UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kristina Nealy
Assignment Date: March 10, 2016
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Sarasota Memorial
1 PATIENT INFORMATION Hospital
Patient Initials: MD Age: 28 Admission Date: January 15, 2016
Gender: Male Marital Status: Single Primary Medical Diagnosis: Diskitis,
osteomyelitis
Primary Language: English
Level of Education: High school Other Medical Diagnoses: (new on this admission)
Hepatitis C
Occupation (if retired, what from?): Unemployed
Number/ages children/siblings: No children or siblings
Served/Veteran: No Code Status: Full code

Living Arrangements: Owns a home with fianc Advanced Directives: No

If no, do they want to fill them out? No
Surgery Date: 1/15/2016
Procedure: CT aspiration, L1-L2 bx and
vertebral bone bx
Culture/ Ethnicity /Nationality: Caucasian
Religion: Atheism Type of Insurance: None

1 CHIEF COMPLAINT: In November I fell off of a ladder while on the job, ever since then I have had
unbearable back pain.

3 HISTORY OF PRESENT ILLNESS:

Patient is a 28-year-old male with acute spondylodiskitis and osteomyelitis at L1 and L2. He states that he hurt his back
on the job in November, he has constant aching pain in his back, moving makes it worse and nothing makes it better.
Patient also suffers from hepatitis C. He has a history of IV drug use but does not want to discuss it with any physicians or
nurses involved in his care. He is currently on 7 Waldamere Tower being treated with 42-day IV antibiotics through a
PICC line; the MD was not comfortable with discharging him home with a PICC line due to his history.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY: Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
11/20/2015 Age (in years) 3 ruptured disks and a fracture

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
etc.)
FAMILY

Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma

Cancer

Tumor
Problems

Stroke
Cause

Allergies

MI, DVT
MEDICAL

Gout

Mental
of

Heart
HISTORY Death

(angina,
(if
applicable)
Father 49 Drug OCD
Mother 60 Brain CA
Natural
Maternal Gma 87 causes/old
age
Natural
Maternal Gpa 90 causes/old
age
Comments: Patient said that he didnt know much about his father and he wasnt a part of his life. He also wasnt sure of any family
medical history. His mom had Bergers syndrome and brain cancer but didnt tell anyone until she was in end stages, she passed away in
June 2015.

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 (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
Pt states that he doesnt believe in vaccines.

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Medications Pt states no allergies

Other (food, tape,

latex, dye, etc.)

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 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)
Osteomyelitis is an infection of the bone and spondylodiskitis is inflammation or infection of the vertebrae.
Osteomyelitis most commonly effects bones in the arms and legs but it can affect the spinal vertebrae, the injuries
are either acute, sub acute or chronic (Treas et al. 2014). Trauma or surgery are the likely causes of osteomyelitis
and it is imperative that the patient gets treatment early to minimize the amount of damage. When the trauma
occurs, infection is able to move to the site via bloodstream, followed by an inflammatory reaction. The
inflammatory reaction causes pressure on the bone (in this specific case its the spinal vertebrae) and this is when
issues occur. Clinical manifestations of osteomyelitis are fever, edema at the site, warmth to touch, tenderness, and
movement and/or joint limitations. Treatment includes rest, antibiotics, pain management, and sometimes surgery
for drainage. Prognosis is good if treated early. (Treas et al. 2014)

5 MEDICATIONS:
Name: acetaminophen (Tylenol) Concentration: Tablet Dosage Amount: 325mg
Route: PO Frequency: Q6H
Pharmaceutical class: Nonopioid analgesic, antipyretic Home Hospital or Both
Indication: For mild pain, fever
Adverse/ Side effects: H/a, fatigue, hepatotoxicity, acute generalized exanthematous pustulosis, S-J syndrome, toxic epidermal
necrolysis,
Nursing considerations/ Patient Teaching: Advise patient to take medication exactly as directed and not to take more than the
recommended amount. Chronic excessive use of >4 g/day (2 g in chronic alcoholics) may lead to hepatotoxicity, renal or cardiac
damage. Avoid alcohol and discontinue medication and call MD if rash occurs.

