UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Aliscia Laliotis
Assignment Date: 10/18/16
MSI & MSII PATIENT ASSESSMENT TOOL .
1 PATIENT INFORMATION Agency: TGH
Patient Initials: CF Age: 60 Admission Date: 10/10/16
Gender: Female Marital Status: Married Primary Medical Diagnosis Myasthenia Gravis
Primary Language: English Exacerbation
Level of Education: 2 years of college Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Nurse for 19 years None
Number/ages children/siblings: Children: 34 y/o and 36 y/o
67 y/o and 68 y/o
Served/Veteran: no Code Status: Full
If yes: Ever deployed? Yes or No
Living Arrangements: Home w/ Husband Advanced Directives: no
If no, do they want to fill them out? yes
Surgery Date: none Procedure: PLEX
Culture/ Ethnicity /Nationality: African American
Religion: Catholic Type of Insurance: Medicare and Tricare

1 CHIEF COMPLAINT: For the PLEX

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) 60 y/o female with PMH significant for seropositive MG (Ach-R Ab) diagnosed in Fall 2015 presenting as a direct
admit for plasma exchange from Dr. John Doe. She last received PLEX in September (with last session on 9/10) and felt
better with improved vision and strength. Over the past 2 weeks has noted worsening symptoms of diplopia, right eyelid
ptosis, fatigue, weakness (Lower extremities greater than upper extremities) and shortness of breath. PLEX session in
September was the 1st time patient has received PLEX and tolerated it well aside from having hypokalemia that was
difficult to correct. She has permacath in place for PLEX and mediport for IV and lab draws. Regarding MG, she was
diagnosed with antibodies. Per clinic notes, NCS was normal. Unable to tolerate Imuran due to fever and sever fatigue.
Unable to tolerate Mestinon due to abdominal cramps. Previously been on IVig, but no longer helped symptoms.
Diagnosed with temporal arteritis and started on prednisone 60 mg in Jan 2016, with negative biopsy. Currently on
cellcept 750 mg

University of South Florida College of Nursing Revision September 2014 1

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
2011/2003 Seropositive Myasthenia Gravis
Breast Cancer with Mastectomy
Hepatitis B
Hypertension
Diabetes Mellitus
2008 Colonoscopy
1/18/2016 Artery Biopsy
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma

Cause

Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
Gout
MEDICAL of

Mental
Heart
HISTORY Death

(angina,
(if
applicable)
COPD,
Father 83 Renal
Failure
Mother 74
Brother 67
Sister 68
relationship

relationship

relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (2015)
Adult Tetanus Is within 10 years? yes
Influenza (flu) (Date) Is within 1 years? yes
Pneumococcal (pneumonia) (Date) Is within 5 years? U
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

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 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Sulfa leukopenia

Medications

Adhesive Tape
Blisters
(silicon)
Other (food, tape,
latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment) Myasthenia Gravis (MG) is a disorder where autoantibodies fight acetylcholine receptors. This one
decreases the amount of active acetylcholine receptors. With less of these receptors available, it leads to a
neuromuscular dysfunction that prevents muscles from reaching action potential therefore inhibiting
contraction. Thymic abnormalities and genetics contribute to the chances of having this disease. The
autoantibodies are present in 80 to 90 percent of affected patients (Bird, 2016). By testing the patients for this
autoantibody, it can determine whether the patient has MG. T lymphocytes are important for treatment because
they can bind to the acetylcholine receptor and their main role is thought to be stimulation of B cell antibody
production. Some medications such as pyridostigmine improves muscle strength which is beneficial to MG
patients since they have generalized muscle weakness. (Bird, 2016)

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name Acetaminophen Concentration capsule Dosage Amount 650 mg

Route oral Frequency q 6 hr PRN

Pharmaceutical class non-opioid analgesics Home Hospital or Both
Indication pain or fever
Adverse/ Side effects Hepatotoxicity, Acute Generalized Exanthematous Pustulosis, Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis
Nursing considerations/ Patient Teaching > 4g a day leads to hepatotoxicity, avoid alcohol, discontinue if you notice a rash

