UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Aimee Achat
Assignment Date:09/16/16
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: SBN - STJ
1 PATIENT INFORMATION
Patient Initials: J.L. Age: 57 Admission Date: 09/13/16
Gender: Female Marital Status: Married Primary Medical Diagnosis:
Primary Language: English Pulmonary nodule
Level of Education: 11th grade Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Supervisor at Bealls N/A
Number/ages children/siblings: none

Served/Veteran: N/A Code Status: Full code

If yes: Ever deployed? Yes or No
Living Arrangements: Lives with husband, dog and cat Advanced Directives: Yes
If no, do they want to fill them out?
Surgery Date: 09/13/16
Culture/ Ethnicity /Nationality: Caucasian; American Procedure: Left upper lobectomy
Religion: Christian Type of Insurance: Blue Cross Blue Shield

1 CHIEF COMPLAINT:
Left upper lobe nodule

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient is a 59 year old married Caucasian female with a past medical history of hypertension and breast cancer. She has a
past surgical history of a bilateral mastectomy, stage 1 reconstruction, right breast lumpectomy, collar bone surgery,
hysterectomy, laparotomy, and tonsillectomy. Patient was undergoing a routine screening mammogram in February, when
there were concerned findings which prompted an MRI and subsequently resulted in bilateral mastectomy. About four
months later, the patient returned to her primary care physician for a follow up and to obtain a baseline CT scan, however
the CT scan revealed a left upper lobe nodule.

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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
1961 Strabismus
1965 Tonsillectomy
1973 Clavicle fracture surgery
1976 Femur arterioplasty
1982 Right salpingo-oophorectomy
1983 Total hysterectomy
1992 Lumpectomy
05/2016 Double mastectomy
09/2016 Left upper lobectomy

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause
Alcoholism

MEDICAL

Glaucoma

Problems

Problems
Allergies

of

Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY
Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father 54 M.I.
Mother 45 I.C.H
Sister 57
Brother 56
Brother 55
Brother
52
relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
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?
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

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 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Sulfa drugs Hives

Medications

Hay fever Watery and itchy eyes

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)
A pulmonary nodule is a small rounded growth in the lung usually less than three centimeters and is usually caused by
infections such as mycobacterium tuberculosis, non-infection causes such as rheumatoid arthritis, or neoplasms such as a
sarcoma (Cleveland Clinic, 2016). According to the Cleveland Clinic (2016), the nodules are diagnosed by different
diagnostic tests: Chest X-rays usually indicated that there is an abnormality on the lung, Computerized Tomography (CT)
scan may be used for a more detailed image of the spot, a Positron Emission Tomography (PET) scan will be ordered to
see if it is benign or malignant and a Biopsy will be done as a final indicator of whether or not the nodule is malignant.
Truong et al. (2013) stated that the factors associated with increased risk were the patients age, the presence of
symptoms, history of smoking, and a history of exposure to asbestos, uranium or radon. A benign nodule will not need to
be taken out, however, if it is malignant without metastasis then it can be removed surgically by thoracotomy or video-
assisted thoracoscopy (Cleveland Clinic, 2016).

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

Route orally Frequency Take 1 tablet by mouth daily

Pharmaceutical class Calcium channel blocker Home Hospital or Both
Indication It dilates blood vessels and improves blood flow for patients with high blood pressure and angina
Adverse/ Side effects: Swelling of legs, stomach pain, nausea, face flushing, arrhythmia, palpitations
Nursing considerations/ Patient Teaching: Change positions slowly to avoid dizziness and falls.

Name Microzide/hydrochlorothiazide Concentration Dosage Amount 25mg

Route orally Frequency Take 1 tablet by mouth daily

Pharmaceutical class: Diuretic Home Hospital or Both
Indication: Used to treat high blood pressure and to treat fluid retention
Adverse/ Side effects: vision problems, nausea, vomiting, tachycardia, muscle pain, dark urine
Nursing considerations/ Patient Teaching: Get vision checks annually with ophthalmologist

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Name Klor-con/Potassium Chloride ER Concentration Dosage Amount 10 mEq

Route orally Frequency Take 1 tablet by mouth daily

Pharmaceutical class: Potassium supplement Home Hospital or Both
Indication: To prevent or to treat low blood levels of potassium.
Adverse/ Side effects: GI effects, nausea, vomiting, abdominal pain, flatulence, diarrhea
Nursing considerations/ Patient Teaching: Have the patient report any type of GI symptoms such as tarry stools or other evidence of GI bleeding.

Name Arimidex/anastrozole Concentration Dosage Amount 1mg

Route orally Frequency Take 1 tablet by mouth daily

Pharmaceutical class: Antineoplastic agent Home Hospital or Both
Indication: adjuvant treatment of hormone receptor-positive early breast cancer
Adverse/ Side effects: constipation, nausea, vomiting, breast swelling or tenderness, vaginal bleeding, hair thinning, weight changes, osteoporosis
Nursing considerations/ Patient Teaching: Adding Calcium and vitamin D supplements in diet and include weight-bearing exercises.

