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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student:Jessica Cadorette
Assignment Date: 3/6/17
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: TGH
1 PATIENT INFORMATION
Patient Initials: S.G Age: 91 Admission Date: 2/28/17
Gender: Female Marital Status: Divorced Primary Medical Diagnosis: right hip fracture

Primary Language: English


Level of Education: Bachelor degree plus some graduate courses Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired from teaching Osteoporosis
Number/ages children/siblings:1 daughter 64 years old
2 older brothers both deceased
Served/Veteran: Code Status: full
If yes: Ever deployed? Yes or No
Living Arrangements: Lives with daughter in two story home. Advanced Directives: Yes
Bedroom is upstairs If no, do they want to fill them out?
Surgery Date: 3/1/17 Procedure:
Intramedullary nailing right hip
Culture/ Ethnicity /Nationality: white
Religion: Catholic Type of Insurance: United Healthcare

1 CHIEF COMPLAINT:
I was on my way to my primary physician and I got up to the bottom of the bed and had the worst case of vertigo. I
grabbed my bedspread and fell.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Pt presented to ED via EMS after a fall at home. Pt suffers from chronic vertigo, pt tried to get out of bed when she got
dizzy and fell. Onset occurred on 2/28/17. Pt had constant aching right hip pain. Walking made the pain worse and when
she elevated her leg it slightly relieved the pain. Pt did not try any treatments before coming to ED. Pain was rated a
10/10. X-ray showed acute right femoral neck fracture. Pt was admitted on 2/28/17 and received intramedullary nailing
on her right hip on 3/1/17.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
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1980 hysterectomy
1980 cholecystectomy
10/28/13 Pericardial window
10/28/13 Transesophageal echo
2016 Breast cancer
2/6/17 Breast lumpectomy

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause
Alcoholism

MEDICAL

Glaucoma

Problems

Problems
Allergies

of

Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY

Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father 84 Emphysema
Mother 95 stroke
Brother 55 cancer
Medical
Brother 70
error
relationship

relationship

relationship

Comments: Pt is unsure when father was diagnosed with emphysema. Pt is unsure when mother was diagnosed with cancer. Brother
was diagnosed with colon cancer at 45.

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? U
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years? Yes, 2016
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

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Medications codeine I constantly threw up

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latex blisters
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)
Osteoporosis is condition defined by decreased bone strength and is most prevalent in postmenopausal women. Clinical

manifestations of osteoporosis are vertebral and hip fractures. Osteoporosis can be diagnosed several different ways

including: chest and bone radiographs, dual x-ray absorptiometry, CBC, basic chemistry panel, and liver function test

(Malik, 2014). Osteoporosis related hip fracture incidences increases with age and typically peaks after 85 years.

Treatment of osteoporosis is management of acute fractures, modifying risk factors, and treating underlying disorders.

Ways to prevent acute fracture related to osteoporosis is weight bearing exercises, initiating fall precautions, and oral

calcium and vitamin D supplements (Kasper et al, 2013).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name amiodarone Concentration: 200mg Dosage Amount: 200mg

Route: oral Frequency: 2x daily


Pharmaceutical class: Antiarrhythmic Home Hospital or Both
Indication: Atrial Fibrillation
Adverse/ Side effects: bradycardia, cardiogenic shock, 2nd or 3rd degree AV block
Nursing considerations/ Patient Teaching: Report signs of pulmonary toxicity (coughing, wheezing, hemoptysis)

Name: Cholecalciferol Vitamin D3 Concentration: 400 units Dosage Amount: 400 units

Route: oral Frequency: daily


Pharmaceutical class: Vitamin D Home Hospital or Both
Indication: prophylaxis- falls
Adverse/ Side effects: abnormal lipids, hypervitaminosis D
Nursing considerations/ Patient Teaching: report signs of hypercalcemia, nausea, anorexia, weight loss

Name: lovenox Concentration 30mg Dosage Amount 30mg

Route: subcutaneous Frequency: twice daily


Pharmaceutical class: anticoagulant Home Hospital or Both
Indication: DVT prophylaxis
Adverse/ Side effects: diarrhea, nausea, anemia, thrombocytopenia, increase LFT
Nursing considerations/ Patient Teaching: report bleeding, pt should lie down during injection, avoid NSAIDs without consulting a physician

University of South Florida College of Nursing Revision September 2014 3


Name: furosemide Concentration: 40mg Dosage Amount 40mg

Route: oral Frequency: twice daily


Pharmaceutical class: loop diuretic Home Hospital or Both
Indication: edema
Adverse/ Side effects: hyperuricemia, hypomagnesaemia, loss of appetite, spasm of bladder
Nursing considerations/ Patient Teaching: advise patient to wear sunscreen, report unusual bleeding/ bruising, eat food high in potassium

Name: pantoprazole Concentration: 40mg Dosage Amount: 40mg

Route: oral Frequency: daily


Pharmaceutical class: proton pump inhibitor Home Hospital or Both
Indication: GERD
Adverse/ Side effects: abdominal pain, diarrhea, Headache, flatulence
Nursing considerations/ Patient Teaching: may increase risk for fractures, report signs and symptoms of hypomagnesemia (dizziness,
palpitations,tetany,seizures)

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

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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 Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Crme of wheat with raisins and brown sugar, This breakfast has an adequate amount of refined grains
scrambled eggs, decaf coffee with creamer. and protein. However, adding a yogurt can help increase
the patients diary intake.

