its also important to emphasize not over-dosing since it can cause paradoxical bronchospasms or decrease effect of the medication
over time. If shortness of breath isnt alleviated or if its accompanied by sweating, dizziness, and palpitation patient should contact the HCP immediately. Patients should
be instructed to warn HCP of any OTC medications or herbs being taken, to avoid smoking, drinking and irritants. Finally, patient should be instructed to rinse mouth
after each use.
Name
Concentration
Dosage Amount
Protonix (pantoprazole)
40 mg
40 mg = 1 tab
Route
Frequency
PO; EC tab
2x daily; a.c (before meal)
Home
Hospital
or
Both
Proton pump inhibitors
Indication
Prophylaxis of ulcers in my patient. Also indicated for erosive esophagitis associated with GERD, maintenance of healing of erosive esophagitis, and pathologic gastric
hypersecretory conditions.
Some of the side effects for this medication include headache, hyperglycemia, abdominal pain, vitamin b-12 deficiency, and hypomagnesemia. Clostridium difficile is the
only adverse effect listed.
For this medication Id monitor blood glucose, do patient teaching on increasing dietary intake of foods with vitamin B-12. Id also teach my patient to report any signs of
superinfection such as diarrhea, foul smelling stool, mucus or pus in the stool, color change (such as tarry stool) in the stool, abdominal pain and fever. Patient should also
be warned to avoid any alcohol, aspirin, NSAIDs, or GI irritating foods as they can increase risk of GI bleed.
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Regular Diet
Diet patient follows at home? Regular Diet
24 HR average home diet:
Breakfast: 2 slices of whole wheat toast with tablespoon
of honey, 3 pieces of bacon and 1 soft scrambled egg
with 3 tablespoon of extra virgin olive oil for cooking.
Lunch: Medium broiled salmon filet (2 tablespoon of
olive oil), boiled string beans (no salt or oil), 2
tablespoon dried cranberry, 2 cups of roman lettuce,
cup of tomatoes.
Dinner: meatloaf ( hamburger meat, 2 eggs, oyster
cracker crumbs ) with string beans and baked sweet
potatoes
Analysis of home diet (Compare to My Plate and

Consider co-morbidities and cultural considerations):
The patient is an 83 Y/O female, who weighs 158
pounds, and is 56 tall. According to BMI calculation, the
patient has a BMI of 25.5 which puts her at the lower range
of the overweight category. The patient did not report
any recent weight/muscle loss or gain.
According to my plate, the patient is currently
consuming 344 calories over the allotted 2,000 calories that
would maintain her current weight. Although she is slightly
over in her daily caloric intake, she has done a great job at
meeting most of her required nutrients. Her protein intake
is at 151g, when the recommended amount is 46 g which
puts her in the OK category. This is good to see because
when her lab values were reviewed, she was in the low
Snacks: apple or banana

