UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: David A Lepin

MSI & MSII PATIENT ASSESSMENT TOOL . Assignment Date: May 27, 2016
Agency: Tampa General Hospital

1 PATIENT INFORMATION
Patient Initials: BW

Age: 51 years old

Admission Date: 5/24/2016

Gender: M

Marital Status:Married

Primary Medical Diagnosis Gangrene

Primary Language: English

Level of Education: 2 years of college (A.S.)

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Unemployed (Disability)

N/A

Number/ages children/siblings: 1 Son (30 y/o) 1 Daughter (24 y/o)

Served/Veteran: Yes
If yes: Ever deployed? Yes

Code Status: Full

Living Arrangements: This patient lives in a 1 floor home in

Advanced Directives: No
Clearwater, FL. He lives with his wife and two grandchildren(5&3) If no, do they want to fill them out? No
Culture/ Ethnicity /Nationality: American
Religion: Christian (Nondenominational)

Type of Insurance: Disability from previous

occupation.

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 1 CHIEF COMPLAINT:
My finger is swollen and itchy.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course
of stay)

51year old male presented to the Transplant Unit of Tampa General Hospital(TGH) on 5/24/2016. This patient was a
direct admit from Morton Plant Mease. On 5/10/2016 the distal portions the patients right middle finger and left fifth
finger were amputated at Florida Orthopedic Institute. The surgical procedure involved amputation and debridement of
necrotic tissue from unhealed wounds that the patient acquired in October 2016 at TGH. The patient reports that a
couple days after the procedure at Florida Orthopedic Institute he experienced an itchy sensation along with
inflammation of his right middle finger, and decided to visit Morton Plant Mease. A culture was taken from the clear
drainage from the surgical wound and the patient was started on Vancomycin. The patient denied any relief with
Vancomycin and had not noticed any changes in his affected finger. He was soon transferred to TGH and admitted for
gangrene. The patient reports that he has had multiple procedures here and has built a rapport with the surgical staff. On
5/24 his complete right middle finger was amputated due to new necrotic tissue. Today he experiences 6/10 intermittent
aching pain located in right hand where his finger was amputated. Pain is worse with pressure. Oxycodone helps relieve
pain. He denies any new drainage from surgical site. Yesterday he stubbed his left third metatarsal on the door of his
room. Ecchymosis is now present on the distal portion of the affected metatarsal. He denies any pain in his left third
metatarsal. A culture obtained on the day of admission before complete amputation revealed staphylococcus aureus. The
patient is receiving Vancomycin every 24 hours and Zosyn every 6 hours. Orthopedic consult is ordered to have the
surgical site evaluated. The patient states The surgeon wants to give it a couple days to see if he can fuse my knuckles
together, so theres not that much of a gap between my fingers. Magnetic resonance imaging(MRI) is also scheduled
for the patients right hand.

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

Operation or Illness

2010

Hypertension (Taking carvedilol)

2015

Stage 5 Chronic Kidney Disease (Transplant)

2010

Diabetes Mellitus Type II (Insulin glargine)

12/2015

Kidney Transplant

Unkown

Tonsillectomy

2015

Cirrhosis (transplant)

10/2015

Liver Transplant

2014

Hepatitis C (transplant)

2015

Anemia (Taking folic acid)

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2
FAMILY
MEDICA
L
HISTOR
Y

Ag
e
(in
ye
ars
)

Cause
of
Death
(if
applicable
)

Al
co
hol
is
m

Env
iron
men
tal
Alle
rgie
s

A
ne Art As
m hri th
ia tis ma

Bl
ee
ds
Ea
sil
y

Ca
nc
er

Di
ab
ete
s

Hea
rt
H
Tro
yp
Gl
G
uble
er
au
ou
(angi
te
co
t
na,
ns
ma
MI,
io
DVT
n

Kid
ney
Pro
ble
ms

etc.)

