UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Jeanne Zamith
Assignment Date: 02/09/2017
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: LRH
1 PATIENT INFORMATION
Patient Initials: DT Age: 53 Admission Date: 01/25/2017
Gender: F Marital Status: Widowed Primary Medical Diagnosis: Diverticulitis
Primary Language: English
Level of Education: High School graduate Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Disabled; worked in computer
software industry
Number/ages children/siblings: 2 children: ages 32 & 34
3 siblings: Ages 45, 47, and one deceased at age 31
Served/Veteran: Code Status: Full resuscitation
If yes: Ever deployed? Yes or No
Living Arrangements: Living with boyfriend in an apartment on the Advanced Directives:
second floor, but is moving to first floor at the end of this month. If no, do they want to fill them out?
Surgery Date: (02/05/2017) Procedure: abscess
drainage
Culture/ Ethnicity /Nationality: German
Religion: Catholic Type of Insurance: Case-pending; Polk County
Health Insurance

1 CHIEF COMPLAINT:
Patient claims her stomach was the size of a basketball and was experiencing severe pain in [her] stomach.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCARTS the symptoms in addition to the hospital course
of stay)
Patient was admitted to the Emergency Department on Wednesday, January 25, 2017 at 2130 as a result of an
enlarged abdominal abscess, a complication of her recent abdominal surgery. Patient claimed to have pain in the LLQ
in the abdominal region. According to the patient, the stomach pain is pretty much constant, worsening depending
on what she eats. When the pain exacerbates, it is sharp and feels as if someone is stabbing her. Patient claims she
tries to follow the recommended diet for her diagnoses to prevent the pain from worsening. The only thing the patient
has found to relieve symptoms are her pain medications. Patient has had multiple abdominal surgeries in attempt to
remove the affected section of the colon and creation/reversal of colostomy, and nothing has seemed to work. On a
pain scale from 0 to 10, before intervention, patient states that her pain is a 9 or a 10. After intervention, patient
claims that her pain level goes down to around a 5 or 6.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
around 2002 Hypertension: No hospitalizations, PCP prescribed metoprolol and told pt. to manage with a low
sodium diet
University of South Florida College of Nursing Revision September 2014 1
 The same time as Hyperlipidemia: No hospitalization, PCP prescribed simvastatin
diagnoses of
HTN
06/2014 GERD: No hospitalizations, PCP told patient to eat less spicy foods, fat, and acid.
Diverticulitis of Colon with Perforation: 7 hospitalizations since diagnosis; multiple abdominal
06/2015 surgeries to create/reverse colostomies and remove affected sections of the colon, antibiotics, and
change of diet.

(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 N/A N/A
Mother 73 N/A
Brother 1 31 MVA
Brother 2 49 N/A
Sister 1 47 N/A
Comments: Include age of onset
Father: Patient claims that she never knew father and is unaware of his age and medical history.
Mother: Patient claims she is unaware of when mother was diagnosed with HTN, but claims her mothers depression began after her
second husband passed away.
Brother 1: Patient claims her brother began drinking excessively when he was 23 and passed away at the age of 31 from a MVA.
Brother 2: Patient states that her brother lives in Ohio and does not know much about him.
Sister 1: Patient stated that her sister was diagnosed with a brain tumor the size of a lemon sometime last year. The tumor is benign.

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) U
Adult Tetanus (Date) Is within 10 years? 2016
Influenza (flu) (Date) Is within 1 years? 2016
Pneumococcal (pneumonia) (Date) Is within 5 years? 2016
Have you had any other vaccines given for international travel or
occupational purposes? Please List