Liquids (include alcohol): 3 cups of silk milk total in a
day, cup of de-cafe coffee or de-caf unsweetened green
tea with 2 teaspoons of sugar.
Pt. nutrient report attached after reference page.
category for both protein and albumin which are needed for
wound healing. Her dietary fiber is also in the OK
category, protecting her from the potential of developing
diseases such as diverticulitis and diverticulosis which are
common in elders who dont consume adequate dietary
fiber. Along with protein and and dietary fiber, her
carbohydrates, saturated fats, linoleic acids, and added
sugars are all within in limits. This being said, although her
saturated fats are within limits, she is right at the border
with 9% calories coming from saturated fats out of the
allotted 10%. This is too close for my comfort and
therefore would be a topic that Id want to address since
she does have a history of hyperlipidemia (HLD). Along
with this Id address her total fat and cholesterol intake
which are both over the allotted requirement, and are again
concerning in regards to her HLD). Shes taking statins for
the HLD but diet also plays a big part as adjunctive therapy
in controlling HLD. The patients sodium was also over the
recommended less than 2300 mg by about 500 mg. This is
concerning because when the patients BNP results came
back, she was in the mild heart failure category. Added salt,
can lead to more water retention, and further decrease
cardiac function. As far as her mineral intake goes, the
patient is under the daily target requirement only in
potassium and folate. For the potassium requirement she is
only 138 mg under the require 4700 mg. Therefore, Im not
too concerned about telling her to increase potassium
especially since she has two medications, Lovenox and
Diovan, which can cause hyperkalemia. Her folate
requirement is 8 g under the required 400 g. This
mineral is useful in helping to create new proteins, RBCs,
and DNA with the help of vitamin C and vitamin B12,
which could be useful for the patients wound healing.
Although the patient has some areas to improve in, she
is doing great in meeting most of her requirements. Both
her calcium and her vitamin D are in the OK zones which
is great because she has hypothyroidism, which can be
correlated with decreased calcium levels. She also has
osteoporosis so its important for her to maintain bone
health as much as she can to slow progression of the
disease down. Its overall great that shes meeting the
requirements for both because vitamin D is needed for the
absorption of calcium. Calcium also plays an important
function in maintaining cardiac health. All of her other
minerals, with the exception of potassium and folate, are
also within in limits.
For recommendations, I would first address the
patients protein sources. I noticed that most of her protein
came from meat product sources such as ground beef, eggs
and pork. The pork she consumed came from bacon, which
is high in fats and cholesterol, as well as sodium. All of
which she is over the recommended targets in. Since she
said she also has a scrambled egg on the side, Id offer the
patient the alternative of cutting the bacon out and doing 2
hard boiled eggs instead, with one of the yolks taken out.
Taking one of the yolks out would keep her cholesterol in
check. This would cut back on the fat from the bacon, and
the added olive oil. The patients lunch seems to be great as
far as staying away from saturated, processed fats and
sodium but I would make the following recommendations
to further improve upon it. I would first advice the patient
to cut back the 2 tbsp. of oil to 1 tbsp. Id also recommend
shed consider adding dry, non-canned legumes such as
lentils, soybeans, peanuts or any kind of beans on the side
throughout the day or to her salad in this specific meal.
These are all high in protein and would decrease the
amount of meat consumption which can come with
saturated fats, cholesterol and high sodium profiles. As far
as the dinner goes, Id recommend that if the recipe allows
the patient remove one of the egg yolks to cut down on
cholesterol. Id also strongly advice that the patient look for
ground beef with lean percentages in the 90% since these
are less fatty than those 60-70% categories. If possible, Id
recommend the patient tries ground turkey which is also
very lean and contains much less fat. To help meet the
folate requirement, Id recommend the patient try adding
more dark green vegetables at dinner also. These could be
broccoli or spinach, as well as the legumes previously
mentioned. Some of my general blanket recommendations
for the patient would be to use 1-2 tsp. of oil for her dishes
instead of 2 tbsp. I would also advice her to measure out 1
tsp. of salt at the beginning of her days (which is the
recommended 2300mg), and put it in a container to use
throughout the day. This may help in preventing her from
going over the recommended amount. To add flavor to her
recipes, since shell have less salt, I would advice the
patient to look into using dry herbs and spices without
added sodium.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
My husband.
How do you generally cope with stress? or What do you do when you are upset?
I try to avoid being upset. I have very sweet children too so I talk things over with them. My two daughters
are great for that, theyre like psychologists.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
No.
+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 I might have, way back but not in my relationship with my husband
Have you ever been hit punched or slapped? Not that I remember
.
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?
N/A
.
Are you currently in a safe relationship? Yes.
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority
Despair
Identity vs.
Role Confusion/Diffusion
Trust vs. Mistrust

