UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Jennifer R. Carter
Assignment Date: 11/8/16
MSI & MSII PATIENT ASSESSMENT TOOL .
1 PATIENT INFORMATION Agency:
Patient Initials: WFI Age:59 Admission Date: 10/18/16
Gender: M Marital Status: Single Primary Medical Diagnosis : SJS/TENS
Primary Language: English
Level of Education: High School Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Detailing cars Acute Kidney Injury, Acidosis, Azotemia,
Asperigilus, CLL, pancytopenia
Number/ages children/siblings: 3 children Hyperkalemia, hypernatremia, immunosuppressed

Served/Veteran: Code Status: Full

If yes: Ever deployed? Yes or No
Living Arrangements: Lives with close friend Advanced Directives: yes
If no, do they want to fill them out?
Surgery Date: N/A Procedure: N/A
Culture/ Ethnicity /Nationality: African American
Religion: Baptist Type of Insurance: N/A

1 CHIEF COMPLAINT: Steven-Johnsons Syndrome

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
WFI is a 59 year old male with a history of chronic lymphocytic leukemia. His last episode of chemotherapy
was done prior to admission. He developed fatigue, fever, neutropenic fever, and strep pharyngitis. He was
treated with antibiotics and then developed a skin rash which rapidly progressed with mucosal and ocular
involvement. Dermatology was consulted and skin biopsy was done confirming diagnosis of SJS/TENS. He
was transferred to TGH on 10/18/16 and has been admitted to burn ICU. Patient now present with acute renal
failure requiring dialysis. Patient presents with groin shiley that has been in for 8 days.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
2006 Leukemia- chemotherapy
Unable to attain Arthritis
Unable to attain Peptic Ulcer
Unable to attain Strep Pharyngitis
Unable to attain Anemia
Unable to attain Neutropenic fever
Unable to attain Bleeding gums

University of South Florida College of Nursing Revision September 2014 1

 Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
etc.)
FAMILY

Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma
Cause

Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
Gout
MEDICAL of

Mental
Heart
HISTORY Death

(angina,
(if
applicable)
Father
Mother
Brother
Sister
relationship

relationship

relationship

Comments: Include age of onset

Unable to attain

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations X
Routine adult vaccinations for military or federal service X
Adult Diphtheria (Date) X
Adult Tetanus (Date) Is within 10 years? X
Influenza (flu) (Date) Is within 1 years? X
Pneumococcal (pneumonia) (Date) Is within 5 years? X
Have you had any other vaccines given for international travel or
occupational purposes? Please List X
If yes: give date, can state U for the patient not knowing date received

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Bendomustine Anaphylaxis
Rituaxin Anaphylaxis
Medications

Other (food, tape,

latex, dye, etc.)
University of South Florida College of Nursing Revision September 2014 2
 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Steven- Johnson Syndorme (SJS) is a severe skin reaction to an infection or certain medication, characterized by cell mediated
cytotoxic reactions against epidermal cells. At times idiopathic, early diagnosis and removal of the causative factor are necessary to
decrease the probability of morbidity and mortality. In terms of pathophysiology, drug metabolites bind to mucocutaneous epithelial
cells. This binding initiates the release of lymphocytes and macrophages, thus resulting in keratinocyte activation and necrosis of the
epidermis. Clinically manifested as bright-pink or red lesions that become blisters and break open, SJS also has involvement with the
mucous membranes of the mouth, eyes, genitals, esophagus, and respiratory tract. Diagnosed by frequent skin cultures and biopsies,
there is no universally accepted treatment plan for SJS. Research on the use of glucocorticoids and intravenous immunoglobin prove
success in some outcomes and detrimental in others. Per Caring for the patient with skin disorders. In Medical- Surgical Nursing:
Preparation for Practice : intravenous fluid replacement must be started to amend dehydration and electrolyte loss, total parenteral
nutrition is necessary to treat protein loss that occurs with skin detachment, and emotional, psychiatric, and supportive care are
amongst the top priorities for management of the disease process.