Name Caltrate + 600/calcium 600 +D Concentration Dosage Amount 600 + D

Route orally Frequency Take 1 tablet by mouth twice a day

Pharmaceutical class: Vitamins Home Hospital or Both
Indication: Treating or preventing Calcium deficiency
Adverse/ Side effects: severe allergic reaction, nausea, vomiting, constipation.
Nursing considerations/ Patient Teaching: Do not take more than directed and include weight-bearing exercise to regimen for strengthening of bones.

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
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? Normal
Diet patient follows at home? Normal
24 HR average home diet:
Breakfast: granola bar, smoothies (yogurt, kale),
Coffee with sugar and milk
Lunch: steamed chicken with vegetables and a cup of rice
Dinner: pork, beef or chicken, potatoes and vegetables
Snacks: Fiber one bars, Hersheys dark chocolate, yogurt
Analysis of home diet (Compare to My Plate and
Consider co-morbidities and cultural considerations):
Include a cup of fruit to diet to increase nutrients. Berries
are a good form of antioxidants for free radicals.
Replace potatoes with mashed, steamed cauliflower to
reduce calories.
Use the palm of your hand as a measurement of how much
lean meat to eat at lunch.
Replace pork with fish for omega fats.

Liquids (include alcohol): 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?
Herself, friends, or husband
How do you generally cope with stress? or What do you do when you are upset?
Patients states that she walks 3 miles a day or talks to friends about problems

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Depressed about how husband views her body with her double mastectomy

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.

Have you ever felt unsafe in a close relationship? ______Yes____________________________________________

Have you ever been talked down to? Yes___________ Have you ever been hit punched or slapped? _Yes__________

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_______Yes__________________ If yes, have you sought help for this? _Therapy for 3 years_______

Are you currently in a safe relationship? Yes

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 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
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: According to Treas (2014), generativity refers to being an active member of society and the individual will feel as
though they are making a difference in the world. Whereas, stagnation refers to the inability to find a way to contribute to society.

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient is in the self-absorption stage/stagnation stage because she feels regretful about not being able to raise/have
children and not finishing her high school diploma in her previous years.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
Due to the patients illness throughout her life, she feels like she has had no control over her fate and has not been able to
accomplish all her goals.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states her illness is due to her smoking for 30 years, her parents both smoked throughout her life, drinking alcohol,
and eating too much junk food.

What does your illness mean to you?

A means to an end

+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? ___________________________________________

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? ___No_______________________________

How long have you been with your current partner?___24 years_____________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? ___Yes, breast cancer__________

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?
Despite going to church on and off throughout her life because her parents did not go, the patient has used religion as her life-line
when she is scared or worried about her health.
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_The patient states that her religion gives her peace and strength for operations and the many health conditions she has.
___________________________________________________________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much?(specify daily amount) For how many years? 33 years
Smoke cigarettes 1-2 packs per day (age 17 thru 50 )

If applicable, when did the

Pack Years: 1-2 ppd x 33 years
patient quit? 50

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

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? 4/5 quart to gallon For how many years? 19 years
Liquor Volume: ~ 1250 ml (age 16 thru 35 )
Frequency:
If applicable, when did the patient quit?
35 years old after diagnosis of breast cancer

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
Marijuana How much? For how many years? 41 years
1 to 2 puffs a day (age 16 thru now )

Is the patient currently using these drugs?

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

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Worked in home construction with insulation and dry wall. Also worked in a paint factory and exposed to the fumes.

5. For Veterans: Have you had any kind of service related exposure?

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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 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: 15 Diverticulitis Life threatening allergic reaction
Bathing routine: once a day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy? 2013
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:
Post-nasal drip Normal frequency of urination: 4 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 1 x/day Diabetes Type:
Routine dentist visits x/year Hypothyroid /Hyperthyroid
Vision screening: every 4 years Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or 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? 11/2015 Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? 16 Encephalitis
last CXR?: 9/10/16 menopause age? Meningitis
Date of last Mammogram &Result:
Other: Other:
01/2016; breast cancer
Date of DEXA Bone Density & Result:
Cardiovascular 2012 - OSTEOPENIA Mental Illness
Hypertension Depression
Hyperlipidemia Schizophrenia
Chest pain / Angina 222 Anxiety
Myocardial Infarction 2012 Bipolar
CAD/PVD Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever

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 Last EKG screening, when? 9/9/16 Arthritis Chicken Pox
Other: Other: Other:
General Constitution
Recent weight loss or gain: weight gain
How many lbs? 30 lbs
Time frame? 5 months
Intentional? No
How do you view your overall health?