Intimacy vs. Isolation
Autonomy vs.
Generativity vs.
Doubt & Shame

Initiative vs. Guilt
Industry 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:
According to Ericksons stages of development, in the ego integrity side a person has determined that their life up to the point
theyre at has had meaning and that changes in health, and life circumstances as well as death are all just a part of life (Treas &
Wilkinson,2014, p. 209). Despite these changes though, they remain positive and move on to gain wisdom. On the other hand, in the
despair side the changes in health, life circumstances, and the realization of inevitable death leave the person with depression,
hopelessness, and distress (Treas & Wilkinson, 2014, p. 210).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient was in the Ego Integrity stage. During my interview with her and throughout the day, my patient didnt
seem in distress, down or depressed. Most of the day she had family visiting her and seemed very happy about that. When
I asked her questions about her marriage, and family she seemed to reflect back with happiness in regards to her life and
her marriage especially. She was proud of her kids, she expressed loving her past work when she conversed with the
Chaplin while I was in the room. She didnt seem to have any remorse or regret about the way shed lived her life. When
asked about her spirituality in regards to her health/current diagnosis she wasnt in distress when answering I just know
that theres nothing I have to worry about, its all in his hands. She accepts lifes circumstances, and dealt with them
without letting them negatively impact her.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
I dont think that my patients diagnosis/hospitalization will have an impact on her developmental stage. If anything, it
will just add to her wisdom because she accepts that lifes circumstances and changes in health can occur at any time.
While I was interviewing her, instead of showing distress, sadness or hopelessness in relation to her diagnosis she wanted
to know the cause of it, and how to care for the wound that she had. Based on the assessment that day, I feel that after
discharge she will remain in the Ego integrity stage.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I have absolutely no idea. I guess just the way my body reacts.
What does your illness mean to you?

Its a nuisance and it takes up time.
+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?
Of course I have. I have three kids.
.
Do you prefer women, men or both genders?
No definitely a straight woman.
.
Are you aware of ever having a sexually transmitted infection?
Ive never had one.
.
Have you or a partner ever had an abnormal pap smear?
I have. I had to have a partial hysterectomy
about 40 years ago.
.
Have you or your partner received the Gardasil (HPV) vaccination? Dont think so / pt. not candidate at time
vaccine was introduced.
Are you currently sexually active? No, my husband had some heart issues about thirteen years ago and that has
affected us.
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? We dont have to worry about that.
How long have you been with your current partner?
61 years
Have any medical or surgical conditions changed your ability to have sexual activity? No, not at all
.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
Not since Im not having sex. I have nothing to worry about.
10
1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
A lot
.
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
I just know that theres nothing I have to worry about, its all in his hands.
.
______________________________________________________________________________________________________
+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)
N/A
N/A
Yes
No
For how many years? X years
(age
thru
) N/A
If applicable, when did the

patient quit? N/A
Pack Years: N/A

Does anyone in the patients household smoke tobacco? If
so, what, and how much? No.
Has the patient ever tried to quit? N/A

If yes, what did they use to try to quit? N/A
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
How much? A glass when we go
What? Red wine.
out every once in a while.
Volume: 1 wine glass.
Frequency: 1-2/month
If applicable, when did the patient quit? N/A
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? N/A
For how many years? N/A
(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?
N/A
11
10 REVIEW OF SYSTEMS NARRATIVE
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen 1x daily SPF: 30
Bathing routine: 1x daily
Other:
Be sure to answer the highlighted area

HEENT
Difficulty seeing pt. indicated
astigmatism.
Cataracts or Glaucoma pt. indicated
they were taken out about 5 years ago
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
3 x/year
Vision screening
1 x/year
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? 5 years ago
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
Hematologic/Oncologic
Anemia
nocturia pt. indicates getting up

about 3x during the night.
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 7 x/day
Bladder or kidney infections
Bleeds easily
Bruises easily
Cancer
Blood Transfusions A year ago in
march.
Blood type if known: Type O
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 pt. indicated
allergy sx during fall and spring.
last CXR?
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam Yearly
Date of last gyn exam? Pt. indicated in
2015. Did not recall date.
menstrual cycle
regular
irregular
menarche
age? Pt. indicated she
could not remember.
menopause pt. indicates around 43

y/o after partial hysterectomy
Date of last Mammogram &Result:
November 2015. Within limits.
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:
12
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
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 No.
How many lbs?
Time frame?
Intentional?
How do you view your overall health? At the moment, not great.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No
Any other questions or comments that your patient would like you to know?
No.
13
10 PHYSICAL EXAMINATION:
General Survey:
Height 56
Weight 158 lb/26.3kg BMI 25.5
Pain: (include rating and
Patient is an 83 Y/O,
(overweight) location) 3/10; R. Leg
well-groomed, female
Pulse 85
Blood Pressure: (include location)
who is AXOX4.
121/71 ; Brachial
Respirations 18
Temperature: (route
SpO2
Is the patient on Room Air or O2
Room air
taken?) 95.5; axilla
93%
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
Pt. has erythematous hematoma on R. Leg extending from below the knee to above the ankle. Pt. has sharpie
markings to track any progression of infection along the leg. Pt. has wound dressing above the ankle with small
amount of tan drainage. Pt. has hematoma in left arm, around the brachial artery as well as swelling and redness in
the right arm around the brachial artery due to IV infiltration. Skin Turgor not elastic.
Central access device