Name albuterol Concentration inhaler Dosage Amount 1 puff

Route inhalation Frequency 4 hr PRN

Pharmaceutical class adrenergics Home Hospital or Both
Indication wheezing and shortness of breath
Adverse/ Side effects nervousness, restlessness, tremor, chest pain, palpitations, paradoxical bronchospasm
Nursing considerations/ Patient Teaching Do not exceed recommended dose, Notify doctor if no response to the usual dose or if one canister is used in less than 2
weeks

Name atorvastatin Concentration tablet Dosage Amount 10 mg

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Route oral Frequency daily
Pharmaceutical class Hmg COA reductase inhibitors Home Hospital or Both
Indication Hypercholesterolemia
Adverse/ Side effects abdominal cramps, constipation, diarrhea, flatus, heartburn, rash, rhabdomyolysis, angioneurotic edema
Nursing considerations/ Patient Teaching Notify doctor if unexplained muscle pain, tenderness, or weakness occurs especially with fever or malaise

Name cholecalciferol Concentration tablet Dosage Amount 400 units

Route oral Frequency daily

Pharmaceutical class fat soluble vitamin Home Hospital or Both
Indication prevention of vitamin D deficiency
Adverse/ Side effects pancreatitis, hypercalcemia
Nursing considerations/ Patient Teaching Take as directed, Monitor calcium levels, Comply with dietary recomendations

Name Citalopram Concentration tablet Dosage Amount 40 mg

Route oral Frequency daily

Pharmaceutical class SSRI Home Hospital or Both
Indication depression
Adverse/ Side effects neuroleptic malignant syndrome, suicidal thoughts, apathy, confusion, drowsiness, insomnia, weakness, torsade de pointes, abdominal
pain, anorexia, diarrhea, dry mouth, dyspepsia, flatulence, increased saliva, nausea, sweating, tremor, serotonin syndrome
Nursing considerations/ Patient Teaching Look for suicidality, Take as directed, change positions slowly to avoid dizziness

Name cyclosporine Concentration ophthalmic emulsion Dosage Amount 1 drop

Route eyes Frequency q 12 hr

Pharmaceutical class polypeptide Home Hospital or Both
Indication prevent organ rejection
Adverse/ Side effects posterior reversible encephalopathy syndrome, progressive multifocal leukoencephalopathy, seizures, tremor, hypertension, hepatotoxicity,
diarrhea, nausea, vomiting, nephrotoxicity, hirsutism, gingival hyperplasia, hypersensitivity reactions, infections
Nursing considerations/ Patient Teaching Take meds at same time each day with meals, notify doctor if diarrhea develops, teach patient correct method of
administering eyedrops and taking BP

Name dextrose 50% Concentration IV syringe Dosage Amount 50 mL

Route intravenous Frequency PRN

Pharmaceutical class caloric source Home Hospital or Both
Indication low blood sugar, hypoglycemia
Adverse/ Side effects hyperglycemia
Nursing considerations/ Patient Teaching Teach patient how to check blood glucose levels, teach patient how to administer dextrose products

Name diphenhydramine Concentration injection Dosage Amount 50 mg

Route intravenous Frequency Daily PRN

Pharmaceutical class antihistamine Home Hospital or Both
Indication itching, given prior to PLEX
Adverse/ Side effects drowsiness, anorexia, dry mouth
Nursing considerations/ Patient Teaching Take medication as directed, teach proper sleep hygiene techniques

Name famotidine Concentration tablet Dosage Amount 40 mg

Route oral Frequency 2 times daily

Pharmaceutical class histamine h2 agonist Home Hospital or Both
Indication treat/prevent stomach ulcers
Adverse/ Side effects confusion, arrhythmias, agranulocytosis, aplastic anemia

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Nursing considerations/ Patient Teaching Take medication as directed, Avoid smoking, Avoid alcohol, report onset of black, tarry stool

Name heparin flush Concentration injection Dosage Amount 5 mL

Route subcutaneous Frequency PRN

Pharmaceutical class anticoagulant Home Hospital or Both
Indication clot prevention
Adverse/ Side effects bleeding, heparin-induced thrombocytopenia, anemia
Nursing considerations/ Patient Teaching report any signs or symptoms of unusual bleeding or bruising