Father

51

MVA

Mother

47

MVA

Me
nta
l
Sto
He
ma
alt Sei ch Stro
zur Ul ke
h
Pr es cer
obl
s
em
s

Tu
mor

Brother
Sister
relationship
relationship
relationship

Comments: Include age of onset

Maternal Grandmother died from Myocardial Infarction at the age of 72.

IMMUNIZATION HISTORY

(May state U for unknown, except for Tetanus, Flu, and Pna)

YES

Routine childhood vaccinations

Routine adult vaccinations for military or federal service

Adult Diphtheria (Date)

Adult Tetanus (Date) Is within 10 years?

Influenza (flu) (Date) Is within 1 years?

NO

Pneumococcal (pneumonia) (Date) Is within 5 years?

Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES

OR ADVERSE
REACTIONS
Medications

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKDA

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Adhesive

Localized dermatitis/itchy sensation

Other (food, tape,

latex, dye, etc.)

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)
Gangrene is the result of inadequate tissue perfusion. It refers to death of tissue and results from severe hypoxic injury,
commonly occurring because of arteriosclerosis, or blockage, of major arteries (Huether & McCance, 2012, p. 86).
Blood circulation is essential for the transportation of wastes and molecules that promote the integrity of the bodys
cells. Some of these vital molecules include proteins and oxygen. If these molecules are not transported to the cells, the
cells can die. This will result in the death of tissue. A patient can experience increased complications with a subsequent
infection. The bacteria will be able to thrive because of the dead tissue and absent defense mechanisms. This infection
needs to be cultured and treated with a specific antibiotic to prevent any further growth. The necrotic tissue will not
regenerate and may be surgically removed.
This patient in particular was experiencing gangrene on his distal right middle finger and also his distal left fifth finger.
It was reported that the affected regions were dry and black before they were amputated. After this procedure, the
patient continued to experience inflammation and an itchy sensation in his right middle finger. A culture revealed that
there was an opportunistic infection of Staphylococcus Aureus. The patient was initially treated with Vancomycin but
experienced no relief. Furthermore, complete amputation of right middle finger was accomplished and he was started on
an additional antibiotic.
The patient has a history of hypertension and Diabetes Mellitus II. Both of these conditions are corrosive to the blood
vessels and may have played a part in the formation of gangrene. Hypertension can lead to atherosclerosis, which can
result in blood vessel occlusion (p. 590). Diabetes Mellitus II also causes poor wound healing. This patient also has a
history of cirrhosis and stage 5 chronic kidney disease. It is without a doubt that his extensive medical history
contributed to his most recent diagnosis.

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name piperacillin-tazobactam (Zosyn)

Concentration 67.5mg/mL

Route IV

Dosage Amount 3.375g

Frequency every 6 hours

Pharmaceutical class Antibiotic(Extended-spectrum penicillin)

(X)Hospital Home or Both

Indication for the treatment of surgical wound infection

Adverse/ Side effects diarrhea, pruritus, hypersensitivity/anaphylaxis, angioedema, superinfection
Nursing considerations/ Patient Teaching signs and symptoms of superinfection, contraindicated in patients with penicillin hypersensitivity

Name Asprin

Concentration 81mg/tablet

Route oral

Dosage Amount 81mg

Frequency once daily

Pharmaceutical class Salicylate/Platelet Inhibitor

Hospital Home or (X)Both

Indication thrombosis prophylaxis

Adverse/ Side effects: nausea, dyspepsia, abdominal pain, gastritis, hepatotoxicity

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Nursing considerations/ Patient Teaching: take with glass of water, don't take on an empty stomach, can cause increased bleeding

Name carvedilol (Coreg)

Concentration 12.5mg/tablet

Route oral

Dosage Amount 12.5mg

Frequency twice daily

Pharmaceutical class Beta-blocker

Hospital Home or

(X)Both

Indication Hypertension
Adverse/ Side effects fluid retention, hypotension, bradycardia
Nursing considerations/ Patient Teaching Take with meals, may increase glucose level, do not stop abruptly