Fluids infusing?
no
Type: 22G IV
yes - what?
Location: L. Forearm
Date inserted: 04/07/2016
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 3/3mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 6 inches & left ear- 6 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Yellow-tinge dentition, pt. has own teeth. Pt. has dental amalgam molar fillings.
Comments: Right eye has some redness and slight yellow due to recent sub-conjunctival hemorrhage.
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 None.
Color: white pale yellow yellow dark yellow green gray light tan brown red
None.
Lung sounds:
RUL CL
LUL CL
RML WH
LLL WH
RLL D
Chest expansion
14
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)
No JVD
PT. Not on telemetry.
Calf pain bilaterally negative-Left leg negative, Pt. could not tolerate testing in R. Leg due to cellulitis
Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: Not assessed Carotid: 3
Brachial: 3
Radial:
3
Femoral:
3
Popliteal: 2 DP: 2
PT: 2
No temporal or carotid bruits
Edema: Yes
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: R. arm near brachial artery/ R. leg anterior tibia/fibula portion 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 04 / 05 / 2016 )
Formed (Pt. indicated)
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown (Pt. indicated)
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: Abdomen firm in all four quadrants.
Not assessed, patient alert, oriented, denies problems
GU
Urine output:
Clear
Cloudy
Color: Light Yellow
Previous 24 hour output:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Musculoskeletal: o Full ROM intact in all extremities without crepitus
Strength bilaterally equal at
5 RUE
5 LUE
2 RLE &
mLs N/A
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
Unsteady gait, uses cane and 1 person assistance.
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] Not assessed
Triceps:
Biceps:
Brachioradial:
Patellar:
Achilles:
Ankle clonus: positive negative Babinski: positive negative
15
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
WBC
(+ 19.4)
(+ 16.1)
(8.8)
Dates
Wound Culture
(04/07/2016)
No trend available for

this lab value.
Lactic Acid
(1.3)
(04/05/2016)

this lab value.
(04/05/2016)
(04/06/2016)
(04/07/2016)
Trend
Theres a decreasing
trend in WBC count from
the day of admission to
the day of
assessment/interview.
Analysis
On admission, the
patients WBC count
were elevated which
correlates well with her
cellulitis dx. WBC
increase when infection is
present in the body in
attempts to fight that
infection. Patient was
placed on broadspectrums antibiotics,
until the wound culture
returned and it seems
they were effective at
containing the infection
because the count
dramatically decreased
from the day of
admission.
Wound culture showed
increased growth of
pseudomonas auruginosa
and gram-positive cocci.
A susceptibility exam is
due to follow to see
which antibiotics will be
effective in treatment
against the organism
found.
This lab value was
probably taken to rule out
the possibility of
septicemia in the patient.
Usually when the lactic
16
Protein
(-5.0)
(04/07/2016)

this lab value.
Albumin
(-2.6)
(04/07/2016)

this lab value.
BUN/Creatinine
(+46)
(20)
(04/05/2016)
(04/07/2016)
Theres a decreasing
trend from time of
admission to present day.
acid levels are elevated

this means that theres
inadequate tissue
perfusion, and that
anaerobic metabolism is
occurring instead of
aerobic (Osborn et al.,
2014). This would be
indicative of sepsis. The
usual levels for lactic acid
should be between 0.3 2.6 mmol/L for adults, so
this patient is within
range (Van Leeuwen and
Bladh, 2015).
Both protein and albumin
are important in wound
healing. Therefore, both
of them being low is
indicative that patient
may take a longer time to
recover from the
cellulitis.
Since the patient has had
edema in her right leg for
two months, as well as
having been diagnosed
with intermittent
dependent edema the
BUN/Creatinine levels
were taken to assess
kidney function. If the
kidneys werent
functioning properly
these would be elevated
and give an explanation
for the edema. At time of
admission the patients
levels were elevated but
since this test include the
BUN its not as reliable
because its not that even
intake of protein foods
can elevate the BUN. It
also seems to have
regulated back down over
time, so I dont think the
edema may be due to
kidney dysfunction.
17
BNP
(+143.4)
(04/06/2016)
C-reactive protein
(+23)
(04/07/2016)