Name: cefepime (Maxipime) Concentration: Liquid Dosage Amount: 2mg w/ 0.9% NS

minibag, 100mL over 30 min
Route: IVPB Frequency: Q8H
Pharmaceutical class: Anti-infectives Home Hospital or Both
Indication: Treatment of bone/joint infections
Adverse/ Side effects: Rash, phlebitis at IV site, seizures, C. diff, anaphylaxis, n/v/d
Nursing considerations/ Patient Teaching: Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal
itching or discharge, loose or foul-smelling stools) and allergy, instruct patient to notify health care professional if fever and diarrhea
develop, especially if stool contains blood, pus, or mucus.

Name: ciprofloxacin (Cipro) Concentration: Tablet Dosage Amount: 750mg

Route: PO Frequency: Q12H
Pharmaceutical class: Anti-infectives Home Hospital or Both
Indication: Treatment of bone/joint infections
Adverse/ Side effects: Diarrhea, nausea, seizures, elevated intracranial pressure, hepatotoxicity, C. diff, anaphylaxis
Nursing considerations/ Patient Teaching: Instruct patient to take medication as directed at evenly spaced times and to finish drug
completely, even if feeling better. Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or
discharge, loose or foul-smelling stools). Call MD if diarrhea develops, especially if it contains blood, pus, or mucus.

Name: ducosate (Colace) Concentration: Capsule Dosage Amount: 100mg

Route: PO Frequency: Q AM
Pharmaceutical class: Stool softener Home Hospital or Both
Indication: Prevention of constipation
Adverse/ Side effects: throat irritation, mild cramps, diarrhea, rash
Nursing considerations/ Patient Teaching: Advise patients that laxatives should be used only for short-term therapy. Long-term
therapy may cause electrolyte imbalance and dependence. Encourage other forms of bowel regulation, and advise patient not to use

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laxatives when abdominal pain, nausea, vomiting, or fever is present.

Name: gabapentin (Neurontin) Concentration: Capsule Dosage Amount: 400mg

Route: PO Frequency: Q8H
Pharmaceutical class: analgesic adjunct, mood stabilizer Home Hospital or Both
Indication: Neuropathic pain
Adverse/ Side effects: Confusion, depression, dizziness, drowsiness, suicidal thoughts, multiorgan hypersensitivity reaction
Nursing considerations/ Patient Teaching: Do not take within 2 hours of an antacid, avoid driving, take exactly as directed, and notify
healthcare provider if any suicidal thoughts occur, depression worsens, new or worse anxiety, etc.

Name: Ibuprofen Concentration: Tablet Dosage Amount: 600mg

Route: PO Frequency: Q8H
Pharmaceutical class: Nonopioid analgesic Home Hospital or Both
Indication: Mild to moderate pain, fever, inflammatory disorders
Adverse/ Side effects: H/a, constipation, n/v, dyspepsia, HF, MI, stroke, GI bleed, hepatitis, exfoliative dermatitis, S-J syndrome,
Nursing considerations/ Patient Teaching: Advise patients to take ibuprofen with a full glass of water and to remain in an upright
position for 1530 min after administration, avoid alcohol, take as directed

Name: Melatonin Concentration: Tablet Dosage Amount: 3mg

Route: PO Frequency: Q HS
Pharmaceutical class: Sedative/hypnotic Home Hospital or Both
Indication: Sleep disorders
Adverse/ Side effects: Hypotension, drowsiness, h/a, dizziness, n/v, abdominal cramps
Nursing considerations/ Patient Teaching: Instruct to take at bedtime as needed, avoid driving as it causes drowsiness, avoid alcohol
and other CNS depressants

Name: traZODone (Desyrel) Concentration: Tablet Dosage Amount: 50mg

Route: PO Frequency: Q HS
Pharmaceutical class: Antidepressant Home Hospital or Both
Indication: Major depression, insomnia, anxiety, chronic pain syndromes
Adverse/ Side effects: Drowsiness, hypotension, dry mouth, tremor, erectile dysfunction, suicidal thoughts
Nursing considerations/ Patient Teaching: Take medication as directed, change positions slowly, avoid concurrent use of alcohol or
any other CNS depressants, advise pt, family, and caregivers to watch for suicidality, notify health care provider immediately if signs of
serotonin syndrome occur.