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Penicillin Apnea & Urticaria
Cipro Urticaria
Medications Sulfa Urticaria
Morphine Pruritus all over body and urticaria
Codine Urticaria
Other (food, tape,
latex, dye, etc.) Sensitive to tape Pruritus around the location of the tape
Bees Apnea & Urticaria
University of South Florida College of Nursing Revision September 2014 2
 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)
Diverticula form in weak portions of the tunica muscularis, where it is penetrated by arteries. Areas where
there is normally a high pressure due to pushing fecal material are especially susceptible to the formation of
diverticula. The diverticular sacs form when the further weakening of the inherent weak portions of the
intestinal wall allows the mucosa to herniate through smooth muscle. Entrapment of undigested food and
bacteria in the diverticular sacs causes inflammation in the diverticula, otherwise known as diverticulitis.
Risk factors for diverticulosis/diverticulitis include: consumption of a low-fiber diet and age, after the age of
60 (Osborn, Wraa, and Watson, 2010, p. 1407-1409). Researchers have found certain gene expressions can
lead to the formation of diverticulitis; however, the expressivity of those genetic components decreases
tremendously with the consumption of a high-fiber diet (Commane, 2009). Diverticular disease, for the most
part, is asymptomatic and usually detected in a routine colonoscopy; however, if the symptoms develop and
diverticulitis occurs, doctors will order a CBC, looking for bleeding and/or infection. If bowel perforation is
suspected, providers may order abdominal x-rays to show the free air due to the perforation (Osborn et al
2010, p. 1407-1409). Currently, research has shown that the most effective treatment of diverticular disease
includes dietary modifications and drug therapy (Commane, 2009). Dietary restrictions may include foods
such as: seeds, nuts, popcorn, grapes, berries, broccoli, and cucumbers. Drug therapy may include broad-
spectrum anti-biotics, Cipro, Flagyl, or Bactrim. Because of the severe pain due to the
inflammation/infection, analgesics may be given as well. Providers also recommend that patients with acute
diverticulitis to rest as much as possible to prevent an increase in intra-abdominal pressure, which could
cause further perforation. If symptoms do not progress, surgery may be needed and usually consists of a
temporary colostomy and/or a bowel resection (Osborn et al 2010, p. 1407-1409).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF), home (reconciliation), routine, and
PRN medication. Give trade and generic name.]
Name: levofloxacin (Levaquin) Concentration: N/A Dosage Amount: 500 mg (1 tablet)

Route: PO Frequency: q24h

Pharmaceutical class: Antibiotic (fluoroquinolone) Home Hospital or Both

Indication: Intra-Abdominal Infection
Adverse/ Side effects: Urticaria, nausea, headaches, ABD pain, changes in taste, sleep disturbances, neurotoxicity, tendon rupture, dysrhythmias

Nursing considerations/ Patient Teaching: Increased the effects of oral hypoglycemics and caffeine; avoid caffeine; stop drug and notify provider of joint pain

Name: metronidazole (Flagyl) Concentration: N/A Dosage Amount: 500 mg (1 tablet)

Route: PO Frequency: q8h

Pharmaceutical class: Antibiotic Home Hospital or Both
Indication: Intra-Abdominal Infection
Adverse/ Side effects: Numbness, tingling, white patches, diarrhea, vision problems, dry mouth, coughing, sneezing, reddish-brown urine in high doses
Nursing considerations/ Patient Teaching: Avoid alcohol, avoid during first trimester of pregnancy, disulfiram reaction (if alcohol is consumed), LOTS of D/Is

Name: acetaminophen-oxycodone (Percocet) Concentration: N/A Dosage Amount: 300 mg-2.5mg (2 tablets)

Route: PO Frequency: q4h

Pharmaceutical class: Opioid analgesic Home Hospital or Both
Indication: Pain secondary to diverticulitis
Adverse/ Side effects: Nausea, vomiting, diarrhea, bradycardia, dysuria, dry mouth
Nursing considerations/ Patient Teaching: No alcohol, Seek medical attention if hallucinations, agitation, diaphoresis, fever, and/or shivering occur

University of South Florida College of Nursing Revision September 2014 3

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular
Diet patient follows at home? about the same as what [shes] eating here
24 HR average home diet:
Breakfast: Patient claims that she doesnt normally eat breakfast but will drink a cup of coffee in the morning.
Lunch: Ham and cheese sandwich (without seeds on bread) and broccoli cheddar soup
Dinner: Chicken, potatoes, and peas or corn
Snacks: I really like chocolate, but I know its not very good for me, so I try not to eat it that often.
Analysis of home diet (Compare to My Plate and Consider co-morbidities and cultural considerations):
Considering the patients diagnoses of diverticulitis, hypertension, and hyperlipidemia, it is important that the patient
follows a diet that is low in sodium, acid, and fat and is high in fiber. The patient seems to follow her recommended diet
to manage diverticulitis pretty well, other than the chocolate that she eats rarely, maybe one chocolate bar every other
week or so. She does not eat foods with seeds because the seeds could lodge into the diverticula, thus, worsening the
diverticulitis. However, considering the patients diagnosis of hypertension, the SuperTracker estimates her meal
consisting of 3615 mg of sodium, approximately 1100 mg more than the recommended amount. A high sodium diet
yields to more water being retained in the body, which raises blood pressure.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your
discussion)
Who helps you when you are ill?
My boyfriend
How do you generally cope with stress? or What do you do when you are upset?
Ive cried a lot in these past two years since the doctors told me about the diverticulitis. I dont really cope that well. I
usually just take it out on my boyfriend, which I know is not good.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The biggest stress I have right now is the stress of this disease. Patient stated that since the diagnosis, she has been also
diagnosed with anxiety and depression and has been prescribed Ativan to relieve those symptoms.