this lab value.
The BNP was also

probably taken because of
the presenting edema the
patient has had for 2
months. The BNP
evaluates cardiac
function, and is one of the
indicators for congestive
heart failure. Usually
when there is congestive
heart failure, the pressure
in the ventricles
increases, therefore
increasing the release of
the BNP substance (Btype, 2016). My patient is
in the 100-300 category
which is indicative of
some possible heart
failure. This could
potentially explain why
shes been having the
edema but its not
conclusive on its own.
Usually the c-reactive
protein is produced by the
liver when there is an
inflammation occurring
acutely somewhere in the
body (C-reactive protein,
2015). Since its elevated
this is indicative that
there is indeed
inflammation going on in
the patients body due to
the cellulitis.
+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.)
Regular diet
Weigh 1x daily monitor any edema
Vital signs q8 hr.
Up with 1-person assistance
Monitoring margins of cellulitis
18
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Impaired Tissue integrity r/t inflammatory process damaging skin and underlying tissue as evidenced by
erythema, swelling, open blister and tightened skin.
2. Impaired walking r/t infection and pain in right leg as evidenced by unsteady, ineffective gait even with cane.
3. At risk for ineffective peripheral tissue perfusion r/t edema as evidenced by weak (2+) pedal pulses.
4. Acute pain r/t inflammatory changes in tissues from infection as evidenced by VAS score 8/10 when standing
5. Ineffective health maintenance r/t lack of knowledge regarding prevention of further incidences of infection
19
15 CARE PLAN
Nursing Diagnosis: Impaired Tissue integrity r/t inflammatory process damaging skin and underlying tissue as evidenced by erythema, swelling, open
blister and tightened skin.
Patient Goals/Outcomes
Nursing Interventions to Achieve

Goal
Patient will report any alterations
Thoroughly monitor/assess the site
in sensation/pain at sight of tissue
of the wound for any changes in
impairment during rounds every 1
increasing redness, swelling, or
hour.
warmth
Establish a baseline at the
beginning of the day for
sensation/pain.
Ask patient during rounds every
hours if they have developed any
tingling (paresthesia) or pain.
Monitor around the site for the 6
Ps: Pain, Pulse, Pallor, Paralysis,
Poikilothermia, and paresthesia
Patient will describe measures to
Monitor the patients skin
protect and heal the tissue,
care/bathing practices; what kind
including wound care by midday of of supplies do they use for this?
shift.
Teach patient/ demo how to change
the bandage, and what supplies to
use (like NS) for cleaning the
wound.
Teach patient to keep leg elevated.
Rationale for Interventions

Provide References
systematic inspection can identify
impending problems early
(Ackley & Ladwig, pp. 842).
Evaluation of Goal on Day Care

is Provided
Goal met- patient reported pain a
few times in the day, no other
alterations in sensation.
Patient should avoid harsh

cleansing agents, hot water,
extreme friction, or force, or toofrequent cleansing (Ackley &
Ladwig, pp. 842).
Goal partially met- patient was able

to describe how to protect the
wound, as well as which showering
products/practices were appropriate
for use.
No rationale available for second

intervention. Patient expressed
wanting to have knowledge in selfwound care for future reference.
Goal not met- patient wound care

not done, not able to teach her.
Leg elevation will protect the

wound, and minimize edema.
Patients wound will decrease in
size and have increased granulation
Assess the wound every day,

noting size and depth.
Serial wound assessments are

more reliable when performed by
Goal not evaluated.

20
tissue within 3-4 days.
Use topical that promotes moist

wound healing environment, and
absorbs any drainage every day.
Assess patients nutrition, and get
nutrition consult.
the same caregiver, with the client

