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UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
Student: Alexis Chirieleison
MSI & MSII PATIENT ASSESSMENT TOOL .
 1 PATIENT INFORMATION
Assignment Date: 4/10/2015
Agency: MPM
Patient Initials: TC
Age: 62
Admission Date: 3/24/2015
Gender: M
Marital Status: Single
Primary Medical Diagnosis cellulitis/sepsis
Primary Language: English
Level of Education: One year of community college
Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): window washer (retired)
Number/ages children/siblings: 6 brothers; 4 sisters (oldest is 68,
youngest is 54); no children
Served/Veteran: No
If yes: Ever deployed? Yes or No
Code Status: Full code
Living Arrangements: lives at home alone; discussed the possibility
of moving into a facility with him
Advanced Directives: No
If no, do they want to fill them out? Yes (he was
given form)
Surgery Date:
Procedure:
Culture/ Ethnicity /Nationality: Irish and Portugese
Religion: catholic
Type of Insurance: Medicaid
 1 CHIEF COMPLAINT: Patient c/o generalized malaise, abdominal discomfort, and worsening lower
extremity edema
 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient presents with generalized malaise, abdominal discomfort, and worsening lower extremity edema. He reports
everything was fine until he was shopping at publix and suddenly felt “sick as a dog” and weak, so he admitted himself to
ED, where he was found to have an elevated white count. Patient was found to have a fever of 101.0 and claims his last
bowel movement was over a week ago. Patient states his discomfort was at an 8/10 until he was given an enema. Had a
large bowel movement the morning of 3/25 and states his abdominal discomfort was relieved. While his cellulitis is still
very severe he states he’s been living with it for years and feels no pain or discomfort from it.
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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
Operation or Illness
Father
Mother
Tumor
Stroke
Stomach Ulcers
Seizures
Kidney
Problems
Mental Health
Problems
Hypertension
(angina, MI, DVT etc.)
Heart Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Cause
of
Death
(if
applica
ble)
Environmental
Allergies
2
FAMILY
MEDICAL
HISTORY
Alcoholism
CVA resulting in left sided weakness
Age (in years)
2007
45
(deceased)
70
(deceased)
Brother
57
Sister
67
Sister
61
Brother
34
suicide
(deceased)
Sister
7
House
(deceased) fire
Comments: Include age of onset
 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? 12/2014
Pneumococcal (pneumonia) (Date) Is within 5 years? 12/2014
Have you had any other vaccines given for international travel or
YES
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NO
2
occupational purposes? Please List
If yes: give date, can state “U” for the patient not knowing date received
 1 ALLERGIES
OR ADVERSE
REACTIONS
NAME of
Causative Agent
Penicillin
Type of Reaction (describe explicitly)
Patient states he was told he broke out in hives when he received
Penicillin as a child.
Medications
N/A
Other (food, tape,
latex, dye, etc.)
 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Cellulitis is an acute bacterial skin and skin-structure infection (ABSSI) of the dermis and subcutaneous tissue. It is
commonly characterized by pain, erythema, warmth, and swelling. It is caused by a bacterial penetration through a break
in the skin. Risk factors include disruption to skin barrier, inflammation, edema due to venous insufficiency and
lymphatic obstruction due to surgical procedures. Increased risk comes with elderly patients or patients with diabetes,
hypertension, and/or obesity. Prevention methods include good skin hygiene, wearing support stockings to decrease
edema, and maintain tight glycemic control. Diagnostic tests used are labs and imaging (temp, HR, BP, CPK, and CRP
levels. Also, consider serum lactate levels. Obtain a blood culture for CBC to assess WBC count. CREST guidelines
recommend wound swabs on open cellulitis wound. Plain radiographs, CT, or MRI are useful if osteomyelitis, fracture,
necrotizing fasciitis, or retained foreign body is suspected or underlying abscess. Gallium scintillography is helpful for
detecting cellulitis superimposed on recently increasing chronic lymphedema of a limb. General treatment measures
include immobilization and elevation of limb(s) involved to reduce swelling, sterile saline dressings or cool aluminum
compresses for pain relief, compression stockings, pneumatic pumps, and diuretic therapy for edema, tetanus
immunization if needed, and marking the area of cellulitis to monitor its progress and assist the efficacy of the antibiotics
regimen. (Al-Qahtani et al, 2015)
 5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name hydrochlorothiazide (Microzide)
Concentration 1 tab
Route PO
Dosage Amount 25 mg
Frequency 1x daily
Pharmaceutical class thiazide
Home
Hospital
or
Both
Indication hypertension and edema
Adverse/ Side effects dizziness, aplastic anemia, orthostatic hypotension, N/V, anorexia, urinary frequency, fatigue/weakness, electrolyte changes
Nursing considerations/ Patient Teaching diuresis onset is 2 hours, peak at 6 hours, duration is 24-72 hours; take with meals or just after to decrease gastric symptoms;
blood sugar may increase in diabetics; take in the morning to avoid interference with sleep; weigh daily to determine fluid loss; may decrease PBI level; avoid changing
positions rapidly.