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name Acetominophen Concentration Dosage Amount 650 mg

Route Oral Frequency PRN

Pharmaceutical class Antipyretic/ nonopiod analgesic Home Hospital or Both
Indication Pain and fever
Adverse/ Side effects SJS/TENS, headache, fatigue, hepatotoxicity
Nursing considerations/ Patient Teaching: advise pt. to not take more than prescribed, avoid alcohol, discontinue if rash worsens

Name alprazolam (Xanax) Concentration Dosage Amount 0.25 mg

Route Oral Frequency PRN

Pharmaceutical class benzodiazepine Home Hospital or Both
Indication Antianxiety
Adverse/ Side effects Dizziness, drowsiness, lethargy, confusion, hangover, headache
Nursing considerations/ Patient Teaching: Nurse should be mindful for S/S of dependence, tolerance, and addiction

Name bacitracin- polymixin b Concentration Dosage Amount 1 tube

Route Topical Frequency 2 times daily

Pharmaceutical class anti-infectives Home Hospital or Both
Indication Treatment of localized infections due to susceptible organisms
Adverse/ Side effects Pseudomembranous colitis, rash
Nursing considerations/ Patient Teaching: Teach pt. to use for as long as prescribed, only for use on minor cuts and burns

Name Chlorhexidine gluconate Concentration Dosage Amount N/A

Route Topical Frequency PRN

Pharmaceutical class Antiseptic Home Hospital or Both
Indication Clean skin after an injury, before surgery, or before injection
Adverse/ Side effects: itching, hives, worsening rash
Nursing considerations/ Patient Teaching

University of South Florida College of Nursing Revision September 2014 3

Name daptomycin (Cubicin) Concentration 6mg/kg x 79.2 kg Dosage Amount

Route: IV Frequency: Every 8 hours

Pharmaceutical class: Antibacterial Home Hospital or Both
Indication: Complicated skin & skin structure infections caused by aerobic gram positive bacteria
Adverse/ Side effects: dizziness, Clostridium difficile associated diarrhea, drug rash
Nursing considerations/ Patient Teaching: Advise pt. to notify provider if rash or fever develop, do NOT treat diarrhea without consulting with provider

Name: ipratropium- albuterol Concentration 0.5 mg- 3 mg/ 3 ml Dosage Amount

Route: Oral/ respiratory Frequency: every 6 hours

Pharmaceutical class: Anticholinergic Home Hospital or Both
Indication: adjunctive management of bronchospasm caused by asthma, maintenance therapy of reversible airway obstruction
Adverse/ Side effects: nervousness, sore throat, cough, bronchospasm
Nursing considerations/ Patient Teaching: Teach pt. proper use, take missed dose ASAP, Notify healthcare professional if s/s dont improve w/in 30 minutes

Name: loteprednol etabonate 0.5% Concentration Dosage Amount 1-2 drops both eyes

Route: opthalmic Frequency: 4 times daily

Pharmaceutical class: corticosteroid Home Hospital or Both
Indication to treat certain eye conditions due to inflammation
Adverse/ Side effects: Discharge from eye, dry eye, runny nose, sore throat, headache, itching, hives, rash
Nursing considerations/ Patient Teaching: Notify healthcare provider if swelling gets worse or if patient develops rash.

Name: voriconazole (VFEND) Concentration Dosage Amount 300 mg

Route: Oral Frequency: every 12 hours

Pharmaceutical class: antifungal Home Hospital or Both
Indication: serious systemic fungal infection such as aspergillosis
Adverse/ Side effects: visual disturbances, hallucinations, QT interval prolonging, hepatotoxicity
Nursing considerations/ Patient Teaching: Teach pt. to avoid direct sunlight, sunlamps, and tanning beds, Alert healthcare professional with development of rash

University of South Florida College of Nursing Revision September 2014 4

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? NPO Analysis of home diet (Compare to My Plate and
Diet patient follows at home? No specific Diet Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Grits, egg, sausage

Lunch: chicken salad sandwich, chips,

Dinner: chicken, mashed potato, green beans

Snacks: n/a

Liquids (include alcohol): diet coke, fruit juices, water

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? Patient states that he lives with a close friend that helps him when he is sick.