Name hydrochlorothiazide Concentration capsule Dosage Amount 25 mg

Route oral Frequency PRN daily

Pharmaceutical class thiazide diuretic Home Hospital or Both
Indication BP > 150 systolic
Adverse/ Side effects Steven Johnsons syndrome, hypokalemia
Nursing considerations/ Patient Teaching Advise patient to continue taking medication even when feeling better, Does not cure hypertension

Name insulin aspart Concentration injection Dosage Amount 2-10 units

Route subqutaneous Frequency 3 times daily with food and at bedtime

Pharmaceutical class pancreatic Home Hospital or Both
Indication blood glucose regulation
Adverse/ Side effects hypoglycemia, anaphylaxis
Nursing considerations/ Patient Teaching know signs and symptoms of hypoglycemia

Name Lisinopril Concentration tablet Dosage Amount 20 mg

Route oral Frequency daily

Pharmaceutical class Ace inhibitor Home Hospital or Both
Indication hypertension
Adverse/ Side effects dizziness, cough, hypotension, angioedema
Nursing considerations/ Patient Teaching notify doctor immediately about rash, mouth sores, sore throat, fever; teach correct technique to obtain BP

Name magnesium oxide Concentration tablet Dosage Amount 200 mg

Route oral Frequency daily

Pharmaceutical class Mineral/electrolyte supplement Home Hospital or Both
Indication treat/prevent hypomagnesemia
Adverse/ Side effects diarrhea
Nursing considerations/ Patient Teaching Dont take this medication within 2 hr of taking any other medication

Name montelukast Concentration tablet Dosage Amount 10 mg

Route oral Frequency daily

Pharmaceutical class leukotriene agonist Home Hospital or Both
Indication prevent and treat asthma
Adverse/ Side effects suicidal thoughts, steven-johnsons syndrome, toxic epidermal necrolysis, Churg-Strauss syndrome
Nursing considerations/ Patient Teaching Assess symptoms on day to day basis for abrupt changes in anxiety, agitation, panic attacks, insomnia, etc.

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Name mycophenolate Concentration capsule Dosage Amount 750 mg

Route oral Frequency 2 times daily

Pharmaceutical class immunosuppressant Home Hospital or Both
Indication prevent rejection of organ transplant
Adverse/ Side effects Progressive Multifocal Leukoencephalopathy, anxiety, dizziness, h/a, insomnia, paresthesia, tremor, edema, HTN, hypotension,
tachycardia, GI bleeding, fever, infection
Nursing considerations/ Patient Teaching Reinforce that this is a lifelong therapy, stopping this medication could lead to organ rejection

Name ondansetron Concentration injection Dosage Amount 4 mg

Route intravenous Frequency q 6 hr PRN

Pharmaceutical class five ht3 antagonists Home Hospital or Both
Indication nausea and vomiting
Adverse/ Side effects serotonin syndrome, h/a, torsade de pointes, constipation, diarrhea, Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis
Nursing considerations/ Patient Teaching Notify physician immediately of irregular heartbeat, take medication as directed

Name potassium chloride Concentration tablet Dosage Amount 20 mEq

Route oral Frequency daily

Pharmaceutical class mineral/electrolyte supplement Home Hospital or Both
Indication treat/prevent potassium depletion
Adverse/ Side effects arrhythmias, abdominal pain, diarrhea, flatulence, nausea, vomiting
Nursing considerations/ Patient Teaching Avoid salt substitutes, seek dietary sources of potassium and comply with recommended diet

Name prednisone Concentration tablet Dosage Amount 10 mg

Route oral Frequency daily

Pharmaceutical class anti-inflammatory Home Hospital or Both
Indication autoimmune disorders
Adverse/ Side effects depression, euphoria, hypertension, peptic ulceration, anorexia, nausea, acne, decreased wound healing, ecchymosis, thromboembolism
Nursing considerations/ Patient Teaching stopping medication suddenly could lead to adrenal insufficiency. Call doctor immediately if abdominal pain or tarry
stools occur

Name rivaroxaban Concentration tablet Dosage Amount 20 mg

Route oral Frequency daily

Pharmaceutical class antithrombotic Home Hospital or Both
Indication prevention of deep vein thrombosis
Adverse/ Side effects bleeding
Nursing considerations/ Patient Teaching Assess for signs of bleeding, have patient report any signs of unusual bleeding or bruising