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? No, I dont care what shape Im in. I dont take that s***.
Have you ever been talked down to? No
Have you ever been hit punched or slapped? No, Ive been pretty lucky.
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, I have a boyfriend that Ive been with for seven years

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:

University of South Florida College of Nursing Revision September 2014 4

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
DT is a 53 year old female, who falls under the Generativity vs. Stagnation stage of Eriksons psychological development. She feels
as if this disease doesnt allow her to have a normal social life and has brought insecurity and depression. Patient is not self
absorbed, but stagnant and focuses more on the disease than the positive aspects of her life, such as her children and her boyfriend
(Treas and Wilkinson, 2015, p. 164).

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
Patient had a job of 19 years she enjoyed but had to file as a disabled worker due to the diverticulitis. She now feels as if the
only thing there is to live for is her boyfriend. Due to constant, severe abdominal pain/surgery, patient dreads going out with
friends or doing activities she used to like before this diagnosis.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient stated that the doctors believe the patient inherited it from someone, but because 10 years ago, people
wouldnt survive this disease, she wouldnt know if [her] family member died with diverticulitis or from
diverticulitis.

What does your illness mean to you?

I hate it. I dread it every single day, but I dont have a choice. I wish I would just stop getting worse then
better then worse then better over and over again.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Have you ever been sexually active? Yes, I was more sexually active, but with this pain, it always hurts.
Do you prefer women, men or both genders? Men, I have a boyfriend.
Are you aware of ever having a sexually transmitted infection? No.
Have you or a partner ever had an abnormal pap smear? The last pap smear the patient had last June was
abnormal, but the doctors think it was possibly a complication of the several surgeries in the lower abdominal
region over the past two years.
Have you or your partner received the Gardasil (HPV) vaccination? I probably have. I feel like I get shots
all the time.
Are you currently sexually active? Not really, this stupid disease makes my whole stomach hurt all the time,
but my boyfriend understands.
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? Patient claims to not take measures to prevent acquiring an STD, but she is in a
monogamous relationship. Patient stated that she went through menopause 7 years ago, so she also does not take
measures to prevent pregnancy.
How long have you been with your current partner? 7 years
Have any medical or surgical conditions changed your ability to have sexual activity? The patient claims
that the diverticulitis causes too much pain to be sexually active.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or
unintended pregnancy? No.

University of South Florida College of Nursing Revision September 2014 5

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Patient claimed that her religion has no importance in her life
Do your religious beliefs influence your current condition?
Well, God didnt cause this. This disease is devilish.

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

SMOKING:
Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes, quit about 6 months ago.
If so, what? Cigarettes
How much? (specify daily amount) 1 pack/day
Pack Years: 277,400
For how many years? 38 years (since 15 years old)
If applicable, when did the patient quit? About 6 months ago
Does anyone in the patients household smoke tobacco? My boyfriend does
If so, what, and how much? He smokes about a pack a day or so.
Has the patient ever tried to quit? Yes, I quit 6 months ago.
If yes, what did they use to try to quit? I kinda just stopped.

ALCOHOL:
Does the patient drink alcohol or has he/she ever drank alcohol? No, I cant drink with diverticulitis, but I was never
really into drinking anyway.
What? I used to drink wine, never hard liquor.
How much? Patient stated that she would drink wine with dinner sometimes.
For how many years? I dont know. Maybe since I was in my mid-twenties?
Frequency? Patient stated that she had a glass of wine with dinner about once or twice a week.
If applicable, when did the patient quit?

CHEMICAL USE:
Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No, and I never will.
If so, what? Did not ask because patient stated that she had never tried the specified substances.
How much? Did not ask because patient stated that she had never tried the specified substances.
For how many years? Did not ask because patient stated that she had never tried the specified substances.
Is that patient currently using drugs? Did not ask because patient stated that she had never tried the specified
substances.
When did the patient quit? Did not ask because patient stated that she had never tried the specified substances.

Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No, not that I know of.
For Veterans: Have you had any kind of service related exposure?
Patient is not a veteran.

University of South Florida College of Nursing Revision September 2014 6

 10 REVIEW OF SYSTEMS NARRATIVE
Integumentary Gastrointestinal Immunologic
Changes in appearance of skin Nausea, vomiting, or diarrhea Chills with severe shaking
Problems with nails Constipation Irritable Bowel Night sweats
Dandruff GERD Cholecystitis Fever
Psoriasis Indigestion Gastritis / Ulcers HIV or AIDS
Hives or rashes (FROM ALLERGIES
Hemorrhoids Blood in the stool Lupus
TO MEDS)
Skin infections Yellow jaundice Hepatitis Rheumatoid Arthritis
Use of sunscreen SPF: 30 or 40 Pancreatitis Sarcoidosis
Bathing routine: Every day Colitis Tumor
Other: Open wounds from 02/05
surgery/scars from multiple previous Diverticulitis Life threatening allergic reaction
surgeries
Appendicitis Enlarged lymph nodes
HEENT Abdominal Abscess Other: Patient denied other issues.
Difficulty seeing: Wears glasses Last colonoscopy? 12/2016
Cataracts or Glaucoma Other: Patient denied other issues. Hematologic/Oncologic
Difficulty hearing Anemia
Ear infections Genitourinary Bleeds easily
Sinus pain or infections nocturia Bruises easily
Nose bleeds dysuria: sometimes Cancer
Post-nasal drip hematuria Blood Transfusions
Oral/pharyngeal infection polyuria Blood type if known:
Dental problems: false teeth/bridge kidney stones Other: Patient denied other issues.
Routine brushing of teeth: 3x/day Normal frequency of urination: 5 or 6/day
Routine dentist visits: 2x/year Bladder or kidney infections Metabolic/Endocrine
Vision screening: 1x/year Diabetes Type:
Other: Patient denied other issues. WOMEN ONLY Hypothyroid /Hyperthyroid
Infection of the female genitalia Intolerance to hot or cold
Pulmonary Monthly self breast exam Osteoporosis
Difficulty Breathing Frequency of pap/pelvic exam: 1x/year Other: Patient denied other issues.
Cough - dry or productive Date of last gyn exam? June 2016
menstrual cycle regular
Asthma Central Nervous System
irregular
Bronchitis menarche age? CVA
menopause age? 38, and the doctors
Emphysema Dizziness
dont know why it was so early.
Date of last Mammogram & Result: June,
Pneumonia Severe Headaches
Clear
Date of DEXA Bone Density & Result:
Tuberculosis Migraines
June, Clear
Environmental allergies Seizures
last CXR? 12/2016 MEN ONLY Ticks or Tremors
Other: Patient denied other issues. Infection of male genitalia/prostate? Encephalitis
Frequency of prostate exam? Meningitis
Cardiovascular Date of last prostate exam? Other: Patient denied other issues.
Hypertension BPH
Hyperlipidemia Urinary Retention Mental Illness
Chest pain / Angina Musculoskeletal Depression
Myocardial Infarction Injuries or Fractures Schizophrenia
CAD/PVD Weakness Anxiety
CHF Pain Bipolar
Murmur Gout Other: PTSD
Thrombus Osteomyelitis
University of South Florida College of Nursing Revision September 2014 7
 Rheumatic Fever Arthritis Childhood Diseases
Myocarditis Other: Patient denied other issues. Measles
Arrhythmias Mumps
Last EKG screening, when? 01/2017 Polio
Other: Patient denied other issues. Scarlet Fever
Chicken Pox
Other: Patient denied other issues.

General Constitution
Recent weight loss or gain
How many lbs? 55 lbs
Time frame? 2 years
Intentional? No
How do you view your overall health? Good, other than this disease.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient claimed that even if she has the slightest of symptoms, she visits her PCP.
Any other questions or comments that your patient would like you to know?
Patient denied having any questions.