Name lisinopril (Prinivil)
Concentration 2 tabs
Route PO
Dosage Amount 20 mg
Frequency 1x daily
Pharmaceutical class ACE inhibitor
Home
Hospital
or
Both
Indication treatment of hypertension
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Adverse/ Side effects HA, dizziness, N/V, diarrhea, hypotension, tachycardia, fatigue, SIADH, cough
Nursing considerations/ Patient Teaching avoid changing positions rapidly; may take without regard to food; avoid high sodium foods; avoid high potassium foods
Name polyethylene glycol 3350 (miraLAX)
Concentration granule
Route PO
Dosage Amount 17g
Frequency 1x daily
Pharmaceutical class osmotic laxative
Home
Hospital
or
Both
Indication constipation
Adverse/ Side effects bloating, flatulence, upset stomach, dizziness, increased perspiration, urticaria
Nursing considerations/ Patient Teaching
Name allopurinol (Aloprim)
Concentration 1 tab
Route PO
Dosage Amount 100 mg
Frequency 1x daily
Pharmaceutical xanthine oxidase inhibitor
Home
Hospital
or
Both
Indication antigout agent
Adverse/ Side effects hypotension, flushing, hypertension, bradycardia, heart failure, drowsiness, diarrhea, hepatitis, N/V, renal failure, hematuria, rash. urticaria, bone
marrow depression, hypersensitivity reaction
Nursing considerations/ Patient Teaching if rash occurs D/C immediately; use with thiazide diuretics or ACE inhibitors increases risk of hypersensitivity reaction;
monitor I&O for signs of decreased kidney function; monitor for joint pain and swelling.
Name cefazolin (Ancef)
Concentration 50 mL
Route IVPB
Dosage Amount 2 g
Frequency q8hr
Pharmaceutical class first generation cephalosporin
Home
Hospital
or
Both
Indication septicemia
Adverse/ Side effects seizures (high doses), pseudomembranous colitis, diarrhea, N/V, cramps, stevens-johnson syndrome, rash, pruritus, urticaria, leukopenia,
neutropenia, thrombocytopenia, phlebitis, serum sickness, superinfection
Nursing considerations/ Patient Teaching assess for infection; observe patient for signs of anaphylaxis; monitor bowel function; may increase liver enzymes
Name enoxaparin (Lovenox)
Concentration .4 mL
Route subcutaneous injection
Dosage Amount 40 mg
Frequency q12hr
Pharmaceutical class antithrombotic
Home
Hospital
or
Both
Indication prevention of VTE, DVT, and/or PE in surgical or medical patients
Adverse/ Side effects bruising, bleeding, hematoma, hematuria, hyperkalemia, dizziness, HA, insomnia, edema, increase in AST/ALT
Nursing considerations/ Patient Teaching monitor closely for signs of bleeding; stop med 12-24 hours before surgery
Name docusate-senna (Senokot-S)
Concentration 1 tab
Route PO
Dosage Amount 50mg-8.6mg
Frequency 2x daily
Pharmaceutical class stool softener/laxative
Home
Hospital
or
Both
Indication constipation
Adverse/ Side effects electrolyte imbalances, dehydration, abdominal cramps, N/V, diarrhea, rashes, urine discoloration
Nursing considerations/ Patient Teaching administer with full glass of water or juice, preferably in the evening; do not administer within 2 hours of other laxatives;
advise that laxatives are only for short term use; encourage bulk in the diet and increased fluid intake
Name
Concentration
Dosage Amount
Route
Pharmaceutical class
Frequency
Home
Hospital
or
Both
Indication
Adverse/ Side effects
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Nursing considerations/ Patient Teaching
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? regular
Diet patient follows at home? regular
24 HR average home diet:
Analysis of home diet (Compare to “My Plate” and
Consider co-morbidities and cultural considerations):
Patient is very overweight and has become increasingly so
due to his edema. He overeats with a diet high in saturated
fats and sodium and does not exercise; his lifestyle is
contributing to his disease and will need to be changed.