Name spironolactone Concentration tablet Dosage Amount 25 mg

Route oral Frequency daily

Pharmaceutical class potassium-sparing diuretics Home Hospital or Both
Indication management of edema
Adverse/ Side effects hyperkalemia, drug rash with eosinophilia and systemic symptoms, Stevens-Johnsons syndrome, toxic epidermal necrolysis
Nursing considerations/ Patient Teaching Assess for skin rash frequently, Notify physician of any muscle weakness, cramps, fatigue, or severe nausea/vomiting

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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? Carbohydrate Consistent 1800 cal Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular Consider co-morbidities and cultural considerations):
24 HR average home diet: My patients at home diet should be adjusted to one that is
Breakfast: coffee, sausage, egg, English muffin more appropriate for her diabetes. Usually patients take
insulin with each meal and at bedtime. If my patient skips
Lunch: salad or sandwich dinner, she could become hypoglycemic with no food in her
body. I dont see enough vegetables in her diet, so I would
Dinner: not much recommend that she eat more. My biggest concern thought
would be her not eating dinner.
Snacks: fruit, crackers, nuts (cashews)

Liquids (include alcohol): water with lemon, coffee

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? My husband

How do you generally cope with stress? or What do you do when you are upset? I used to swim and bike ride but I cant
anymore so I just pray.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) I had anxiety
about my port not working, and I was very restless during my PLEX

+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

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 4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry
vs. Inferiority Identity vs. Role Confusion/Diffusion 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: (generativity) ability to give and to care for others vs. (self-absorption) self-absorption; inability to grow as a
Person (Varcarolis, et al, 2010, p. 23)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: fulfilling
life goals that involve family, career, and society; developing concerns that embrace future generations (Varcarolis, et al, 2010, p. 23).
My patient exhibits characteristics of being in the generativity developmental stage in several ways. She is a grandparent and and she
expressed to me the tremendous care she has for her grandchildren. She greatly appreciates the care that her family provides for her
wishes she could return the favor. She does the most that she can for herself. She was very willing to help me with this Patient
Assessment Tool.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: I think my patient
used to struggle with the impact of her disease on her life, but she has learned to cope with it. She has a very lengthy list of conditions,
but she said she has come to terms with it through prayer and family support.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? I really dont know. It might be random or it might be genetic

What does your illness mean to you? Its just one of many

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record

Have you ever been sexually active?

_____yes_______________________________________________________________
Do you prefer women, men or both genders? _men________________________________________________________
Are you aware of ever having a sexually transmitted infection? __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? ______not really________________ 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? ____no______________________________

How long have you been with your current partner?___13 years____________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? __yes_____________________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
no

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
__Its important. I prefer non-denominational ________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
__no____________________________________________________________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much?(specify daily amount) For how many years? X years
(age thru )

If applicable, when did the

Pack Years:
patient quit?

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? Dad used to smoke 10 cigarettes If yes, what did they use to try to quit?
a day

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Margarita (fruity drinks) How much? 1 For how many years?
Volume: 1 drink (age 21 thru 41 )
Frequency: once a week
If applicable, when did the patient quit?age 41

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what? Marijuana
How much? Tried it once For how many years? N/A
(age thru )

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No
The day she tried it

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
no

5. For Veterans: Have you had any kind of service related exposure?

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: 50 Diverticulitis Life threatening allergic reaction
Bathing routine: daily Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy? 2008
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: A+
Post-nasal drip Normal frequency of urination: 6-8x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2 Diabetes Type: 2
x/day
Routine dentist visits 0 x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? 12 Encephalitis
last CXR? January 2016 menopause age? 52 Meningitis
Date of last Mammogram &Result:2003
Other: Other:
cancer
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
University of South Florida College of Nursing Revision September 2014
 Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening? August 2016 Arthritis Chicken Pox

General Constitution
Recent weight loss or gain
How many lbs? 20 lbs
Time frame? Since January 2016
Intentional? no
How do you view your overall health? good

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
deQuervains thyroiditis which leads to hypothyroidism

Any other questions or comments that your patient would like you to know?
no

University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:

