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COLLEGE OF NURSING
Student: Krista Caprio
MSI & MSII PATIENT ASSESSMENT TOOL .
1 PATIENT INFORMATION
Patient Initials: L.D.
Age: 52
Gender: Female
Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: No surgeries
Procedure: No procedures
1 CHIEF COMPLAINT: I have fainting episodes all the time, but the other day was the worst it has ever
been. I passed out completely while paying for gas. I lost consciousness and hit my head. I was brought into the
hospital by an ambulance.
3 HISTORY OF PRESENT ILLNESS:
The patient has had fainting spells for about 6 months. She said that sometimes she can feel them coming,
because she gets nauseous, therefore she lies down and the feeling goes away. She stated that she is scared
because she does not know what is causing them, and she has had to change her life around for the past 6
months to try and work around the fainting spells. She stated that they could happen when shes doing activities
such as driving, but they also occur when she is just sitting doing nothing. Recently she had an episode that she
claims is the worst it has ever been. She completely lost consciousness and only remembers paying the cashier
for gas and then waking up in the hospital. The patient was hypertensive upon arriving to the hospital and was
projectile vomiting. She stated that this has never happened to her before. The patient was admitted through the
emergency department on 9/17. Since then she has gone through many tests such as a head CT, cervical spine
CT, EKG, and an ECHO. These test were ordered in order to rule out any head trauma from her fall as well as
University of South Florida College of Nursing Revision September 2014
try to find a reason for why these fainting spells are happening. So far, all tests have been negative and the
patient will be discharged in the next day or so.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
Date
Operation or Illness
1980
Car accident that resulted in a head injury. The patients states she does not know what type
of head injury occurred
Tonsils removed
4 Laparoscopies due to endometriosis
1968
Dates are
unknown to the
patient
2003
Hysterectomy
Father
75
Mother
74
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
Cause
of
Death
(if
applicable
)
Sepsis
Environmental
Allergies
2
FAMILY
MEDICAL
HISTORY
Alcoholism
Hypertension, Patient is taking Metoprolol 50mg by mouth (PO) twice daily and Enalapril 20mg PO
once daily
2008
Brother
Sister
Sister
48
Sister
50
45
relationship
Comments: Patient
states she does not know age of onset for her familys diseases. She denies any other family
illnesses. The patient was diagnosed with hypertension in 2008; she is on medication though it is not controlled .
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
Adult Tetanus
Influenza (flu)
YES
NO
Pneumococcal (pneumonia)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS
NAME of
Causative Agent
Type of Reaction
Clindamycin
Lortab
Tape
Latex
Medications
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)
Hypertension is a chronic elevation in blood pressure. Two factors can affect blood pressure: cardiac output and
systemic vascular resistance. Patients with high blood pressure may have an increased cardiac output, an
increased resistance, or both. Usually in older adults, the reason for high blood pressure is the stiffening of the
vasculature such as stiffening of the aorta which will increase pressure. There are many risk factors for
hypertension, some modifiable and some not. For example, older age, male gender, African Americans,
smokers, diabetics, having a family history, being obese/over -weight, excessive sodium in your diet, drinking
too much alcohol, stress, and living a sedentary lifestyle are just some of them. People are diagnosed with stage
1 hypertension when their systolic blood pressure is from 140-159 and their diastolic is 90-99. In order to be
diagnosed, there has to be at least 2 or more high blood pressure readings at several doctors appointments.
Antihypertensive medications can be given to control hypertension, some examples are, beta-blockers, ACE
inhibitors, angiotensin2 receptor agonists, calcium channel blockers, direct vasodilators, and thiazide diuretics.
All antihypertensive drugs work by either decreasing cardiac output, decreasing the peripheral vascular
resistance, or both. The first treatment to managing hypertension is life-style modification. This includes
decreasing sodium in the diet, losing weight, increasing exercise, controlling diabetes, and cessation of
smoking. Medications are used when the modifications have not been successful. Prognosis for people with
hypertension is good if it is controlled with lifestyle changes and medications. Hypertension is a leading risk
factor for coronary artery disease. If hypertension is not managed properly, clients diagnosed with hypertension
are at a huge risk for heart attack and stroke. Long- term uncontrolled hypertension is also damaging to the
organs such as the kidneys and can lead to renal disease/ kidney failure (Foex & Sear, 2004).
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.] (Nursing Central from Unbound Medicine)
Name: metoprolol (Lopresor)
Concentration: 50mg
Dosage Amount: 50mg
Route: By mouth (PO)
Frequency: Twice a day
Pharmaceutical class: Antihypertensive
Home
Hospital
or
Both
Indication: Treatment of hypertension
University of South Florida College of Nursing Revision September 2014
Adverse/ Side effects: Fatigue, weakness, anxiety, depression, dizziness, bradycardia, hypotension, pulmonary
edema, rashes, constipation, diarrhea, nausea/vomiting,
Nursing considerations/ Patient Teaching: Take medication as directed, abrupt withdrawal can cause lifethreatening arrhythmias, hypertension, or myocardial infarction. Check pulses and blood pressure daily. May
cause drowsiness avoid activities such as driving until response to drug is known. Notify provider is slow pulse,
difficulty breathing, dizziness, rash.