Lunch: chicken salad, roll with butter, Italian wedding soup This lunch provides protein and carbohydrates. To help
increase the patients dairy intake adding a smoothie with
milk or having a couple sticks of string cheese. The patient
is over her amount of protein so perhaps she can cut her
chicken salad portion is half.

Dinner: sliced turkey with mashed potatoes and coconut ice Patient has a good dinner with a good source of protein. To
cream for dessert help increase the patients diary intake she could perphaps
have a glass of milk with her dinner.

Snacks: kind bars, banana chips Patient has a good choice in snacks. However, since the
patient is over her fruit intake and low in her diary intake
the patient should eat some yogurt for a snack with some
granola mixed, which will also increase her grains.

Liquids (include alcohol): water, orange juice

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?
Daughter
How do you generally cope with stress? or What do you do when you are upset?
University of South Florida College of Nursing Revision September 2014 5
I like to talk about my stress with my daughter.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I am feeling anxious that I wont be able to get back to my regular routine. I want to still be able to drive to go see my
friends.

+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? no

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: In this stage 65 years and older, adults become senior citizens and productivity decrease and one explores life as a
retired person. Adults develop integrity when one takes the time to look back at life and sees themselves having a successful life. One
develops despair when one sees their life as unproductive, feels guilty about the past, and that they did not accomplish life goals
(Treas, Wilkinson 2014)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient is in the ego integrity phase. She is in this stage because she has no regrets on how her life how turned out, and
believes she has lived a successful life. My patient stated looking back on my life, I am so proud of how it turned out and
am so happy how my daughter turned out. This patient does not have a negative outlook on her life.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
This hospitalization has had a slight impact on her developmental stage because my patient is worried about being able to
return to her ADLs due to her age. Despite the worry my patient still believes that regardless of what the future holds she
is still happy the way her life has gone.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Falling down like a fool

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What does your illness mean to you?
Interfering with my social life and the nature of my existence.

+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? _________no__________________ If yes, are you in a monogamous relationship?
_____n/a_______________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? ___nothing_______________________________

How long have you been with your current


partner?____n/a____________________________________________________

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

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

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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?
It is very important because it makes me feel happy and connected._______________________
_____________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
It helps me cope____________
_______________________________________________________________________________________
______________________________________________________________________________________________________

+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? 52 years
cigarettes 5 cigarettes daily (age 18 thru 70 )

If applicable, when did the


Pack Years: 13 years
patient quit? When pt was 70

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit? yes
so, what, and how much? no If yes, what did they use to try to quit? nothing

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? White wine How much? 1 glass For how many years? 69 years
Volume: 4oz (age 22 thru currently )
Frequency: 1 glass every couple of
months
If applicable, when did the patient quit?
n/a

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

Is the patient currently using these drugs?


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

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

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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: 15 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?
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:
Normal frequency of urination: 8-
Post-nasal drip Other:
9/day
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2/day Diabetes Type:
Routine dentist visits 2/year Hypothyroid /Hyperthyroid
Vision screening every other year 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 UTI Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? June Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies- pollen, oak menarche age? 11 Encephalitis
last CXR? 2/28/17 menopause age? 60 Meningitis
Date of last Mammogram &Result:
Other: Other:
January, lump on right breast
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 right hip Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 3/6/17 Arthritis Chicken Pox
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Other: Other: Other:

General Constitution
Recent weight loss or gain No
How many lbs?
Time frame?
Intentional?
How do you view your overall health? I fee like my overall health is very good due to the fact that Im still here.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Chronic leg edema

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

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10 PHYSICAL EXAMINATION:

General Survey: Height 53 Weight 153lbs BMI Pain: (include rating and
Pulse 82 Blood Pressure: (include location) location)
Respirations 16 136/34 brachial arm 3 right leg
Temperature: (route SpO2 100% Is the patient on Room Air or O2
taken?) room air

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: Location: Date inserted:


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 2 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 8 inches & left ear- 9 inches
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: thick thin Amount: scant small moderate large there is no sputum production
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL clear LUL clear
RML clear LLL clear
RLL clear

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 No JVD

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Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

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: did not check Popliteal: did
not check DP: 2 PT: 2
No temporal or carotid bruits Edema: 2+ [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: right leg 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 3 / 5 / 17 ) 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: 2100 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 __1_____ 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 kyphosis is present
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 did not
assess Romberg
Stereognosis, graphesthesia, and proprioception intact- did not assess 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: did not assess Biceps: did not assess Brachioradial: did not assess Patellar: 2+ Achilles: did not assess Ankle
clonus: positive negative Babinski: positive negative

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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