Name senna-docusate

Concentration 8.6-50mg/tablet

Route oral

Dosage Amount 8.6-50mg

Frequency twice daily

Pharmaceutical class laxative

Home

Hospital

or

(X)Both

Indication constipation
Adverse/ Side effects fluid/electrolyte loss, diarrhea, abdominal pain, nausea, vomiting, urine discoloration
Nursing considerations/ Patient Teaching long term use may cause dependency and irreversible impairment of bowel, contains large amounts of sugar

Name Folic acid

Concentration 5mg/tablet

Route oral

Dosage Amount 5mg

Frequency once daily

Pharmaceutical class Water-soluble vitamin

Home

Hospital

or

(X)Both

Indication Anemia
Adverse/ Side effects (rare) erythema, pruritus, can leave bad taste in mouth, anorexia, nausea, altered sleep patterns
Nursing considerations/ Patient Teaching use in extreme caution with undiagnosed anemia

Name insulin glargine (Lantus)

Concentration 100units/mL

Route subcutaneous

Dosage Amount 24 units

Frequency twice daily

Pharmaceutical class insulin

Home

Hospital

or

(X)Both

Indication Diabetes mellitus II

Adverse/ Side effects hypoglycemia, weight gain, hypokalemia
Nursing considerations/ Patient Teaching do not skip meals, monitor blood glucose

Name oxycodone(Oxycontin)

Concentration 5mg/capsule

Route oral

Dosage Amount 15mg

Frequency every 4 hours PRN

Pharmaceutical class Analgesic/Opiate

Home

Hospital

or

(X)Both

Indication for moderate to sever pain

Adverse/ Side effects constipation, respiratory depression, drowsiness, nausea
Nursing considerations/ Patient Teaching monitor respiratory rate and bowel movements, also check for physical dependence

Name vancomycin(Vancocin)

Concentration 3mg/ml

Route IV

Dosage Amount 1500mg

Frequency every 24 hours

Pharmaceutical class antibiotic

Home

(X)Hospital

or

Both

Indication surgical wound infection

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Adverse/ Side effects ototoxicity, tinnitus, vertigo, red man syndrome

Nursing considerations/ Patient Teaching do not infuse too quickly, monitor for superinfection

Name tacrolimus (Prograf)

Concentration 3mg/capsule

Route oral

Dosage Amount 3mg

Frequency once daily

Pharmaceutical class immunosuppresant

Home

Hospital

or

Both

Indication liver and kidney transplant rejection prophylaxis

Adverse/ Side effects infection, nephrotoxicity, insomnia, neurotoxicity, hypertension, hyperglycemia
Nursing considerations/ Patient Teaching monitor renal function, patient will have increased susceptibility to infection

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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? consistent carbo diet

Analysis of home diet (Compare to My Plate and

Diet patient follows at home? regular diet

Consider co-morbidities and cultural considerations):

24 HR average home diet: regular diet

According to [Link], this patient exceeds the

daily recommended amount of calories. He also exceeds
the recommended amount of refined grains, daily sodium
intake, and saturated fats. Given his diagnosis of Diabetes
Mellitus II, this patient should limit added sugars. A
majority of the added sugars in his diet come from soft
drinks and whole milk. To avoid this, the patient can
switch to skim or reduced fat milk. He should also attempt
to avoid soft drinks. The increased daily sodium
consumption and saturated fats contribute to hypertension.
The patient also reports that he does not engage in any
physical activity despite playing inside with his
grandchildren. He should limit margarine and added salt to
his mashed potatoes. Potatoes chips also contain a great
amount of sodium. Another recommendation to reduce this
patients sodium intake would be to switch from pork
bacon to turkey bacon. Furthermore, he can eat eggs
whites rather than whole scrambled eggs. The only form of
fruit into this patient participates in is from fruit juice.
Many fruit juices may contain added sugars. I would
recommend whole fruits for essential vitamins and to
maximize fiber consumption.

