UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Garrett Mongelluzzo

MSI & MSII PATIENT ASSESSMENT TOOL .

Assignment Date: 4/9/16

Agency: MPM

1 PATIENT INFORMATION
Patient Initials: AD

Age: 52

Admission Date: 1/19/16

Gender: Male

Marital Status: Single

Primary Medical Diagnosis

Primary Language: English

Right-Sided CVA

Level of Education: High School Graduate

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Truck Driver

DVT of Left Upper/Lower Extremities

Number/ages children/siblings: No children or siblings

Acute Left Rib Fractures

Served/Veteran: No
If yes: Ever deployed? Yes or No

Code Status: Full

Living Arrangements: Lives alone in a two bedroom home with no

stairs.

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: N/A
Procedure: N/A

Culture/ Ethnicity /Nationality: Western/Caucasian/American

Religion: Catholic

Type of Insurance: Not Insured

1 CHIEF COMPLAINT:
My friends found me on the floor of my home when they came to visit.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient admitted 1/19/16 via EMS after being found on floor. Patient diagnosed with right sided CVA. His right carotid
artery is totally occluded and has left-sided deficits with weakness of left upper and lower extremities. He also has
extensive DTV of left upper and lower extremities and acute left rib fractures.
O= Chronic
L= Left Knee
D= Comes and goes
C= Achy, it just hurts.
A= Trying to move
R = Nothing
T = Medications
S = 8/10 score on 0-10 pain scale

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease

Father

65

Mother

67
N/
A
N/
A

Brother
Sister

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable
)
Stroke

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Clostridium Difficile Associated Diarrhea vancomycin
Depression/Psychosis sertraline (Zoloft)
Hypertension metoprolol
Hypercholesterolemia atorvastatin (Lipitor)

Age (in years)

Date
February 2016
June 2010
August 2008
August 2008

Cancer

relationship
relationship
relationship

Comments: Father died at 65 from CVA and mother died at 67 from colon cancer.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? U
Influenza (flu) (Date) Is within 1 years? U
Pneumococcal (pneumonia) (Date) Is within 5 years? U
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKA
Medications

NKA
Other (food, tape,
latex, dye, etc.)

5 PATHOPHYSIOLOGY:
Cerebrovascular accidents are classified pathophysiologically as global hyperperfusion (shock), ischemic (thrombotic,
embolic), or hemorrhagic. Risk factors are as follows: arterial hypertension, smoking, diabetics, polycythymia,
thrombocytopenia, presence of lipoprotein A, impaired cardiac function, hyperhomocysteineemia, atrial fibrillation,
chlamydia pneumonia (Huether & McCcance). Sudden signs of a stroke include numbness the in face, arms, legs
(especially on one side of body), acute confusion, acute vision changes, acute dizziness, difficulty walking, loss of
balance/coordination, and a sudden headache. Treatment and prognosis vary based on type of stroke and area of brain
affected. Treatments for an ischemic stroke include restoring blood flow, aspirin, and TPA if within 3 hours. Other
procedures include a carotid endarterectomy and angioplasty/stents. For a hemorrhagic stroke the bleeding must be
controlled and ICP decreased. Procedures that be done include surgical clipping, coiling, surgical AVM removal,
stereotactic radiosurgery, and intracranial bypass. Outcomes will vary. This patient had a right-sided CVA, which means
he has left sided deficits. Intensive PT and OT is often required, as it is in this case.

5 MEDICATIONS:
Name: atorvastatin (Lipitor)

Concentration: tablet

Route: oral

Dosage Amount : 20 mg
Frequency: 1x daily

Pharmaceutical class: hmg coa reductase inhibitor

Home

Hospital

or

Both

Indication: Adjunctive management of primary hypercholesterolemia and mixed dyslipidemia.