Breakfast: 2 fried eggs with potatoes and a cup of coffee
Lunch: tomato soup, prune juice, fries, chocolate mousse
2 diet gingerales
Dinner: chicken ala king
Snacks:
Liquids (include alcohol): cup of coffee, 2 diet gingerales,
prune juice
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
“My Plate” as a reference.
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1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? “I take care of myself but if I’m seriously ill the neighbors will stop in.”
How do you generally cope with stress? or What do you do when you are upset? “I generally try not to let things get to me
Me. My brother killed himself because he let too many things build up. I don’t dwell and just try to focus on the positives”
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“My recent weight gain has me a little upset but other than that I’m a happy camper.”
+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”
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Have you ever been talked down to? “Sure.” Have you ever been hit punched or slapped? “Yes, but not in a relationship”
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? “I’m currently single”
 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Trust vs. Mistrust
Intimacy vs. Isolation
Autonomy vs.
Generativity vs.
Doubt & Shame
Initiative vs. Guilt
Industry vs.
Self absorption/Stagnation
Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your
patient’s age group:
Old age is a time for reflecting upon one’s own life and its role in the grand scheme of things, and seeing it filled
with pleasure and satisfaction or disappointment and failures. Integrity would be achieved if the adult has a sense of
fulfillment abut life and a sense of unity within himself and with others, he will accept death with a sense of integrity; if
not the individual will despair and fear death.
While my patient has many reasons to be in despair, he has a very positive outlook on life. He is very pleasant and
understands that life comes with troubles but dwelling on them will not help the situation. He’s eager to change his diet
start losing weight to hopefully assist in improving his condition as much as he can.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
He seems used to his condition. He’s been dealing with the cellulitis for many years, however, he is eager to make some
lifestyle modifications.
+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“I really don’t know. I’ve had it for a long time”
What does your illness mean to you?
“Nothing really. It means I’m human. We get sick, treat it, and hopefully move on.”
+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? “Unfortunately, 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? “I use a rubber”
How long have you been with your current partner? N/A
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Have any medical or surgical conditions changed your ability to have sexual activity? “My stroke left my left side very
weak.”
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?
“I believe in the big Guy but I’m not very religious.”
Do your religious beliefs influence your current condition?
“Not at all”
+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? Cool menthol cigarettes
How much?(specify daily amount)
3.5 packs a day
Yes
No
For how many years? 50 years
(age 9
thru 59
)
If applicable, when did the
patient quit? 3 years ago
Pack Years: 175
Does anyone in the patient’s household smoke tobacco? If
so, what, and how much? No
Has the patient ever tried to quit?
If yes, what did they use to try to quit? Patient claims he
used nothing to quit
2. Does the patient drink alcohol or has he/she ever drank alcohol?
What?
How much?
Volume:
Frequency:
If applicable, when did the patient quit?
Yes
No
For how many years?
(age
thru
)
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
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 “I don’t think so”
5. For Veterans: Have you had any kind of service related exposure? N/A
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 10 REVIEW OF SYSTEMS NARRATIVE
Gastrointestinal
Integumentary
Changes in appearance of skin “aging
spots”
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen denies use
SPF:
Bathing routine: every other day
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 (dentures)
Routine brushing of teeth
Routine dentist visits
Vision screening last month
Other:
Immunologic
Nausea, vomiting, or diarrhea
Constipation
Irritable Bowel
Chills with severe shaking
Night sweats
GERD
Fever
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? Never had one
Other:
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: 6 x/day
Bladder or kidney infections
Had a bladder infection 5 years ago
1x/day
1x/year
Hematologic/Oncologic
Metabolic/Endocrine
Diabetes
Type: prediabetes
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? Yesterday (3/24)
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? Tele
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? NONE
Date of last prostate exam?