Breakfast: 2 eggs, 2 strips of bacon, 1 cup mashed potatoes

Lunch: 1-2 cups of Mac n Cheese

Dinner: 1 chicken breast with 1.5 cup spaghetti

Snacks: 1 cup of cereal, 1 bag of chips

Liquids (include alcohol): 16 fl oz orange juice, 24 fl oz

soft drink, 8 fl oz whole milk, 8 fl oz water

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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?
The patients wife helps him when he is ill.

How do you generally cope with stress? or What do you do when you are upset?
The patient reports that very little makes him stressed. He tries to keep a positive mindset, and believes that being upset
only makes things worse. When the patient feels down he surrounds himself with family to distract his mind.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The patient denies any depression or anxiety but would like to return to his house and family.

+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?______Yes_________ Have you ever been hit punched or slapped?
_______No_______

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

Are you currently in a safe relationship? Yes

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 (X)Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair

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Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for
your
patients age group: 40 - 64 years old Generativity vs self absorption/stagnation. Generativity is the process of guiding the next
generation, or improving the whole of society. Stagnation occurs when development ceases: A stagnant middle adult cannot guide
the next generation or contribute to society (Treas, 2014, p. 190).

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The generativity vs self absorption/stagnation stage of psychosocial development is the stage in which middle adults are
transitioning to older adultshood. In this transition stage middle adults are preparing the future generations for
adulthood, or remaining stagnant and trying to find their role in society. This is the stage where many people experience
midlife crises. This patient in particular is in the generativity stage. He enjoys his time with his grandchildren. He is on
disability and has full custody of his grandchildren. The patient reports that he is on disability and this provides ample
time for him to spend with his two grandchildren. This patient prefers to play and invest his time with his grandchildren,
especially when he is feeling down. He is hopeful for their future. The patient expressed his excitement to recuperate so
he can return home.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The impact of this patients condition has influenced him in a positive way. He is hopeful to return to his wife and
grandchildren. The patient is keeping a positive attitude despite his life changing amputation. He hopes that his
grandchildren will learn from his mistakes.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The patient states Its probably from all the stuff I have going on with me. He believes that this illness is due to his medical
history.

What does your illness mean to you?

To this patient this illness is just a part of his life. The patient would just like to get better and go home. e does not
believe that his current situation should affect his mood.

+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

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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? ________Yes___________________________________

Are you currently sexually active? _____Yes______________________ If yes, are you in a monogamous
relationship? _______Yes_____________ When sexually active, what measures do you take to prevent acquiring a
sexually transmitted disease or an unintended pregnancy? __________Wife is
postmenopausal________________________

How long have you been with your current partner?______________________________31

years__________________________

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?

The patient reports that religion does not play a significant role in his life. He prays occasionally and visits a nondenominational
christian church on the holidays with his family.
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?
Cigarettes

Yes

How much?(specify daily amount)

For how many years? 12 years

1/2 - 1 pack a day

(age 29

thru

41

If applicable, when did the

patient quit?

Pack Years: 12 years

10 years ago (age 41)

Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? Yes

If yes, what did they use to try to quit? 10 years ago

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What?

No

How much?

For how many years?

Volume:

(age

thru

Frequency:
If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?

No

If so, what?
How much?

For how many years?

(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Yes. (See next question)

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5. For Veterans: Have you had any kind of service related exposure?
Yes. When the patient was deployed to Grenada he was exposed to many occupational hazards. Some of these
included bullets, loud noises, explosions, and also insects. he can recall multiple days of increased sun exposure
and second hand smoke from other members around him. The patient reports that there were several
occurrences when he could not shower or change his clothing/gear.