Adverse/ Side effects: rhabdomylosis, abdominal cramps, constipation, diarrhea, flatus, heartburn, rashes, angioneurotic edema
Nursing considerations/ Patient Teaching: Instruct patient to notify health care professional if unexplained muscle pain, tenderness, or weakness occurs,
especially if accompanied by fever or malaise.
Name: metoprolol (Lopressor)

Concentration: tablet

Route: oral

Dosage Amount: 25 mg
Frequency: 2x daily

Pharmaceutical class: beta blocker

Home

Hospital

or

Both

Indication: hypertension
Adverse/ Side effects: fatigue, bradycardia, heart failure, pulmonary edema, erectile dysfunction
Nursing considerations/ Patient Teaching: Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia. Notify
provider if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, light-headedness, confusion, depression, rash, fever, sore throat, unusual
bleeding, or bruising occurs.
Name: clopidogrel (Plavix)

Concentration: tablet

Route: oral

Dosage Amount: 75 mg
Frequency: 1x daily

Pharmaceutical class: platelet aggregation inhibitor

Home

Hospital

or

Both

Indication: Reduction in atherosclerotic events (MI, stroke, vascular death) in patients at risk for such evens including recent MI, stroke, or PVD.
Adverse/ Side effects: bleeding, acute generalized exanthematous posulosis, drug rash with eosinophilia and systemic symptoms, steven-johnson syndrome, toxic

University of South Florida College of Nursing Revision September 2014

epidermal necrolysis, neutropenia, thrombotic thrombocytopenia purpura

Nursing considerations/ Patient Teaching: Notify provider if experience fever, weakness, chills, sore throat, rash, unusual bleeding or bruising, extreme skin
paleness, purple skin patches, yellowing of skin or eyes, or neurological changes occur.
Name: nicotine (Nicoderm)

Concentration: patch

Route: transdermal

Dosage Amount: 14 mg
Frequency: 1x daily

Pharmaceutical class: smoking deterrent

Home

Hospital

or

Both

Indication: Adjunct therapy (with behavior modification) in the management of nicotine withdrawal in patients desiring to give up smoking.
Adverse/ Side effects: headache, insomnia, tachycardia, burning at site, erythema, pruritis
Nursing considerations/ Patient Teaching: Apply patch at same time each day, apply to clean site, no more than one patch at a time, rotate sites.
Name: polyethylene glycol (MiraLax)

Concentration: powder

Route: oral

Dosage Amount: 17g

Frequency: 1x daily

Pharmaceutical class: osmotic

Home

Hospital

or

Both

Indication: treatment of occasional constipation

Adverse/ Side effects: abdominal bloating, cramping, flatulence, nausea
Nursing considerations/ Patient Teaching: Do not use for more than 2 weeks. Prolonged or excessive use may result in electrolyte imbalance and laxative
dependence.
Name: sertraline (Zoloft)

Concentration: tablet

Route: oral

Dosage Amount:75 mg
Frequency: 1x daily

Pharmaceutical class: SSRI

Home

Hospital

or

Both

Indication: Major depressive disorder

Adverse/ Side effects: neuroleptic malignant syndrome, suicidal thoughts, dizziness, drowsiness, fatigue, insomnia, headache, diarrhea, dry mouth, nausea,
sexual dysfunction, sweating, tremor, serotonin syndrome
Nursing considerations/ Patient Teaching: Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify
provider immediately if thoughts about suicide or dying, attempts to commit suicide, new or worsening depression or anxiety, agitation or restlessness, panic
attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior if symptoms of serotonin
syndrome occur.
Name: warfarin (Coumadin)

Concentration: tablet

Route: oral

Dosage Amount: 4 mg
Frequency: 1x daily

Pharmaceutical class: coumarins (anticoagulant)

Home

Hospital

or

Both

Indication: Prophylaxis and treatment of venous thrombosis, pulmonary embolism, decrease risk of future thrombotic events.
Adverse/ Side effects: bleeding, cramps, nausea, dermal necrosis
Nursing considerations/ Patient Teaching: report signs of unusual bleeding, bruising, pain, color, temperature change to provider. Do not drink alcohol or take
other Rx, OTC, or herbal products, especially those containing aspirin or NSAIDS.

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Thin liquids
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:
After analyzing the patients diet, it is evident that he is
lacking essential nutrients that he would get from fruit and
vegetables. He should be eating 2 cups of fruit and 2
cups of vegetables each day. According to his average 24hour diet he is getting few servings of both. He is only
getting about 1/4th of the dairy that he should be taking in. I
would also recommend that he lower his fat and sodium
intake. I believe that the DASH diet would be beneficial to
him and help him manage his hypertension and high
cholesterol. I would recommend that instead of white bread
and onion buns that he switch to whole grain breads and try
to limit processed foods like packed lunch meat and bacon.
He is also eating foods with empty calories (chips, ice
cream). I believe we also need to discuss his alcohol intake,
7-14 beers a week can have many negative effects on his
overall health and may require some patient teaching about
what alcohol and do and other methods he can use to cope
with stressors.
Breakfast: 2 eggs, 4 slices of bacon, 2 pieces of white toast

Lunch: Turkey sandwich with potato chips

Dinner: Cheeseburger (onion bun, American cheese)
Snacks: Ice cream
Liquids (include alcohol):
water, coke zero, coffee w/creamer, 1-2 beers
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.