in the same position, and using the
same techniques (Ackley &
Ladwig, pp. 842).
EBN: choose dressing that
provide a moist environment, keep
periwound skin dry, and control
exudate and eliminate dead space
Even the improvement of wounds
and ulcers through use of
nutritional support isnt back up yet
by clinical trials, the National
Pressure Ulcer Advisory Panel
encourages use of nutrition
assessment and treatment with
nutrition support (Ackley &
Ladwig, pp. 843).
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:
21
SS Consult
Dietary Consult
PT/ OT cellulitis on R. leg impairs walking.
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: Impaired walking r/t infection and pain in right leg as evidenced by unsteady, ineffective gait even with cane.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will demonstrate safety in
Remind patient of correct use of
Devices give stability and help
Patient goal met- By midday, I
assisted walking by midday
cane/reinforce when patient uses it compensate for poor balance.
didnt need to remind patient what
(12:00).
correctly. Since patient is weak in
Canes provide stability in persons
side to use her cane on, she was
the right leg, due to pain I
with hemiparesis (Ackley &
doing it on her own.
reminded her to use the cane on the Ladwig, pp. 895).
left side.
Patient will report increased
strength, and tolerance when
walking by the end of the day.
Offer the patient to walk frequently

with assistance.
Use patient bathroom instead of
bedside commode if patient can
tolerate it
Slowly get patient up in bed, and
then slowly stand them up
whenever ambulating them.
Standing/weight bearing benefits

gut motility, spasticity, and
respiratory/bowel/bladder function,
and promotes muscle stretching
Pt. goal not met- patient reported

still feeling equal amount of
weakness in the morning when
ambulating to the bathroom. Her
tolerance seemed the same also.
Helps clients adapt to and tolerate

upright position changes/postures
Pulse rate and arterial blood

Monitor patient tolerance when
oxygenation indicate
walking offer breaks in between if cardiac/exercise tolerance (Ackley
patient gets severe pain, dyspnea,
& Ladwig, pp. 896).
22
Patient will not acquire any new

injuries by d/c as result of fall/lack
of toileting (incontinence).
diaphoresis, dizziness or pulse ox

and BP drop. If after break these
continue, then stop the walking.
Do scheduled toileting/need rounds
for patient every day.
Assessment and root cause

Long term goal- not evaluated.
analysis indicated that inpatients
who fell had gait problems, were
Assess patient for swaying, balance confused, and were self-toileting;
issues or fears they may have when individualizing preventions
walking.
decreased fall rates (Ackley &
Ladwig, pp. 896).
Refer patient to PT.
fear of falling and repeat fallers
Encourage patient to walk
are common. Balance rehabilitation
everyday even if they walk slower. provide individualized treatment
for persons with various
diseases/deficits (Ackley &
Ladwig, pp. 896).
Slow gait may be related to fear of
falling; decreased strength in hip
extensors, hip abductors
Include a minimum of one

Long term goal per care plan
23
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
24
References
Ackley, B. J., & Ladwig, G. B. (2010). Nursing diagnosis handbook: An evidence-based guide to
planning care. Maryland Heights, MO: Mosby
B-type Natriuretic Peptide (BNP) Blood Test. (n.d.). Retrieved April 10, 2016, from
http://my.clevelandclinic.org/services/heart/diagnostics-testing/laboratory-tests/b-typenatriuretic-peptide-bnp-bloodtest
C-reactive protein: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved April 10, 2016, from
https://www.nlm.nih.gov/medlineplus/ency/article/003356.htm
Deglin, J. H., Vallerand, A., & Sanoski, C. (2016). Davis's Drug Guide for Nurses (14th ed.). FA
Davis Company. Retrieved April 10, 2016.
Osborn, K. S., & Osborn, K. S. (2014). Medical-surgical nursing: Preparation for practice.
Boston: Pearson.
SuperTracker: My Foods. My Fitness. My Health. (n.d.). Retrieved April 09, 2016, from
https://www.supertracker.usda.gov/default.aspx
Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing: Concepts, skills, & reasoning (p. 209,
210). Philadelphia, PA: F.A. Davis Company.
Van Leeuwen, A. M., & Bladh, M. L. (2015). Davis's comprehensive handbook of laboratory &
diagnostic tests with nursing implications. Retrieved April 10, 2016.
25
Nutrients Report 04/06/16 - 04/06/16