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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? Regular Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular Not very healthy Consider co-morbidities and cultural considerations):
From the information Ive gathered from my patient
about his daily diet at home and according to My
Plate, the patient eats too many fats/carbs and does not
fulfill the recommended food categories on a daily basis.
He did not mention any type of intake of vegetables or
fruits at all during the interview but he did state that he
drinks a lot of water per day.
24 HR average home diet:
Breakfast: I never really eat breakfast but if I do its My Plate stresses the importance of breakfast, the
eggs or cereal. patient stated he rarely eats breakfast.

Lunch: Sandwiches (all different types) and burgers

(fast food)

Dinner: Different things, whatever my fianc cooks or

wherever we go out to eat.

Snacks: Junk food like chips, cookies, etc.

Liquids (include alcohol): Water & green tea

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 fianc

How do you generally cope with stress? or What do you do when you are upset? I get angry and yell. Fianc agreed
with this statement.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life): None really,
I always look for a solution.

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+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? Yes, I have dated some crazy women.

Have you ever been talked down to? Yes____________ Have you ever been hit punched or slapped? Yes_________

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

Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: 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:
According to Treas & Wilkinson, Eriksons psychosocial identity versus role confusion stage of development
usually occurs from ages 11 to 21. A person who fails to recognize his abilities and sense of self is unable to
experience a solid place in the world. This is manifested by dysfunctional interpersonal relationships and
occupational performance. Delinqent and rebellious behavior may be prominent when the task of identity
formation is not met. (Treas et al. (2014) Erikson determined that people can regress or progress to later stages
during times of stress and unforeseen life events.

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
I have determined that the patient is experiencing role confusion/diffusion; although he is 28 years old he seems to
be trying to find his identity still. From the short amount of time I spent with him, he opened up quite a bit but
didnt seem to take things very seriously. For instance, he is currently unemployed and continues to use IV drugs,
cocaine, and marijuana without any plans to stop even though he is very much aware that this behavior is what got
him in this situation and being stuck in the hospital. Also, he has a felony charge which inhibits him from getting a
good paying job. He is engaged but his fianc is in a similar situation as him, they do not use protection during
sexual intercourse and the patient hasnt even told the fianc about his hepatitis C diagnosis. He stated that he
hasnt had very healthy intimate relationships in the past and that his father wasnt a part of his life, he is also still
grieving over the recent loss of his mother and he is angry that she didnt tell him about having cancer. The notes
in the EMAR say that he and his fianc are currently homeless but the patient told me that they own a house
together. It seems as though the patient has not yet found his identity and resorts to destructive, delinquent and
rebellious behavior due to a series of unfortunate events and a rough past.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: As I
previously stated, I dont believe the patient takes his condition seriously. He did say that he agreed to staying in

University of South Florida College of Nursing Revision September 2014 6

the hospital as much as he didnt want to because he wants to get better and no longer be in pain. The patient is
still in the same stage of development as he was before this happened but if this really is an eye opener, he may turn
his life around and make developmental progress.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? Falling off the ladder and I guess the infection is probably due to IV
drug use

What does your illness mean to you? My world will never be the same, it is definitely a wake up call.