University of South Florida College of Nursing Revision September 2014

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
I have a few neighbors that help me out.
How do you generally cope with stress? or What do you do when you are upset?
Ill usually call a buddy and talk for a bit, they usually make me laugh a bit and Ill feel better.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient states that he is often depressed and has dealt with depression most of his life but it has been worse of late now
that he has been hospitalized.
+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________________________________
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?
_Yes__________________________ If yes, have you sought help for this? _Yes________
Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: Generativity Is the ability to give and to care for others; self absorption is the inability to grow as a person. An
example of self-absorption is after I work all day, I just want to watch television and dont want to be around people (Halter, pg. 23).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient stated that he has failed to fulfill many goals he set when he was younger. He often feels alone and does not
have much family or friends to turn to outside of a few people next door. He feels like he does the same thing every day
but doesnt exhibit a desire to change. I would say this is the definition of stagnant.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

I would say that his condition has definitely affected his developmental stage. He has been in a hospital for a month and a
half laying in his bed the majority of the day. Social workers have had a difficult time getting him into a rehab facility
because of his insurance status and he is essentially stuck until they can find a place for him to go receive more
intensive PT/OT.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Me not taking care of myself and making poor choices that are catching up with me now.

University of South Florida College of Nursing Revision September 2014

What does your illness mean to you?

It means I cant take care of myself right now.

+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? _women_____________________________________________
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? _Condom___________________________
How long have you been with your current partner?__Single________________________________
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

University of South Florida College of Nursing Revision September 2014

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

What importance does religion or spirituality have in your life?
Patient states that he has lived his entire life believing that you either go to heaven or hell based on the choices you make. He states he
tries to avoid sinning and being good to others because of this.
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?
If so, what?
How much?(specify daily amount)
N/A
N/A

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
N/A
Does anyone in the patients household smoke tobacco? If
so, what, and how much?
No

Has the patient ever tried to quit?N/A

If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? Beer
How much?
Volume:12
Frequency: 1-2 x daily
If applicable, when did the patient quit?
N/A

No
For how many years?
(age 20s

thru 52

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

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No
5. For Veterans: Have you had any kind of service related exposure?
N/A

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:1x daily
Other:

Be sure to answer the highlighted area

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

5x/day

Hematologic/Oncologic

Metabolic/Endocrine
1 x/day
x/year

Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 1/19/16
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 1/19/16

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam? Unknown
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other: Psychosis

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox

University of South Florida College of Nursing Revision September 2014

Other:

Other:

Other:

General Constitution
Recent weight loss or gain
How many lbs? 10 pounds
Time frame? 2 months
Intentional? No
How do you view your overall health? Poor

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

10 PHYSICAL EXAMINATION:
General Survey:
Height: 186 cm
Weight: 81
BMI: 23.7
Pain: (include rating and
AOx3, clean, pleasant,
location)
Pulse: 73
Blood Pressure: (include location):
not in severe distress.
8/10 , left knee
Left
arm,
122/87
Respirations: 18
Temperature: (route
Is the patient on Room Air or O2:
SpO2 : 96% on RA
ROOM AIR
taken?) 97.6 (Orally)
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
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type:
Location:
Date inserted:
Fluids infusing?
no
yes - what?

flat
loud

HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments: Did not perform whisper test. Patient showed no signs of diminished hearing.
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL- CL
LUL- CL
RML- CL
LLL- CL
RLL- CL

Chest expansion

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

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11

Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
Did not get rhythm strip

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 73 Carotid: N/A Brachial: N/A Radial: 73 Femoral: N/A Popliteal: N/A
DP: N/A PT: N/A
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 3 / 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
Other Describe:
GU
Urine output:
Clear
Cloudy
Color:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Not assessed, patient alert, oriented, denies problems

Previous 24 hour output: 900
without assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __5_____ RUE ____1___ LUE ____5___ RLE

or

mLs N/A

with assistance

& ____1___ in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

Biceps:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

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12

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS

Lab
Calcium

Dates
9.0
8.3

(3/15/16)
(3/2116)

Normal (8.5 - 10.2)

Albumin
2.4 L
3.5
Normal (3.4 - 5.4)
Hgb
11.8 L
12.7 L
Normal (13.5-17.5)
X-Ray (Lt. Knee 2V)
X-Ray (Chest 1V)

(3/15/16)

Trend
Calcium levels have
dropped slightly. Will
monitor and possibly get
order for calcium
supplement.