Name: enalapril (Vasotec)
Concentration: 20mg
Dosage Amount: 20mg
Route: PO
Frequency: Once daily
Pharmaceutical class: Antihypertensive
Home
Hospital
or
Both
Indication: Alone or with other agents in the management of hypertension
Adverse/ Side effects: Dizziness, fatigue, headache, weakness, hypotension, diarrhea, nausea/vomiting, dyspnea,
hyperkalemia, angioedema
Nursing considerations/ Patient Teaching: Take medication as directed, avoid salt substitutes containing
potassium, change positions slowly, avoid driving and other activities requiring alertness until response is known,
notify provider of rash, sore throat, fever, irregular heartbeat, swelling of the face, dry cough may occur until
medication is discontinued, monitor blood pressure
Name: enoxaparin (Lovenox)
Concentration: 40mg
Dosage Amount: 40mg
Route: Subcutaneous
Frequency: Once daily
Pharmaceutical class: antithrombotics
Home
Hospital
or
Both
Indication: Prevention of DVT, VTE, or PE
Side effects/Nursing considerations: Dizziness, headache, insomnia, hyperkalemia, fever, bleeding, edema,
report any symptoms of unusual bleeding or bruising, not to take with aspirin or ibuprofen without consulting a
healthcare professional
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular
When looking at the nutrition report my patient was
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Patient states that she has some friends and he ex-husband that usually help
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs.
Mistrust
Autonomy vs.
Role Confusion/Diffusion
Ego Integrity vs. Despair
Intimacy
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage
for your Patients age group:
Since my patient is 52 years old her category would be the generativity vs. stagnation. In this stage, we usually
establish careers settle down in a relationship and begin families. We give back to society through raising our
kids, being productive at work, and involved in the community. When we fail to achieve these things we
become stagnant and feel unproductive (McLeod, 2013).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
Through talking with my patient, I concluded that she was in the stagnant developmental stage. I picked this
one, because she is 52 years old, divorced, has no children, and lives by herself. She is also unemployed. The
stage of generativity is when the person gives back and, and my patient has not done this. Im not sure
specifically how long she has been unemployed, but she has been divorced for a long time. She stated that when
she is home she really doesnt do much; she just walks her dog. In my opinion, this is not giving back to society.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
My patient stated that she has been dealing with her condition for about 6 months. For this reason, I dont think
this particular condition has had much of an influence on her developmental stage of life. As stated before the
stagnant phase is when you have not given back to the community through your job, children ect. So, a
condition that started recently should not have affected her to the degree of not having children and no job when
she told me that she has been unemployed and without insurance for a long time.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? The patient indicates that she is not sure what the cause of
her illness is. That is why she is in the hospital.
What does your illness mean to you? The patient stated that her illness means she is sick and she is not sure
why or what to do about it. She is hoping that being in the hospital will help to figure that out and relive some
of her stress.
+3 SEXUALITY ASSESSMENT:
Have you ever been sexually active? Yes
Do you prefer women, men or both genders? Men
Are you aware of ever having a sexually transmitted infection? No
Have you or a partner ever had an abnormal pap smear? No
Have you or your partner received the Gardasil (HPV) vaccination? No
Are you currently sexually active? No
If yes, are you in a monogamous relationship? N/A
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or
an unintended pregnancy? Condoms
How long have you been with your current partner? The patient is not with a partner
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
1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
The patient states that she was baptized as a child but she does not practice any religion.
University of South Florida College of Nursing Revision September 2014
Yes
No
For how many years? 42years
(age 13
thru
52
Pack Years: 42
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No
Has the patient ever tried to quit? Yes she quit 3 months
ago
If yes, what did they use to try to quit? Quit cold turkey
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? Kahlua and sometimes wine
How much? Two drinks
Volume: 350ml
Frequency: Only on holidays
If applicable, when did the patient quit?
N/A
No
For how many years?
(age 13
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? N/A
For how many years? N/A
Is the patient currently using these
drugs? N/A
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks? No
5. For Veterans: Have you had any kind of service related exposure? N/A
HEENT
Difficulty seeing - Glasses
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems- Teeth are breaking
Routine brushing of teeth
2 x/day
Routine dentist visitsSometimes1x/year
Vision screening- 1x/ year
Other:
Immunologic
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? N/A
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
Hematologic/Oncologic
Metabolic/Endocrine
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? 9/17/15- negative findings
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other: Syncopal episodes
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Childhood Diseases
Measles
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 9/17/15,
negative findings
Other:
Pain
Gout
Osteomyelitis
Mumps
Polio
Scarlet Fever
Arthritis
Chicken Pox
Other:
Other:
General Constitution
Recent weight loss or gain
How many lbs? 125105
Time frame? A couple weeks, due to unknown cause
Intentional?