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

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

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10 PHYSICAL EXAMINATION:

General Survey: well- Height: 170 cm Weight: 87.6 kg BMI: 30 Pain: (include rating and
groomed and dressed Pulse: 73 Blood Pressure: (include location) location)
appropriately Respirations: 20 134/84 (brachial) 2/10 (incision site)
Temperature: (route SpO2 97% Is the patient on Room Air or O2
taken?) 97 (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
Patient has an incision site dressing that is clean and dry.

Central access device Type: Location: Date inserted:

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- 13 inches & left ear- 13 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: No missing teeth or known dental problems
Comments:

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 thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: clear without adventitious sounds
RUL: CL LUL: CL
RML: CL LLL: CL
RLL: CL

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

Cardiovascular: No lifts, heaves, or thrills
Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD

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Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3
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
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 09 / 15 / 2016 ) Formed Semi-formed Unformed Soft Hard Liquid Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe:

GU Urine output: Clear Cloudy Color: yellow Previous 24 hour output: 800 mLs
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

Musculoskeletal: 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]
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: +2 Biceps: +2 Brachioradial: +2 Patellar: +2 Achilles: +2 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):
Chest CT scan positive for left upper lobe nodule
PET scan revealed 1.4 cm left upper lobe nodule with SUV of 3.5

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

HGB Hemoglobin was normal Bleeding from the
12.7 09/13/16 pre-op but dropped surgery caused the
11.6 09/14/16 slightly after the surgery. hemoglobin to drop.

+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.)
After tolerating clear and soft diets, patient is now on a regular diet, vitals will be taken every 4 hours, and
patient can ambulate with assistance. Consults were placed with the surgeon on patients progress and
With the pulmonary doctor on recovery. Patient will continue to use incentive spirometer five times an hour.

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

1. Ineffective breathing pattern r/t pain

2. At risk for infection r/t invasive procedure

3. Acute pain r/t surgical procedure, coughing, deep breathing

4. Risk for bleeding

5. Deficient knowledge r/t self-care, effective breathing exercises, pain relief

6. Risk for injury

7. Risk for vascular trauma

University of South Florida College of Nursing Revision September 2014 12

CARE PLAN
Patient Goals/Outcomes
Patient will have improved chest
expansion by the end of the shift.
The patient will have an absence
of dyspnea at the time of discharge
Include a minimum of one
Long term goal per care plan
University of South Florida College of Nursing Revision September 2014
Nursing Diagnosis: Ineffective breathing pattern r/t pain
Nursing Interventions to
Achieve Goal
Patient will use incentive
spirometer 5 times an hour.
Patient will walk with assistance
around the unit as tolerated.
Rationale for Interventions
Provide References
Using an incentive spirometer can
reduce the risk of atelectasis
(Ackley, 2011)
Ambulation can help break up
secretions that block airways.
(Ackley, 2011)
Evaluation of Goal on Day Care
is Provided
Patient will have reached an
appropriate level on the marker
without difficulty.
Patient will be walking without
dyspnea.
13
 15 CARE PLAN
Patient Goals/Outcomes
Patient will demonstrate proper
hand washing at the end of the
day.
Nursing Diagnosis: At risk for infection r/t invasive procedure
Nursing Interventions to Rationale for Interventions
Achieve Goal Provide References
The nurse will educate the patient By introducing the use of hand
on how to properly wash hands. rubbing with an alcoholic solution,
there was significant improved
hand-cleansing compliance
(Ackley, 2011)
Evaluation of Goal on Day Care
is Provided
Patient will remain free from
symptoms of infection by the end
of the day.

Patient will incorporate healthy Educate patient on the importance Tissue repair requires increased Patient incision site will be healing
eating habits by her follow-up of lean protein to help with the protein and carbohydrates properly at office visit.
appointment. healing of her wound. (Ackley, 2011)

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

University of South Florida College of Nursing Revision September 2014 14

 * 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 15

 References

Ackley, B.J., & Ladwig, G.B. (2011). Nursing Diagnosis Handbook: An evidence-based guide to

planning care. St Louis, MO: Elsevier.

Cleveland Clinic. (2016). Pulmonary nodules. Retrieved from

http://my.clevelandclinic.org/health/diseases_conditions/hic_Pulmonary_Nodules

Treas, L. S., & Wilkinson, J. M. (2014). Basic Nursing. Philadelphia, PA: F.A. Davis Company.

Truong, M. T., Ko, J. P., Rossi, S. E., Rossi, I., Viswanathan, C., Bruzzi, J. F., . . . Erasmus, J. F.

(2013, October 19). Update in the Evaluation of the Solitary Pulmonary Nodule.

Radio Graphics, 34(6), 1658-1679. http://dx.doi.org/10.1148/rg.346130092

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