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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 (X)

GERD

Cholecystitis

Fever

Problems with nails (X)

Indigestion

Gastritis / Ulcers

HIV or AIDS

Dandruff

Hemorrhoids

Blood in the stool

Lupus

Psoriasis

Yellow jaundice Hepatitis (X)

Rheumatoid Arthritis

Hives or rashes

Pancreatitis

Sarcoidosis

Skin infections (X)

Colitis

Tumor

Diverticulitis

Life threatening allergic reaction

Bathing routine: Once daily, usually

mornings

Appendicitis

Enlarged lymph nodes

Other: Gangrene

Abdominal Abscess

Other:

Be sure to answer the highlighted area

Last colonoscopy? (DUE)

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: O Positive

Post-nasal drip

Normal frequency of urination:

day

Oral/pharyngeal infection

Bladder or kidney infections

Use of sunscreen N/A

SPF:

3-4/

Other:

Metabolic/Endocrine

Dental problems
Routine brushing of teeth
Routine dentist visits

1/day

Diabetes (X)

1/year

Type: II

Hypothyroid /Hyperthyroid

Vision screening September 2015

Intolerance to hot or cold

Other:

Osteoporosis
Other:

Pulmonary
Central Nervous System

Difficulty Breathing
Cough - dry
Asthma

or

productive

WOMEN ONLY
Infection of the female genitalia

CVA
Dizziness

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University of South Florida College of Nursing Revision September 2014

Bronchitis

Monthly self breast exam

Severe Headaches

Emphysema

Frequency of pap/pelvic exam

Migraines

Pneumonia

Date of last gyn exam?

Seizures

Tuberculosis

menstrual cycle

Environmental allergies

menarche

age?

Encephalitis

last CXR? Unknown

menopause

age?

Meningitis

Other:

Date of last Mammogram &Result:

regular

irregular

Ticks or Tremors

Other:

Date of DEXA Bone Density & Result:

Cardiovascular

MEN ONLY

Mental Illness

Hypertension (X)

Infection of male genitalia/prostate? N/A

Depression

Hyperlipidemia

Frequency of prostate exam? Yearly

Schizophrenia

Chest pain / Angina

Date of last prostate exam? September

2015

Anxiety

Myocardial Infarction

BPH N/A

Bipolar

CAD/PVD

Urinary Retention N/A

Other:

CHF

Musculoskeletal

Murmur

Injuries or Fractures (X)

Childhood Diseases

Thrombus

Weakness

Measles

Rheumatic Fever

Pain (X)

Mumps

Myocarditis

Gout

Polio

Arrhythmias

Osteomyelitis

Scarlet Fever

Last EKG screening, when? Unknown

Arthritis

Chicken Pox

Other:

Other:

Other:

General Constitution
Recent weight loss or gain N/A
How many lbs? N/A
Time frame? N/A
Intentional? N/A
How do you view your overall health? Good

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
N/A

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Any other questions or comments that your patient would like you to know?
N/A

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10 PHYSICAL EXAMINATION:
General Survey: The patient is a 51 y/o male A&O x 4. Height 66inches Weight 147lbs BMI 25% Pain: (6/10
intermittent ache near new surgical site Pulse 78 Blood Pressure: 147/85, left arm
Respirations 18
Temperature: 97.9 (oral)

SpO2 99% (Right hand) Is the patient on Room Air or O2 Room air

Overall Appearance: [Dress/grooming/physical handicaps/eye contact]

Clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, Dry dressing wrapped around
right hand and left pinky finger

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

(X) awake, calm, relaxed, interacts well with others, judgment intact

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

(X) clear, crisp diction

Mood and Affect: (X) pleasant

(X) cooperative

apathetic bizarre

anxious

agitated

cheerful

tearful

(X) talkative

withdrawn

quiet

boisterous

flat

aggressive hostile loud

Other:
Integumentary
Skin is warm, dry, and intact
(X) Nails without clubbing

(X)Skin turgor elastic

No rashes, lesions, or deformities

(X) Capillary refill < 3 seconds

(X) Hair evenly distributed, clean, without vermin

Surgical wound from amputation of right middle finger and distal portion of left fifth digit, ecchymosis on third
metatarsal of right foot