10 PHYSICAL EXAMINATION:

General Survey: A & O x3
Temperature: (route
taken?) 97.8F 98.24F
ORAL
Height: 5 ft. 6 in. Weight: 165 pounds BMI: 26.6 Pain (include rating and
Pulse: 88 89 Blood Pressure: (include location): location): LLQ; 9/10
RR: 1616 125/58 104/55
SpO2: 96% 98% Is the patient on Room Air or O2

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 (patient has an open wound
currently healing via secondary intention`)
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: PICC Location: Right Shoulder Date inserted: 01/25/2017
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
University of South Florida College of Nursing Revision September 2014 8
 Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 3/mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: *Did not assess*
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Some teeth missing, fake teeth present
Comments: Was not able to determine whether or not thyroid gland was enlarged or within normal limits

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 *Did not percuss because of incisions and
ABD pain*
Sputum production: None Amount: No sputum
Color: No sputum
Lung sounds: Clear, no rhonchi, wheezing present.
RUL: CL, No RH, CR or WH present. LUL: CL, No RH, CR or WH present.
RML: CL, No RH, CR or WH present. LLL: Did not auscultate because of ABD pain
RLL: Did not auscultate because of ABD pain
(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
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: 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: N/A
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: 02/08/2017) 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: Bowel sounds were present in RUQ & LUQ, but nurse was unable to auscultate LLQ and RLQ because
of wounds located in the LQ of the ABD. Also, did not percuss because of ABD pain. Organomegaly, ABD area, present
because of recent ABD surgery.

GU Urine output: Clear Cloudy Color: pale yellow Previous 24 hour output: 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 RUE: 5 LUE: 5 RLE: 5 LLE: 5
[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
Patient was unable to complete most ROM exercises that engage the core due to ABD trauma from surgery

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

University of South Florida College of Nursing Revision September 2014 9

 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: 2 Achilles: 2 Ankle clonus: negative Babinski: negative

Patient was in pain at time of assessment and did not want to get out of her bed to complete the test for proprioception and
the Rombergs test; however, graphesthesia and stereognosis were intact.

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):

Lab Results Dates Trend Analysis

WBC 9.6 02/04/2017 WBCs are trending Patient had surgery to
(4500-10000 12.2 02/07/2017 upwards, despite the remove an abdominal
WBCs/mcL) treatment of anti- abscess four days ago.
biotics. The values Due to a combination of
were considered within the disease process and
normal range, but are surgical intervention,
now slightly elevated. inflammation and
infection are present, and
white blood cells are
inevitably present.
Hgb 10.3 02/04/2017 Hgb and Hct are Considering the patient is
(12-15.5 g/dL) 10.9 02/07/2017 trending upwards, post-op, some blood was
getting closer toward loss, which causes
Hct 28.4 02/04/2017 normal values. H&H to temporarily
(34.9-44.5%) 29.6 02/07/2017 decrease, causing anemia.
Colonoscopy Inflamed and 06/2015 The colonoscopy The signs of diverticulitis
infected diverticula 12/2016 showed diverticulitis is are not progressing as
present still present, even after evidenced by constant
a two year battle and inflammation and
multiple abdominal infection of diverticula.
surgeries, including Treatment needs to be
creation/removal of modified and further
colonostomies. education about diet
needs to occur.
Abdominal CT Diverticular 06/2015 The CT from 06/2015 The signs of diverticulitis
perforation + 02/2017 showed only are worsening as
abscess formation diverticulitis and evidenced by formation
perforation; however, of abscess in abdomen.
the most recent CTs Treatment needs to be
results showed abscess modified and further
formation, which education about diet
needed immediate needs to occur.
surgical intervention.

+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.)
DT is currently on clear liquid diet. Vitals are within normal limits; however, blood pressure is low,
possibly as a result of the surgery. Considering the hypotension and post-op status, the health care team
placed her on an assist x1 with bathroom privileges. Patient has no further diagnostic tests.
Gastroenterologist is on the case, and social work has been contacted to discuss options the patients
insurance has in regards to home health for wound care.

University of South Florida College of Nursing Revision September 2014 10

 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) (Ackley, 2007)

1) Chronic Pain r/t inflammation of bowel aeb patient pain scale 9/10 since diagnosis and pain increases
after eating
2) Imbalanced nutrition: less than body requirements r/t vomiting and diarrhea aeb abdominal pain, patient
stating I just cant keep anything down.
3) Deficient knowledge r/t diet needed to control disease, medication regimen aeb multiple previous
hospitalizations due to poor diet control

15 CARE PLAN
Nursing Diagnosis: Chronic Pain r/t inflammation of bowel aeb patient pain scale 9/10 since diagnosis and
increased pain level after eating (Ackley, 2007).