How do you generally cope with stress? or What do you do when you are upset? Patient states that he goes to church
often and chats with his church friends as a way to cope with stress.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life). Patient denies
any recent difficulties.

+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? NO 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? N/A

Are you currently in a safe relationship? Patient states that he is not currently in a relationship.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry
vs. Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs.
Despair
University of South Florida College of Nursing Revision September 2014 5
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: Generativity

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
It is believed that the patient is in the stage of generativity. This is my opinion because the patient experienced many
thoughts of caring for others in the church and wanting to get his health back on track so he can continue learning and
teaching about his religion.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
This illness and hospitalization has hindered my patient from interacting like he usually does and continuing to develop to
the next stage.

What do you think is the cause of your illness?

Patient states that he thinks the cause of his illness is related to chemotherapy.
What does your illness mean to you?
The patient states his illness doesnt mean anything more than just a bad reaction to the chemotherapy.
+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? 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? NO

How long have you been with your current partner? N/A
Have any medical or surgical conditions changed your ability to have sexual activity? Yes

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 states that religion is a very important component of his
life and that he does not miss church very often.
Do your religious beliefs influence your current condition? The patient does not think his current condition and religious beliefs are
related.

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
For how many years? N/A
If so, what? N/A How much?(specify daily amount)
years
N/A

If applicable, when did the

Pack Years: N/A
patient quit? N/A

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit? N/A
so, what, and how much? N/A If yes, what did they use to try to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Beer How much? 1 can For how many years?
Volume: (age 30 thru 59 )
Frequency: Occasional
If applicable, when did the patient quit?
Patient has not quit but instead just has not thought of having a beer.

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? If not, when did he/she quit?
Yes No N/A

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
The patient is unsure of whether or not he has been exposed to any occupational or environmental hazards/ risks.

5. For Veterans: Have you had any kind of service related exposure?
The Patient is unsure of whether he has been exposed to any kind of service related exposure, but doubts that he has.

University of South Florida College of Nursing Revision September 2014

 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 GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: Diverticulitis Life threatening allergic reaction
Bathing routine: Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy?
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: A
Post-nasal drip Normal frequency of urination: x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Acute Kidney Injury Metabolic/Endocrine
Routine brushing of teeth Diabetes Type:
x/day
Routine dentist visits x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
University of South Florida College of Nursing Revision September 2014
 Last EKG screening, when? 10/ 31/16 Arthritis Chicken Pox
Other: Other: Other:

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health? Pt. views his overall health as declining and is anxious about getting on the right track.

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

University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:

General Survey: Height: 177.8 cm Weight 81.4 kg BMI Pain: (include rating and
Pulse 59 Blood Pressure: (include location) location)
Respirations 13 127/60 Left arm 0
Temperature: (route SpO2 99% room air Is the patient on Room Air or O2
taken?) 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]

Garbled, hoarse

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): skin presents with rashes and blisters, poor skin turgor, nails presenting with clubbing
Central access device Type: Port Location: Right chest Date inserted: inserted
with administration of chemotherapy several years ago
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 pupil size / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments: Lesions on ears, nose, lips, buccal mucosa, floor of mouth and tongue. Eyelids, orbital area, eyelashes, lacrimal
glands with edema and drainage

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick Amount: moderate
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: Rhonchi at all fields
RUL LUL
RML LLL
RLL

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

University of South Florida College of Nursing Revision September 2014

Cardiovascular: No lifts, heaves, or thrills
Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
Patient not placed on EKG at current moment