Central access device N/A Type:

Location:

Date inserted:

Fluids infusing? yes - what? piperacillin-tazobactam 3.375g in 0.9% NaCl 50 mL IVPB via left metacarpal vein,
22gauge, another 22g in left hand(no fluids currently running)

HEENT: (X)Facial features symmetric

midline
(X)Thyroid not enlarged

(X)No pain in sinus region (X)No pain, clicking of TMJ

(X)No palpable lymph nodes

(X)Trachea

(X)sclera white and conjunctiva clear; without discharge

(X) Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
(X)PERRLA pupil size 3 mm bilateral (X)Peripheral vision intact (X)EOM intact through 6 cardinal fields without
nystagmus
(X)Ears symmetric without lesions or discharge
(X)Nose without lesions or discharge
lesions

(X)Whisper test heard: right ear-

24

inches & left ear-

24

inches

(X)Lips, buccal mucosa, floor of mouth, & tongue pink & moist without

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Dentition: teeth in tact, appropriate color

Comments:
Pulmonary/Thorax: (X)Respirations regular and unlabored
symmetric

(X)Transverse to AP ratio 2:1 (X)Chest expansion

(X)Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production:

N/A

Amount: N/A

Color: N/A
Lung sounds:
RUL

CL

LUL CL

RML

CL

LLL

RLL

CL

CL

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

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Cardiovascular: (X) No lifts, heaves, or thrills

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

(X)No

Calf pain bilaterally (X)negative

(X)Pulses bilaterally equal [rating scale: 3-normal
Apical pulse: 2+
Carotid: 2+
Brachial: 2+
Radial: 2+
Femoral: 2+
Popliteal: 2+
DP: 2+
PT: 2+
(X)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
pitting
non-pitting
(X)Extremities warm with capillary refill less than 3 seconds
GI
(X) 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 26 / May / 2016
)
(X)Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
(X)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:

(X)Not assessed, patient alert, oriented, denies problems

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

mLs

Musculoskeletal: (X)Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ___5____ RUE ___5____ LUE ____5___ RLE & ___5____ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
(X)vertebral column without kyphosis or scoliosis

(X)Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Exception; 6/10 intermittent aching pain on right middle finger
Neurological: (X)Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
(X)CN 2-12 grossly intact
(X)Sensation intact to touch, pain, and vibration
(X)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: 3

Achilles:

Ankle clonus: negative Babinski: 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
Glucose

Dates
Trend
5/24, 5/25, 5/26, 5/27 160, 137, 111, 133

Potassium

5/26

4.0

BUN

5/26

17

Within normal limits. This helps

assess renal function.

Creatinine

5/26

1.2

Within normal limits. Used to

assess renal function. This patient
has a history of stage 5 CKD and
renal on 12/2015.

Vancomycin

5/26

33.9

Analysis
Glucose levels have been elevated.
This patient has a history of DM 2
Within normal limits. May have
been obtained to assess renal function

.
Elevated level of vancomycin. This
medication was held on 5/26 due to
abnormal lab value.
.

Wound culture

5/24

Rare growth of staphylococcus

aureus. This wound is infected.

AST/ACT/LFT
MRI
Hemoglobin

5/26

9.6

Hematocrit

5/26

29.1

.
I would assume that these labs
be drawn to assess liver function.
Scheduled
.
.
This is a low value. The patient has
a history of anemia. I would
would expect further lab draws to
assess trends
.
.
This is a low value. Given the
patients history I would expect
further draws for trends.

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+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.)
The patient is currently on a consistent carbohydrate diet. Accu checks are AC and HS. Insulin glargine will
be administered twice a day. He is independent with bathroom privileges. Dressings on right middle finger
and left third metatarsal are changed once a shift with dry dressing. Continue Vancomycin every 24 hours,
dependent on serum level (10-20 ug/mL) and Zosyn every 6 hours. Oxycodone will be administered every 4
hours as needed for moderate to severe pain. Orthopedic consult is in place to have the patients surgical site
assessed and to discuss possible reconstructive measures to fuse his knuckles together.