+3 SEXUALITY ASSESSMENT:
Have you ever been sexually active? Yes
Do you prefer women, men or both genders? Women
Are you aware of ever having a sexually transmitted infection? No
Have you or a partner ever had an abnormal pap smear? Dont think so
Have you or your partner received the Gardasil (HPV) vaccination? Pt didnt know what this is but his fianc said she
has had the HPV vaccination

Are you currently sexually active? Yes

If yes, are you in a monogamous relationship? Yes
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? None
How long have you been with your current partner? 1.5 year
Have any medical or surgical conditions changed your ability to have sexual activity? No
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

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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? None
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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? Cigarettes How much? 1 pack a day For how many years? 10 years
Age 18 thru 28 (current)

If applicable, when did the

Pack Years: 10
patient quit? N/A

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit? Not yet
so, what, and how much? Yes, 1 pack of cigarettes a day

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes (but not much anymore) No
What? Beer, wine, or liquor How much? Not a lot For how many years? 12
Volume: N/A (age 16 thru 28 (now))
Frequency: Rarely, only on occasion
If applicable, when did the patient quit?
23 is when I quit drinking like everyday.

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what? Marijuana, cocaine, and heroin
How much? A lot For how many years? 12
Age 16 thru 28 (Now)

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No

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

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 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: Diverticulitis Life threatening allergic reaction
Bathing routine: Normal 1-2x daily Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy?
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:
Post-nasal drip Normal frequency of urination: 4-5x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 1-2x/day Diabetes Type:
Routine dentist visits None/year Hypothyroid /Hyperthyroid
Vision screening No 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? Encephalitis
Last CXR? menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Date of last prostate exam? Dont
Chest pain / Angina Anxiety
know
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
Arrhythmias Osteomyelitis Scarlet Fever

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 Last EKG screening, when? Arthritis Chicken Pox
Other: Other: Other:

General Constitution
Recent weight loss or gain
How many lbs? 35 lbs
Time frame? Since November
Intentional? No
How do you view your overall health? Great until recently

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

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10 PHYSICAL EXAMINATION:

General Survey: Pt is a Height: 179.1 cm or Weight: 62.4 kg or BMI: 19.46 Pain: (include rating and
pleasant 28 y.o. male 58 137.5 lbs location) 3-4 out of 10
who is alert & oriented Pulse: 76 Blood Pressure: (include location) Location: back
x3. Respirations: 18 104/56 L brachial
Temperature: (route SpO2 : 100% Is the patient on Room Air or O2
taken?) 97.4 Oral
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

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

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

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

clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
Central access device Type: PICC Location: Right brachial Date inserted: 1/19/2016
Fluids infusing? no yes - what? 0.9% NS and antibiotics continuously running Q8H

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 / 3mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: Not tested
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production

Lung sounds: Clear to auscultation from apices to bases

RUL LUL
RML LLL
RLL

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

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 Cardiovascular: No lifts, heaves, or thrills
Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD

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: 1/28/2016) 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: Not witnessed Previous 24 hour output: 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 __5__ RLE & __5__ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia: Pain in back

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: Not tested
[rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative

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

WBC WBCs have been within The patient is on day 10
7.2 1/23/2016 normal limits within the out of 42 of his
past week. antibiotics, this lab shows
9.3 1/28/2016 that it is working
Normal (4.5-11) effectively to treat the
infection.
University of South Florida College of Nursing Revision September 2014 12
RBC The RBCs seemingly Normal
4.15 1/23/2016 stay in the low normal but
wasnt quite below
4.23 1/28/2016 normal during the
Normal (4-5.2) hospitalization.
HGB Within normal limits Normal, the HCT and
12.2 1/23/2016 RBCs are within normal
limits as well.
12.2 1/26/2016

12.4 1/28/2016
Normal (12-16)
HCT Within normal limits Low HCT can indicate a
37.2 1/23/2016 couple different things:
anemia, over-hydration,
37.7 1/26/2016 edema, or renal disease.