Patient Goals/Outcomes:
Patient will use a self-report pain tool to identify current pain level and establish a comfort-functioning
goal by end of shift.
Patient will explain the importance of rest post-op and with diverticulitis with perforation.
Patient will notify a health-care worker for pain level greater than the comfort-function goal.
Nursing Interventions + Rationales:
Nurse will assess the pain level in a client using a valid and reliable self-report pain tool.
o The first step of pain management is determining how severe the pain is. Using a scale that is
universal provides clarity to the rest of the team providing care for that specific patient.
Nurse will assess the client for pain routinely, along with the characteristics of the pain, during activity
and rest.
o Routine monitoring of pain management allows room for improvement, thus improving patient
care and comfort level.
Nurse will educate patient about the importance of rest.
o Patients with acute diverticulitis should rest as much as possible to prevent an increase in intra-
abdominal pressure, which could cause further perforation.
Nurse will assess pain location, characteristics, and intensity with every report of pain.
o Regular assessment of these symptoms allows for better pharmacological pain control and
nonpharmacological means of alleviating pain; i.e. assisting patient in moving pillow to decrease
pain in specific areas.
Evaluation of Goal:
Patient was able to self-report a pain level of 9/10.
Patient verbalized the importance of rest both post-op and with diverticulitis with perforation.
Patient assessed pain location, characteristics, and intensity five times throughout the shift. Student
nurse explained the patients pain level to nurse, and nurse was able to give the patient PRN pain
medications.

University of South Florida College of Nursing Revision September 2014 11

Nursing Diagnosis 2: Imbalanced nutrition: less than body requirements r/t vomiting and diarrhea and lack of
interest in food aeb abdominal pain, patient stating I just cant keep anything down, and unintentional loss of
55 pounds in one year (Ackley, 2007).

Patient Goals/Outcomes:
Patient will consume adequate amount of calories, while maintaining an appropriate diet for patients
with diverticulitis.
Patient will maintain proper electrolyte balance.
Patient will understand, and verbalize, the importance of proper nutrition in both wound healing and in
gastrointestinal health in general.
Nursing Interventions + Rationales:
Nurse will assess for dehydration.
o Excessive diarrhea causes dehydration, which could lead to dysrhythmias, seizures, cramping,
decreased mental status, etc.
Nurse will encourage physical activity throughout the day.
o While rest is important with those with diverticulitis, mobility is also pertinent, especially post-
op, to allow for proper digestion of food and gut mobility.
Nurse will determine the time of day the patient prefers to eat.
o This will allow for patients to feel independent, comfortable, and at home. This also allows
for the patient to get into a habit of proper dieting and meal times.
Nurse will monitor electrolyte balance and report abnormalities.
o Excessive vomiting and diarrhea cause fluid depletion, and thus, electrolyte imbalances as well.
Nurse will educate patient about the importance of consuming a diet that is approved for patients with
diverticulitis, which includes: seeds, nuts, popcorn, grapes, berries, broccoli, and cucumbers.
o Understanding the importance of diet compliance decreases the chance for recurrence of
diverticulitis.
Evaluation of Goal:
Throughout the shift, patient showed no sign of electrolyte imbalance. There were no previous
electrolyte imbalances in most blood work (02/07).
Patient ambulated twice throughout the shift but reported an increase of pain due to abdominal surgery.
Patient verbalized five different foods she should avoid to prevent recurring diverticulitis.

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 12

 References

Ackley, B. J., Ladwig, G. B., & Elsevier, c2008. (2007). Nursing diagnosis handbook: An Evidence

Based Guide to Planning Care (8th ed.). Edinburgh: Elsevier Mosby.

Choose MyPlate. (2016, January 12). Retrieved October 26, 2016, from Choose MyPlate,

https://www.choosemyplate.gov/

Commane, D. (2009). Diet, Ageing and Genetic Factors in the pathogenesis of diverticular

disease. World Journal of Gastroenterology,15(20).

Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical Surgical Nursing: Preparation for

Practice. Boston: Pearson.

Treas, L. S., & Wilkinson, J. M. (2014). Basic Nursing: Concepts, Skills, and Reasoning. Philadelphia,

PA: F.A Davis Company, 164.

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University of South Florida College of Nursing Revision September 2014 14