How do you view your overall health? Patient states that besides her fainting spells she believes she is in pretty good health
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
10 PHYSICAL EXAMINATION:
General Survey: This
Height: 61.5in
Weight: 113lbs
BMI: 21.09
Pain: No pain
patient is an alert and
Pulse: 72 BPM
Blood Pressure:149/101 Left upper
oriented, very pleasant,
arm
Respirations: 18
but anxious 52 year old
women. She becomes
stressed when she talks
about her illness because
she does not know what
is causing it; however,
she is cooperative and
likes to talk.
Temperature: 98.4
SpO2: 100
Is the patient on Room Air or O2:
degrees Fahrenheit, oral
Room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
flat
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
loud
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
Central access device: N/A Type: 20g peripheral IV
Location: Right hand
Date inserted: 9/17/15
Fluids infusing?
no
yes - what?
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: equal distance on right and left sides
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Patients teeth are yellow; she states she has not been to the dentist in a while. Her teeth are chipping.
Comments:
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
10
Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No JVD
or
with assistance
Biceps: 2
Brachioradial:
Patellar: 2
Achilles: 2
negative
11
10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Lab
Troponins
Dates
9/17
Head CT
9/17
Trend
Each of these lab tests
were done one time. They
were used to figure out
why the patient is fainting
randomly. In addition, if
there was any trauma
after her fall. For all of
these tests the results
were negative. There
were no significant
findings that showed a
possible solution to why
she was having these
episodes.
Analysis
The patients troponin
levels were 0. These were
ordered with the purpose
of seeing if there was any
sort of damage to the
heart for example, a
myocardial infarction that
could have been the
reason for her lightheadedness and fainting.
Troponin levels would be
increased if there was any
damage to the heart.
ECHO
9/17
13
15 CARE PLAN
Nursing Diagnosis: Risk for ineffective tissue perfusion related to syncopal episode
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
1.Client will demonstrate adequate 1. Monitor for signs of decreased
Signs of decreased cardiac output
Throughout the shift the patient
perfusion of tissues as evidence by cardiac output; monitor vitals,
such as a low blood pressure high
maintained adequate tissue
adequate vitals within normal
listen to heart and lung sounds,
heart rate, and lack of peripheral
perfusion. Her vitals maintained
parameters for this patient and
monitor labs
pulses are things we need to
within normal parameters specific
stable neuro status by the end of
2. Monitor neuro status every 4
monitor for to ensure the patient is to her. There were no signs of
shift.
hours
getting adequate blood flow to the
decreased cardiac output or change
3. Maintain heart rate under 100
brain and other tissues. A change
in neuro status throughout the shift.
and systolic blood pressure over 90 in neuro status could indicate a
but under 120
lack of blood flow as well as O2 to
the brain and other tissues (Ackley,
2010).
Patient Goals/Outcomes
1. Administer hypertensive
medications as indicated
2. Maintain a quiet relaxed
environment
3. Monitor input and changes in
urine output
14
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
Nursing Diagnosis: Risk for fall or injury related to dizziness and syncopal episode
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
1. Client will remain safe from falls 1. Bed will be kept in low position Putting these interventions in place The client did not experience any
throughout shift
at all times with brakes engaged,
will increase the safety of the
falls throughout shift. Precautions
no slip yellow socks will be worn
patient by decreasing her risk of
were put into place and the client
2. Keep needed items within reach, falling. Teaching the client to rise
called for assistance when it was
encourage client to use call bell
slowly will prevent her blood
needed.
when assistance is needed
pressure form dropping quickly
3. Client will be taught to rise
which can lead to dizziness and
slowly and take her time
falling (Ackley, 2010).
2. Client will protect herself from
1. Client will be taught to remain
Teaching the client to stay hydrated The client was taught these
injury due to dizziness throughout
hydrated
will decrease the risk of
interventions and implemented
shift
2. Client will be taught symptoms
dehydration which can lead to
them throughout the shift. The
to report
dizziness/lightheadedness.
client remained in bed while dizzy
3. Client will be taught activities to Teaching the client to report
and stayed hydrated. No worsening
avoid while feeling dizzy
worsening symptoms such as
symptoms occurred.
excessive nausea and vomiting will
help her get treated earlier and
decrease the risk of progressing
symptoms. Lastly, teaching the
client to avoid activities such as
walking while dizzy will decrease
her risk of falling/injury (Ackley,
University of South Florida College of Nursing Revision September 2014
15
2010).
If the client knows and understands
these practices she will be able to
reduce her risk of injury for when
she is to be discharged home
(Ackley, 2010).
16
References
Ackley, B. J., & Ladwig, G. B. (2010). Nursing diagnosis handbook: An evidence-based guide to
planning care. Maryland Heights, MO: Mosby.
ChooseMyPlate.gov. (n.d.). Retrieved from http://www.choosemyplate.gov/
Foex, P., Sear, J. W. (2004) Hypertension: Pathophysiology and treatment. Continuing
Education in Anaesthesia, Crtical Care & Pain, (4)3, 71-75. doi:
10.1093/bjaceaccp/mkh020
McLeod, S. (2013). Erik Erikson. Retrieved from http://www.simplypsychology.org/ErikErikson.html
Nursing Central from Unbound Medicine
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