Albumin levels are

trending up but still in the
low normal range.

(3/21/16)

Analysis
The low calcium level
could have been a result
of his diet, meds, or
kidneys not functioning
properly. Low calcium
can cause confusion,
muscle cramps, and
tingling in extremities.
Low albumin can be seen
in inflammation and is
often associated with poor
nutritional status.

(3/21/16)

Hemoglobin is trending
upward. Still not within
normal range but trending
there.

The numbers indicate

blood loss of some sort
but body is producing
more oxygenated RBCs.

3/20/16

N/A

2/29/16

N/A

Small bone effusion, no

fracture.
Atherosclerotic changes
of Aorta

(3/15/16)

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

Thin liquids diet
Neuro checks Q4
Turn patient, reposition with pillows between bony prominences Q2
I & O Q8
Weigh 1 x daily
Chair out of bed 30 min-1hr
Vitals Q4
Orthostatic Vitals Q8
Activity - Up with Assistance
Occupational therapy
Physical therapy
Speech therapy
8 NURSING DIAGNOSES
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13

1. Risk for aspiration R/T impaired swallowing

2. Risk for falls R/T left sided weakness
3. Impaired mobility R/T neuromuscular impairment AEB limited ability to perform gross motor skills
4. Risk for impaired skin integrity R/T immobility

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14

 15 CARE PLAN
Nursing Diagnosis: Risk for aspiration R/T impaired swallowing / Risk for falls R/T left-sided weakness / Risk for impaired skin integrity R/T
immobility
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Risk for aspiration R/T impaired swallowing
Patient will maintain patent airway Auscultate lung sounds frequently
Auscultation of lung sounds was
Goal met
and clear lung sounds until end of
and before and after feedings; note shown to be specific in identifying
shift.
any new onset of crackles or
clients at risk for aspirating
wheezes (Ackley & Ladwig, 2014). (Ackley & Ladwig, 2014).
Client will swallow and digest oral When feeding client, watch for
Signs of aspiration should be
Goal met
feeding without aspiration until end signs of impaired swallowing or
detected as soon as possible to
of shift
aspiration, including coughing,
prevent further aspiration and to
choking, or spitting food (Ackley
initiate treatment that can be
& Ladwig, 2014).
lifesaving (Ackley & Ladwig,
2014).
Risk for falls R/T left-sided weakness
Patient will identify long term
Teach patient how to use assistive
If patient is using assistive aids
Goal met
strategies to promote safety and
devices properly.
properly the chances of him falling
prevent falls after discharge.
after discharge are greatly reduced.
Patient will remain free from falls
Orient the client to the
Keeping the necessary items within Goal not met, shift ended but
during hospitalization.
environment. Place the call light
patient reach will decrease the need working toward goal of no falls
and necessary items in reach and
for the patient to get out of bed;
during hospitalization.
show how to call for assistance.
therefore, decreasing the risk of
Answers call light promptly
falls.
(Ackley & Ladwig, 2014).
Risk for impaired skin integrity R/T immobility
Patient will not exhibit signs and
Reposition/turn patient and use
Shifting the patient and taking
Goal met
symptoms of decreased skin
pillows for bony prominences
pressure of certain areas will help
integrity. Assess for skin integrity
every 2 hours until end of shift.
to prevent skin breakdown/ulcers.
every 2 hours during shift.

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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

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References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning
Care (10th Edition). Maryland Heights, Missouri: Mosby Elsevier.
Halter, M. J. (2014). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (7th, Ed.) St. Louis ,
Missouri: Elsevier Saunders.
Huether, S. E., & McCcance, K. L. Understanding Pathophysiology (Vol. Fifth Edition). St. Louis , Missouri:
Elsevier Mosby.
USDA. (2015). Retrieved April, 2016, from ChooseMyPlate: www.choosemyplate.gov

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