37.4 1/28/2016
Normal (35-47%)
Platelet Platelets are within Normal
244 1/23/2016 normal limits

253 1/28/2016
Normal (150-400)
Glucose Glucose is within normal Very close to 100, pt had
98 1/23/2016 limits probably eaten before
labs were drawn
95 1/28/2016
Normal (70-100)
Sodium Sodium is within normal Normal
141 1/23/2016 limits.

140 1/28/2016
Normal (135-145)
Potassium Potassium is within Normal
3.7 1/23/2016 normal limits.

3.9 1/28/2016
Normal (3.5-5.0)
BUN BUN was a tad bit Pt was recently diagnosed
21 H 1/23/2016 elevated but went back with Hepatitis C, elevated
down WNL. BUN can indicate damage
17 1/28/2016 to the liver but it is not
Normal (6-20) high enough to assume
this. BUN is also related
to kidney function.
Creatinine Creatinine is within Normal. Closely related
0.61 1/23/2016 normal limits. to kidney function.

University of South Florida College of Nursing Revision September 2014 13

 0.67 1/28/2016
Normal (0.6-1.3)
Quantitative HCV RNA Very high This is the amount of
1,366,684 H 1/28/2016 hepatitis C virus in the
Normal (<15) blood. This value is
significantly high which
indicates that the patient
has Hep C.
Wound culture 1/15/2016 + Positive for pseudomonas
aeruginosa (bacteria)

+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.)
Pt is being kept in the hospital to finish his 42-day antibiotics to treat the infection in his spine. Vitals Q4H,
labs drawn as needed, and daily consults. The healthcare team is currently trying to get a psych consult for
depression but the patient refuses and denies depression, states that he just wants to smoke a cigarette and
he will be fine.

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

1. Pain related to inflammation and swelling as evidenced by patient rating pain 7 on a scale from 0 to 10.

2. Risk for infection related to inadequate primary and secondary defenses.

3. Impaired physical mobility related to pain and limitation of movements as evidenced by patient showing signs of
discomfort when moving.

4. Ineffective coping related to life change as evidenced by use of drugs and destructive behavior.

University of South Florida College of Nursing Revision September 2014 14

 15 CARE PLAN
Nursing Diagnosis: Pain related to inflammation and swelling as evidenced by patient rating pain 7 on a scale from 0 to 10.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patients pain will be < 3 on a scale Assess pain intensity level using a Single-dimension pain ratings are Met.
from 0 to 10 by the end of the shift. valid and reliable self-report pain valid and reliable as measures of
tool. pain intensity level (Ackley &
Ladwig, 2014).
Determine if the client is
experiencing pain during
interview/assessments. If pain is Determining OLDCARTS are
present, conduct and document a critical to determine the underlying
comprehensive pain assessment cause of pain and effectiveness of
and implement or request orders to treatment.
implement pain management
interventions to achieve a
satisfactory level of comfort. Cognitive-behavioral (mind-body)
strategies can restore the clients
Administer ordered analgesics. sense of self-control, personal
efficacy, and active participation in
In addition to administering his or her own care.
analgesics, support the clients
nonpharmacological methods to
help control pain, such as
distraction, imagery, relaxation,
and application of heat and cold.
Provide comfort measures.

Check vital signs during (Ackley et al., 2014).

assessment.
Patient will use a self-report pain Teach client to use the self-report The use of comfort function goals Met.
tool to identify current pain pain tool to rate the intensity of provides direction for the treatment
intensity level and establish a past or current pain. plan (Ackley et al., 2014).
comfort-function goal by the end of
University of South Florida College of Nursing Revision September 2014 15
the shift.
Patient will describe how
unrelieved pain will be managed
before being discharged home.
Numerical pain rating scale (0-10)
Teach and implement
nonpharmacological interventions
when pain is relatively well
controlled with pharmacologic
interventions.
Non pharmacological interventions
should be used to supplement, not
replace, pharmacological
interventions (Ackley & Ladwig,
2014).
Unmet, patient is not being
discharged home and admits to not
wanting to quit doing illegal drugs
to help with his pain.