BPH
Urinary Retention
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness (from CVA)
Pain
Gout
Osteomyelitis
Arthritis
Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
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monitor
Other:
Other:
Other:
General Constitution
Recent weight loss or gain
How many lbs? 30lbs
Time frame? 4 months
Intentional? “No”
How do you view your overall health? “Very bad”
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
“Nope”
Any other questions or comments that your patient would like you to know?
No
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±10 PHYSICAL EXAMINATION:
General Survey: wellgroomed, overweight
male, with severe lower
extremity edema
Temperature: (route
taken?)
Height 5’9”
Pulse 99
Respirations 18
Weight 306.8 lbs
BMI
Blood Pressure: (include location)
124/78 (R. arm)
SpO2 94%
Is the patient on Room Air or O2
Pain: (include rating and
location) 0/10
3L o2 NC
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
flat
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
loud
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
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) cap refill was greater than 3 seconds
Central access device Type: Peripheral IV reseal
Location: Right hand
Date inserted: 3/24
Fluids infusing?
no
yes - what? Ancef
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 full HEENT assessment
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
Cardiovascular:
No lifts, heaves, or thrills
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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)
No JVD
Calf pain bilaterally negative
Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 99 Carotid: 2+ Brachial: 2+ Radial: 2+ Femoral: 2+ Popliteal: unable to assess DP: unable to
assess
PT: unable to assess (Doppler was to be brought in because of severe lower extremity edema)
No temporal or carotid bruits
Edema:
[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 3/25/2015
)
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:
without assistance
or
mLs N/A
with assistance
Musculoskeletal:  Full ROM intact in all extremities without crepitus
Strength bilaterally equal at _______ RUE 5/5 LUE 3/5 RLE 4/5 & 3/5 in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
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
Romberg’s 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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±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
CT of abdomen
Sodium-142; chloride104; BUN-16; potassium4.2; CO2-23; creatinine.87; glucose-105 (High)
Dates
3/24/2015
3/24/2015
Trend
No trend; only one CT
Waiting on new labs-only
one set drawn so far
PT-10.3; INR-.9; ApTT26.6
Analysis
CT revealed fluid filled
abdomen-enema was
given
WBC is elevated and
patient came in with a
fever, low BP, and
elevated HR; blood
culture confirmed
bacteremia; diagnosed
with sepsis; antibiotic
treatment ordered.
WBC-12.5 (High)
+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.)
Regular diet, up with assist (walker), accu checks q4hr, CBC, Ancef treatment, consult with home health, daily
weights and I/O monitoring
 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Ineffective peripheral tissue perfusion r/t edema aeb diminished pulses in lower extremities
2. risk for shock r/t sepsis
3. risk for impaired skin integrity r/t impaired circulation
4. Risk for vascular trauma r/t infusion of antibiotics
5.
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± 15 CARE PLAN
Nursing Diagnosis: Ineffective peripheral tissue perfusion r/t edema aeb diminished pulses in lower extremities
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Demonstrate adequate tissue
Check the brachial, radial, dorsalis Diminished or absent peripheral
Patients’ lower peripheral pulses
perfusion aeb palpable peripheral
pedis, posterior tibial, and popliteal pulses indicate arterial
are still diminished; patient was
pulses, warm and dry skin,
pulses bilaterally. If unable to find insufficiency with resultant
cold; patients’ cap refill is still
adequate urine output, and absence them use a Doppler stethoscope.
ischemia (Fausci et al, 2008)
greater than 3 seconds-GOAL
of respiratory distress
NOT MET
Note skin color and feel
Skin pallor or mottling, cool or
temperature of the skin
cold skin temp, or an absent pulse
can signal arterial obstruction,
which is an emergency that
requires immediate intervention
(Dillon, 2003)
Verbalize knowledge of treatment
regimen, including appropriate
exercise and medications and their
Check capillary refill
Nail beds usually return to a
pinkisk color 2-3 seconds after
compression if perfusion is good
(Dillon, 2003)
Note skin texture and presence of
hair, ulcers, or gangrenous areas on
the legs or feet.
Thin, shiny, dry skin with hair loss;
brittle nails; and gangrene or
ulcerations on toes and anterior
surfaces of the feet are seen in
clients with arterial insufficiency
(Bickley & Szilagyi, 2007)
Note the presence of edema in the
extremities and rate severity on a
four-point scale.