General Survey: Height 411 Weight 168 lbs BMI 33.9 Pain: (include rating and
Pulse 84 Blood Pressure: (include location) location) 2 in muscles
Respirations 15 131/52 sitting in left leg
Temperature: (route SpO2 Is the patient on Room Air or O2
taken?) 98.7
100 O2 2 L
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

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

awake, calm, relaxed, interacts well with others, judgment intact

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]

clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: Permacath and mediport Location: UR chest/UL chest Date inserted: 2015/10-10-16
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 / mm 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:
Comments: reddish in nares d/t nasal cannula

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion 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 clear
Lung sounds: clear
RUL clear LUL clear
RML clear LLL clear
RLL clear

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

University of South Florida College of Nursing Revision September 2014

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

No telemetry or 12 leak EKG done on this patient

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT:3
No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: pitting non-pitting
Extremities warm with capillary refill less than 3 seconds

GI Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 10 / 18 / 16 ) Formed Semi-formed Unformed Soft Hard Liquid Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe:

GU Urine output: Clear Cloudy Color: Previous 24 hour output: 875 mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __5_____ RUE ___5____ LUE __4_____ RLE & ____4___ 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: +2 Biceps: +2 Brachioradial: +2 Patellar: +1 Achilles: +1 Ankle clonus: positive negative Babinski: positive negative

University of South Florida College of Nursing Revision September 2014

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 Dates Trend Analysis

Na, K, Cl, Co2, BUN, 10/12-10/18 Within range WNL
Creat, Glucose
Hemoglobin 10/12-10/18 9.7, 9.2, 9.7, 10.8, 9.5, Levels are low due to
9.4 PLEX procedures
Hematocrit 10/12-10/18 31.5, 30.2, 31.5, 34.7, Levels are low due to
30.3, 30.3 PLEX procedures

+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.)
PLEX, vitals every 6 hours, daily labs, carbohydrate consistent diet 1800 calories, fibrinogen checks before
PLEX treatments, blood glucose checks before each meal and at bedtime

8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Ineffective breathing pattern related to neuromuscular weakness of the respiratory muscles and throat as evidenced by
shortness of breath.
2. Impaired physical mobility related to weakness of voluntary muscles as evidenced by decreased muscle strength in
extremities.
3. Risk for unstable blood glucose related to diabetic process.

4.

5.

University of South Florida College of Nursing Revision September 2014

 15 CARE PLAN
Nursing Diagnosis: Impaired physical mobility related to weakness of voluntary muscles as evidenced by decreased muscle strength in extremeties.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Long term goal: Minimize Assess patients fatigue MG patients experience muscle Ask the patient if they are
symptoms of MG weakness and fatigue. Assessing experiencing fatigue.
fatigue could lead to understanding
whether the patient is able to
ambulate
Increase lower extremities muscle Monitor for signs of respiratory Respiratory muscles are weakened Check O2 Saturation (within 95-
strength and lung expansion with insufficiency by Myasthenia Gravis. 100), check respirations (12-20),
rehabilitation and medication. check chest expansion with
butterfly method on patients back
Control Pain Administer medications as directed Its important that MG patients Medications are given on time
by the physicians orders. receive their medication to avoid
myasthenic crisis from lack of
acetylcholine.
Improve patients ability to chew Monitor patients ability to chew MG affects the bulbar muscles Patient can safely chew and
and swallow food to avoid and swallow involved in chewing and swallow food
aspiration. swallowing (Osborn, et al, 2010,
p. 628)
Include a minimum of one
Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
*Dietary Consult
*PT/ OT
*Pastoral Care
Durable Medical Needs
F/U appointments
*Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
*Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

 References

Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical surgical nursing: Preparation for practice. Boston,

MA: Pearson.

Varcarolis, E. M., Halter, M. J., & Varcarolis, E. M. (2010). Foundations of psychiatric mental health nursing: A

clinical approach. St. Louis, MO: Saunders/Elsevier.

Bird, S. J., MD. (2016, September 20). Pathogenesis of Myasthenia Gravis. Retrieved November 8, 2016, from

http://www.uptodate.com/contents/pathogenesis-of-myasthenia-gravis?

source=search_result&search=myasthenia gravis pathophysiology&selectedTitle=1~150

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014