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

1. Ineffective peripheral tissue perfusion r/t obstruction of arterial blood flow as evidenced by necrotic tissue.
2. Delayed surgical recovery r/t decreased oxygen supply to body, increased cardiac workload as evidenced by anemia.
3. Impaired physical mobility r/t musculoskeletal impairment, impaired movement as evidenced by difficulty grabbing items with
right hand.

4. Ineffective self health management r/t complexity of therapeutic regimen, deficient knowledge, lack of
acknowledgement of seriousness of condition as evidenced by hyperglycemia.
5. Risk for infection r/t delayed surgical recovery.

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 15 CARE PLAN
Nursing Diagnosis: Ineffective tissue perfusion r/t obstruction of arterial blood flow as evidenced by necrotic
tissue.
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal
Patient will demonstrate
adequate tissue perfusion
as evidenced by palpable
peripheral pulses, warm
and dry skin, and
adequate urine output.

1. Check the brachial,

radial, dorsalis pedis,
posterior tibial, and
popliteal pulses
bilaterally.
2. Note skin color and
feel the temperature of
the skin.
3. Check capillary refill.
4. Complete a bladder log
including patterns or
urine elimination, urine
loss (if present),
nocturne, and volume
and type of fluids
consumed.

Rationale for
Interventions
Provide References

Evaluation of Goal on
Day Care is Provided

1. Diminished or absent
peripheral pulses
indicate arterial
insufficiency with
resultant ischemia.
2. Skin pallor or mottling,
cool or cold skin
temperature, or an
absent pulse can signal
arterial obstruction.
3. Nail beds usually
return to a pinkish
color within 2 to 3
seconds after
compression.
4. The bladder log
provides an objective
verification of urine
elimination patterns
and allows comparison
of fluids consumed
versus urinary output.

1. Brachial, radial,
dorsalis pedis,
posterior tibial, and
popliteal pulses were
assessed and 2+
bilaterally.
2. Skin color was
appropriate for patient.
3. Capillary refill time
was < 3 seconds.
4. Intake and output was
recorded in the
patients medical
record.

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Patient will verbalize

knowledge of treatment
regimen, including
appropriate exercise and
medications and their
actions and possible side
effects.

1. Encourage exercise
such as walking from
30 to 60 minutes per
day as ordered by the
physician.
2. Teach the client to
recognize the signs and
symptoms that should
be reported to the
health care staff.
3. Assess pain
management strategies
and their effectiveness.
4. Provide clear, simple
instructions about plan
of care.

1. Brief exercise results in

an improvement in
cutaneous perfusion,
particularly individuals
with diabetes.
2. This will help the
client gain knowledge
of treatment, and
identify exacerbation.
3. Effective pain
management is
recommended to assist
adherence to the
medical regimen.
4. Health care
professionals should
give clear,
unambiguous and
tailored information to
encourage adherence to
medical regimen.

Patient will identify

changes in lifestyle
needed to increase tissue
perfusion.

1. Stress the importance

1. These are all
of controlling a
modifiable risk factors
diabetic condition,
for atherosclerosis.
hypertension, and
2. Malnutrition
reducing stress.
contributes to anemia,
which further
2. Assess the clients
nutritional status,
compounds the lack of
paying close attention
oxygenation to tissues.
to obesity,
3. Use of cushioned
hyperlipidemia, and
footwear can decrease
malnutrition. refer to a
pressure on the feet,
dietician if appropriate.
decrease callus
formation, and help
3. Explain the importance
of good foot care.
save the feet.
Teach the client and
family to wash and
inspect the feet daily.
Recommend that the
diabetic client wear
padded socks, special
insoles, and jogging
shoes.