Discuss the clients fears of Cognitive-behavioral (mind-body)

undertreated pain, side effects, and
addiction.
strategies can restore the clients
sense of self-control, personal
efficacy, and active participation in
his or her own care (Ackley &
Ladwig, 2014).

Patient will be able to perform
activities of recovery and ADLs
easily before and after discharge
(long term)
Ask the patient to set a comfort-
functioning goal by selecting a pain
level on the self-report tool that
will allow performance of desired
or necessary activities of recovery
with ease.
Changes are made according to the Unmet, patient is still in the
patients response and achievement hospital.
of the goals of recovery or
rehabilitation (Ackley & Ladwig,
2014).

University of South Florida College of Nursing Revision September 2014 16

 Nursing Diagnosis: Risk for infection related to inadequate primary and secondary defenses.
Patient Goals/Outcomes
Patient will remain free from
symptoms of infection throughout
the shift.
Nursing Interventions to Achieve
Goal
Consider targeted surveillance for
MRSA.
Observe and report signs of
infection such as redness, warmth, shaking, chills, and hypotension
discharge, and increased body
temperature.
Rationale for Interventions Evaluation of Goal on Day Care
Provide References is Provided
The rate for MRSA surgical site Met.
infection (SSI) identified decreased
from 0.23% to 0.09% (Ackley et
al., 2014).
Change in mental status, fever,
are indicators of sepsis (Ackley et
al., 2014).

Assess skin color, moisture, Hospital acquired pressure areas,

Patient will demonstrate
appropriate care of infection prone
site before being discharged.
texture, and turgor. Keep accurate, skin tears, and infections are
ongoing documentation of changes. associated with pain, reduced
mobility, increased risk of inpatient
complications, and increased health
Use appropriate hand hygiene care costs (Ackley et al., 2014).
(handwashing or use of alcohol-
based hand rubs). Meticulous infection prevention
precautions are required to prevent
Administer antibiotics as ordered. health care-associated infection,
with particular attention to hand
hygiene (Ackley et al., 2014).
Ensure the clients appropriate Daily showers or baths can help Met.
hygienic care with handwashing; to reduce the number of bacteria on
bathing; oral care; and hair, nail, the clients skin. The oral cavity is
and perineal care performed by a common site for infection Ackley
either the nurse or client. et al., 2014).

Instruct patient on how to

properly clean surgical incision. Cleaning the surgical incision is
very important in preventing
Make sure the patient infection.
understands discharge instructions
and what is expected of him.
University of South Florida College of Nursing Revision September 2014 17
Patient will maintain white blood Note and report laboratory values While the WBC count may be in Met.
cell count and differential within (white blood cell and differential, the normal range, an increased
normal limits during length of serum protein, serum albumin, and number of immature bands may be
treatment and after. cultures). present (Ackley et al., 2014).
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 To learn about programs and support groups with issues and diagnosis relative to the patient.
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
*F/U appointments Patient should follow up with his primary care doctor and a GI doctor.
*Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No Publix has discounts on antibiotics.
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014 18

 References

Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to planning

care (Tenth ed., pp. 575-582 & 480-483). Maryland Heights, MO: Elsevier Mosby.

Nursing Central. (2015). Unbound Medicine Inc. (Version 1.25) [software]. Available from

http://nursing.unboundmedicine.com/nursingcentral/ub/index/Davis-Lab-and-Diagnostic-

Tests/All/A

Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (Eds.) (2014). Medical-Surgical Nursing

Preparation for Practice (2nd ed., pp. 639, 1491-1492). Upper Saddle River, New Jersey:

Pearson.

Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning (p. 164). Philadelphia,

PA: F.A. Davis Company.

U.S. Department of Agriculture. ChooseMyPlate.gov Website. Washington, DC. Daily Food Plans.

http://www.choosemyplate.gov/tools-supertracker. Accessed March 10, 2016.

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University of South Florida College of Nursing Revision September 2014 20