Patient cannot adequately care for
himself if he is unaware of his
disease process and the treatment
University of South Florida College of Nursing – Revision September 2014
Patient was able to teach back his
disease process and side effects of
his medications-GOAL MET
16
actions and possible side effects
Identify changes in lifestyle needed
to increase tissue perfusion
he is getting.
Discuss lifestyle with the client to
determine if the client has any
habits that may be worsening or
contributing to his condition in any
way.
Certain aspects of a disease may be
revised with the proper lifestyle
adjustment.
Patient correctly identified his
weight as an issue with his disease.
He is eager to make the appropriate
lifestyle changes-GOAL MET
Include a minimum of one
Long term goal per care plan
±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
□SS Consult
□Dietary Consult
□PT/ OT
□Pastoral Care
□Durable Medical Needs
□F/U appointments
□Med Instruction/Prescription
 □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
□Palliative Care
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17
± 15 CARE PLAN
Patient Goals/Outcomes
Maintain a systolic BP above 90
mm Hg during shift
Maintain a MAP above 65 mm Hg
Maintain a HR between 60-100
with normal sinus rhythm
Maintain a urine output greater
than .5mL/kg/hr
Have warm, dry skin
Nursing Diagnosis: Risk for shock r/t sepsis
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Monitor vital signs, BP, RR, and
Elevated HR, decreased BP,
pulse oximetry
increased RR, and decreased spO2
are indicators of shock (Bridges &
Dukes, 2005; Fauci et al, 2008;
Dellinger et al, 2009)
Temperature greater than 38 C or
less than 36 C, along with higher
WBC count or lower count plus the
symptoms above are indicators of
septic shock (Dellinger et al, 2009;
Nelson et al, 2009)
Monitor I&O, and daily weights
With the systemic inflammatory
response associated with sepsis, the
Encourage fluids
vascular membrane becomes
permeable and third spacing
Administer Diuretic as ordered
occurs. This will increase the I/O
ratio and weight due to edema
(Dellinger et al, 2009)
Complete a full nursing physical
A full nursing assessment is crucial
examination including examination in identifying multiple
of the skin.
complications of shock such as
hypoperfusion of internal organs
that manifest as decreased bowel
sounds and SOB (Bridges &
Dukes, 2005)
Cool, clammy skin, and mottling
are symptoms of tissue
hypoperfusion (Dellinger et al,
2009)
Pale clammy skin will be present in
shock states (Goodrich, 2006)
University of South Florida College of Nursing – Revision September 2014
Evaluation of Goal on Day Care
is Provided
Client’s vital signs were WNLGOAL MET
For the patient’s weight the urine
output must be greater than 70 mL
per hour. Patient’s urine output was
greater than this-GOAL MET
Patient’s skin was dry, but lower
extremities were colder than upper;
patient often complained of being
cold and asked for warm blanketsGOAL NOT MET
18
Include a minimum of one
Long term goal per care plan
±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
□SS Consult
□Dietary Consult
□PT/ OT
□Pastoral Care
□Durable Medical Needs
□F/U appointments
□Med Instruction/Prescription
 □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
□Palliative Care
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19
References
Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to
planning care (9th ed.). St. Louis, MO: Mosby Elsevier.
Al-Qahtani, J., Homsi, A., & Nour, B. (n.d.). Cellulitis. In Nursing central.
Bridges EJ, Dukes MS: Cardiovascular aspects of septic shock; pathophysiology, monitoring, and
treatment, Crit Care Nurse 25(2): 14-42, 2005
Dellinger
RP,
Cinel
I,
Sharma
S
et
al:
Septic
shock,
12,
2009,
Septic
shock,
www.emedicine.com/med/topic2101.htm. Accessed September 29, 2009
Erikson's Stages of Development. (n.d.). Retrieved from
http://www.pccua.edu/keough/erikson's_stages_of_development.htm
Fauci A, Braunwald E, Kasper D et al: Harrison’s principles of internal medicine, ed 17, New York,
2008, McGraw-Hill
Food Tracker. (n.d.). Retrieved from Choose My Plate website
https://www.supertracker.usda.gov/foodtracker.aspx
Goodrich C: Endpoints of resuscitation: what should we be monitoring? AACN Adv Crit Care 17(3):
308-316, 2006
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