Hgb 3/2,3/3,3/5 Values are low but A decrease in hemoglobin
7.9 g/dL,8.2 g/dL,9.1 trending upward is expected
g/dL postoperatively due to
bleeding from the wound
and bleeding into soft
tissues. It may take up to
4 days before hemoglobin
levels return to normal
range ( Nagra, Popta,
Whiteside, Holt, 2016).
Hct 3/2,3/3,3/5 Low but trending upward Blood loss is an
24.5 %,22.4%,27.1% important complication
that occurs during hip
surgery, therefore hct
levels are expected to
drop postoperatively.
However, if hct levels are
still low 48 hours after
surgery, blood transfusion
may occur (Seijas et al,
2015).
BUN 3/2,3/3,3/5 Values were high and BUN can be increased
28 mg/dL,32 mg/dL,20 have returned to normal following surgery due to
mg/dL values a number of reasons
including dehydration.
BUN should be
monitored 5 days
postoperatively and if
they have not return to
normal range kidney
damage may occur
(Hassan, Sahlstrom,
Dessau, 2015).
x-ray 2/28 Only one x-ray was taken X-ray was done in order
to diagnose fracture. X-
ray showed osteoporosis
related fracture.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,


multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
University of South Florida College of Nursing Revision September 2014 13
accu checks, etc. Also provide rationale and frequency if applicable.)
Vitals every 4 hours- floor policy, pt is on a regular diet, ambulate activity is as tolerated, weigh pt every Monday
and Thursday due to edema and pt is on Lasix.

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


1. impaired physical mobility r/t pain + discomfort aeb reports of pain and discomfort on movement

2.fear r/t future mobility aeb patient stating Im scared I will not be able to my old routines

3. risk for falls r/t fractured right hip aeb not being able to put weight on right foot

4.

5.

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15 CARE PLAN
Nursing Diagnosis: impaired physical mobility r/t pain + discomfort aeb reports of pain and discomfort on movement

Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Short term:
Reduce pain+ discomfort Medicate patient before activity Pain limits mobility and is often Patient was given pain medication
exacerbated by mobility (Ackley, before therapy. After activity
Ladwig, 2011). patient stated a 2 on a pain scale of
0-10 and was able to tolerate
activity today.
reduce edema Elevating right leg when lying Reducing edema will help relieve Patient obtained a foam pillow to
down pressure on feet and will increase elevate right leg when sitting
mobility (Ackley, Ladwig, 2011). down.
Increase physical activity to 100 Obtain a walker before activity Assistive devices can help increase Patient was given a walker from
steps today mobility (Ackley and Ladwig, PT and used it to ambulate around
2011). the room today. Due to walker
patient was able to tolerate walking
100 steps.
Long term:
Display increased strength and Allow patient to perform own ADL Providing unnecessary assistance Patient performed ADLs today.
function of affected leg with ADLs may promote
dependence and a loss of mobility
(Ackley and Ladwig, 2011).
Have patient perform active ROM These exercises will help reverse I explained to patient that flexing
exercises using both upper and weakening and atrophy of muscles. and extending hips, ankles, and
lower extremities. Will allow pt to increase strength knees will help increase her
of muscles (Ackley and Ladwig, strength. However, patient did not
2011). perform these exercises.

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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

15 CARE PLAN
Nursing Diagnosis: fear r/t future mobility aeb patient stating Im scared I will not be able to my old routines

Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Short term:
Verbalize known fears Assess source of fear with the Having the patient verbalize fear
Patient verbalized fear as not being
patient will allow the patient to talk about
able to walk properly again thus
the fear and reduced stress related
not allowing here to live the life
to the fear (Ackley and Ladwig,
she once did. Patient verbalize that
2011). talking about her fear helped calm
her down.
Stay with the patient when they Healing touch may reduce stress, When patient talked about her fear
express their fear and provide anxiety, and pain and provide a I stayed with her to provide
verbal and nonverbal reassurance greater sense of well-being (Ackley reassurance. I maintained eye
and Ladwig, 2011). contact with her at all times and
she started crying and I touched her
hand at that time. Patient thanked
me for being with her.
Demonstrate coping behaviors that Explore coping skills previously Recounting previous experiences Patient says she copes by talking
University of South Florida College of Nursing Revision September 2014 16
reduce fear used and reinforce these skills and that were perceived by the patient with her daughter and it helps her. I
explore other outlets. as having been dealtt with offered her how journaling about
successfully strengthens effective her feelings could be another
coping and helps eliminate coping skill for when her daughter
ineffective coping mechanism is not around.
(Ackley and Ladwig, 2011).
Long term:
Report and demonstrate reduced Encourage patient to express their One of the main ways in which I explained this to the patient and
fear fears in narrative form. people adjust to threat associated she said when she feels fearful and
with serious illness is through the is about to talk about it with her
use of narrative, which helps make daughter she said she would do
sense of illness (Ackley and this.
Ladwig, 2011).

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 17


References

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0299-0

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Seijas, R., Espinosa, W., Sallent, A., Cusco, X., Cugat, R., Ares, O. (2015). Comparison of Pre- and Postoperative

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Doi:10.2174/1874325001509010432

Treas,L.S., & Wilkinson, J.M (2014). Basic Nursing: concepts, skills,& reasoning. Philadelphia: F.A. Davis.

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University of South Florida College of Nursing Revision September 2014 19