Your plan is based on a default 2000 Calorie allowance.
Nutrients
Target
Average Eaten
Status
Total Calories
2000 Calories
2344 Calories
Over
Protein (g)***
46 g
151 g
OK
Protein (% Calories)***
10 - 35% Calories
26% Calories
OK
Carbohydrate (g)***
130 g
188 g
OK
Carbohydrate (% Calories)***
45 - 65% Calories
32% Calories
Under
Dietary Fiber
25 g
27 g
OK
Total Sugars
No Daily Target or Limit 97 g
No Daily Target or
Limit
Added Sugars
< 50 g
35 g
OK
Total Fat
20 - 35% Calories
43% Calories
Over
Saturated Fat
< 10% Calories
9% Calories
OK
Polyunsaturated Fat
No Daily Target or Limit 9% Calories
No Daily Target or
Limit
Monounsaturated Fat
No Daily Target or Limit 21% Calories
No Daily Target or
Limit
Linoleic Acid (g)***
12 g
15 g
OK
Linoleic Acid (% Calories)***
5 - 10% Calories
6% Calories
OK
-Linolenic Acid (% Calories)***
0.6 - 1.2% Calories
0.8% Calories
OK
-Linolenic Acid (g)***
1.1 g
2.0 g
OK
Omega 3 - EPA
No Daily Target or Limit 1411 mg
No Daily Target or
Limit
Omega 3 - DHA
No Daily Target or Limit 2016 mg
No Daily Target or
Limit
Cholesterol
< 300 mg
853 mg
Over
Minerals
Target
Average Eaten
Status
Calcium
1000 mg
1283 mg
OK
Potassium
4700 mg
4562 mg
Under
Sodium**
< 2300 mg
2825 mg
Over
Copper
900 g
2715 g
OK
Iron
18 mg
18 mg
OK
Magnesium
310 mg
424 mg
OK
Phosphorus
700 mg
1963 mg
OK
Selenium
55 g
264 g
OK
Vitamin D
15 g
36 g
OK
Vitamin E
15 mg AT
16 mg AT
OK
Vitamin K
90 g
182 g
OK
Folate
400 g DFE
352 g DFE
Under
Thiamin
1.1 mg
1.7 mg
OK
Riboflavin
1.1 mg
3.1 mg
OK
Niacin
14 mg
42 mg
OK
Choline
425 mg
1016 mg
OK
Information about dietary supplements.

*** Nutrients that appear twice (protein, carbohydrate, linoleic acid, and -linolenic acid) have two separate recommendations:
1) Amount eaten (in grams) compared to your minimum recommended intake.
2) Percent of Calories eaten from that nutrient compared to the recommended range.
You may see different messages in the status column for these 2 different recommendations.

Final Pat 5

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Final Pat 5

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UNIVERSITY OF SOUTH FLORIDA

MSI & MSII PATIENT ASSESSMENT TOOL .

Assignment Date: 04/07/2016

Admission Date: 04/05/2016

Marital Status: Married

Primary Medical Diagnosis Cellulitis

Primary Language: English

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired; Elementary School

Code Status: Full Code

Living Arrangements: Lives home with husband and dog.

Advanced Directives: Yes

Culture/ Ethnicity /Nationality: English, Scottish, and Irish.

Type of Insurance: Medicare

University of South Florida College of Nursing Revision September 2014

(angina, MI, DVT etc.)

Age (in years)

University of South Florida College of Nursing Revision September 2014

Type of Reaction (describe explicitly)

Other (food, tape,

Pt. indicated envirnmental allergies

Runny nose, itching, sneezing.

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching

University of South Florida College of Nursing Revision September 2014

Analysis of home diet (Compare to My Plate and

University of South Florida College of Nursing Revision September 2014

Snacks: apple or banana

Pt. nutrient report attached after reference page.

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014

are great for that, theyre like psychologists.

+2 DOMESTIC VIOLENCE ASSESSMENT

Trust vs. Mistrust

Doubt & Shame

University of South Florida College of Nursing Revision September 2014

What does your illness mean to you?

University of South Florida College of Nursing Revision September 2014

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

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

If applicable, when did the

Pack Years: N/A

Has the patient ever tried to quit? N/A

For how many years?

Is the patient currently using these drugs?

If not, when did he/she quit?

University of South Florida College of Nursing Revision September 2014

10 REVIEW OF SYSTEMS NARRATIVE

Be sure to answer the highlighted area

Nausea, vomiting, or diarrhea

Chills with severe shaking

nocturia pt. indicates getting up

Central Nervous System

age? Pt. indicated she

could not remember.

menopause pt. indicates around 43

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014

Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]

Central access device

Date inserted: 04/07/2016