1. Patient verbalized the

benefits of exercising
for at least 30 minutes
a day.
2. Patient verbalized the
signs and symptoms
that should be reported
to the healthcare staff.
3. Patient verbalized
effectiveness of pain
medication and
common side effects.
4. Patient confirmed
understanding of
instructions given
about plan of care.

1. Patient identified the

importance of
controlling chronic
medical conditions.
2. The patient identified
possible changes in his
diet.
3. The patient confirmed
understanding of good
foot care in relation to
Diabetes Mellitus II.

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Nursing Diagnosis: Ineffective self health management r/t complexity of therapeutic regimen, deficient knowledge,
lack of acknowledgement of seriousness of condition as evidenced by hyperglycemia.

Patient Goals/Outcomes Nursing Interventions to

Achieve Goal
Patient will describe
activity/exercise patterns
that meet therapeutic
goals.

Rationale for
Interventions
Provide References

Evaluation of Goal on
Day Care is Provided

1. Develop a contract
1. The nursing
1. Patient verbalized a
with the client to
intervention of client
change in behavior in
maintain motivation
contracting provides a
regards to exercise
for changes in
concrete means of
patterns.
behavior.
keeping track of
2. PT/OT referral was
2. Refer to health care
actions to meet healthcreated.
professionals for
related goals.
3. Family member
questions and self-care
verbalized support for
2. Enhanced nursing case
management.
management may both
increased physical
3. Identify what the client
improve self-care and
activity to help manage
and/or family know and
reduce emotional
Diabetes Mellitus II.
adjust teaching
distress for clients with
accordingly.
diabetes.
3. Teach the client and
family about all aspects
of the therapeutic
regimen, providing as
much knowledge as the
client and family will
accept, in a culturally
congruent manner.

Patient will describe daily 1. Help the client self

1. Self-management
1. Patient verbalized
food and fluid intake that
mange his own health
education helps
importance of change
meets therapeutic goals.
through teaching about
achieve positive health
in diet.
strategies for changing
outcomes such as
2. Patient spoke
habits such as
systolic blood pressure.
personally with
overeating, sedentary
dietician.
2. Lack of knowledge and
lifestyle, and smoking
understanding of the
3. Patient identified foods
diet and its relation to
and drinks not
2. Help he client identify
and modify barriers to
diabetes is a common
conducive to plan of
effective selfbarrier.
care.
management.
3. Cultural beliefs and
values may influence a
3. Assess the influence of
cultural beliefs, norms,
patients diet.
and values on the
individuals
perceptions of the
therapeutic regimen.
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Patient will collaborate

with healthcare providers
to decide on a therapeutic
regimen that is congruent
with health goals and
lifestyle.

1. Establish a
1. Nurse-client
collaborative
partnerships reflect
partnership with the
nursing models for
client for purposes of
practice and this
meeting health-related
approach differs from a
goals.
traditional health care
model in which the
2. Help the client enhance
self-efficacy or
provider assumes
confidence in his own
authoritative and
ability to manage the
paternalistic
illness.
approaches to care.
3. Involve family
2. Specific selfmembers in the
management strategies
knowledge
to improve selfdevelopment, planning
efficacy are associated
or self-management,
with significant
and shared decision
improvements in selfmaking.
efficacy and selfmanagement
behaviors.
3. Family management is
found to be integral to
self-management.

1. Partnership with
patient was created to
establish goals.
2. Personal goals were
created and patientcentered.
3. Family member was
involved in goals to
promote a healthy
lifestyle and control the
patients chronic
medical conditions.
4. Patient verbalized
understanding of
following up with a
primary are provider.

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.
Maryland Heights, MO: Elsevier.
Clinical Pharmacology. (2016). retrieved June 08, 2016, from [Link]/[Link]
Food Tracker. (2016). Retrieved June 08, 2016, from [Link]
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (5th ed.). St. Louis, Mo:
Elsevier
Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning. Philadelphia, PA: F.A.
Davis Company.

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