Calf pain bilaterally negative Pulses bilaterally equal 2+ carotid and radial, 1+ Dorsalis pedis
Apical pulse: 59 Carotid: Brachial: Radial: Femoral: Popliteal: DP: PT:
No temporal or carotid bruits Edema: Ankles, feet [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-
8mm) ]
Location of edema: Ankles, feet 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 11 / 1 / 16 ) Formed Semi-formed Unformed Soft Hard Liquid
Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe: Scrotum presents with discoloration, tenderness, and rash

GU Urine output: Clear Cloudy Color: Previous 24 hour output: N/A mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness Patient presents with oliguria with usage of straight catheter

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at _______ RUE _______ LUE _______ RLE & _______ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative

University of South Florida College of Nursing Revision September 2014

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 Dates Trend Analysis

RBC: 2.44 Low Indicates anemia and
10/31/16 verifies dx of leukemia,
RBC decreases with renal
failure, and is expected to
be low with SJS/TENS
BUN: 111 10/ 31/16 High indicates that the kidney
is no longer removing
urea from blood
adequately and is
indicative of impaired
renal function. There is
an expected increase with
SJS/TENS
Creatinine: 4.3 10/31/16 High Indicates poor clearance
of creatinine and suggest
renal impairment
Phosphorus: 5.1 10/31/16 High Kidney disease impairs
excretion. Pt will need a
phosphate binder
Albumin: 1.8 10/31/16 Low Increased excretion of
albumin indicate renal
dysfunction
Hematocrit: 20.7 10/31/16 Low Levels are expected to be
low with leukemia
Hemoglobin: 7.0 10/31/16 Low Levels indicative of
leukemia
Punch biopsy 10/18/16 Postive for SJS/TENS

Chest X-ray 10/18/16 No abnormal findings

+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.)

Diet NPO, bedside glucose monitoring q6h, constant reviewing of vitals, pastoral care consults, nephrology consult
following lab values, ophthalmology consult to examine exudative eye drainage.

University of South Florida College of Nursing Revision September 2014

 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Impaired skin integrity related to skin lesions.

2. Risk for infection related to loss of skin integrity.

3. Imbalanced nutrition: less than body requirements related to difficulty swallowing.

4. Disturbed body image related to disease.

5. Deficient knowledge related to disease and treatment plan.

University of South Florida College of Nursing Revision September 2014

 15 CARE PLAN
Patient Goals/Outcomes
Prevent further skin breakdown
and necrosis
Address patient comfort
Minimize the amount of dried
blood on patients mouth
Nursing Diagnosis: Impaired skin integrity related to skin lesions.
Nursing Interventions to Achieve Rationale for Interventions
Goal Provide References
Reposition patient every two hours Prevent pressure ulcers and reduce
risk for infection
Repositioning, Keeping pain score Due to limited research, comfort
between 0-3 and supportive care is priority in
the management of SJS/TENS
Perform routine oral care every In addition to providing comfort,
four hours this will salvage skin integrity of
the buccal area and may help with
the patients current dysphagia.
Evaluation of Goal on Day Care
is Provided
Patient repositioned and propped
up on pillows every two hours
Patient reported that pain was
within the set range by the end of
the shift.
Nurse did not see the urgency in
providing mouth care and this task
was not completed during shift.

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

University of South Florida College of Nursing Revision September 2014

F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

 References

Halter, M.J. (2014). Relevant theories and therapies for nursing practice. In Foundations of Psychiatric Mental
Health Nursing (pp. 19-37). St. Louis, MO: Elsevier
Osborn, K. S., Wraa, C.E., Watson, A. B., Holleran, R. (2014). Caring for the patient with skin disorders. In
Medical- Surgical Nursing: Preparation for Practice(pp.1858-1865). New
York, NY: Pearson.
.Vallerand, A.H., Sanoski, C.A., Deglin, J.H., Mansell, H.G. (2015). Daviss drug guide for nurses. Fifteenth
Edition. [Mobile application software]. Retrieved from:
https://play.google.com/store/apps?hl=en.

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014