UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Michael Sandin
Assignment Date: 03/21/2017
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: TGH
1 PATIENT INFORMATION
Patient Initials: JW Age: 58 Admission Date: 03/18/2017
Gender: Marital Status: Single Primary Medical Diagnosis
Primary Language: English Bimalleolar, closed right ankle fracture
Level of Education: High School Diploma Other Medical Diagnoses:
Occupation (if retired, what from?): Welding Alcohol intoxication
Number/ages children/siblings: Stated that he had no children or Closed nondisplaced fracture of proximal phalanx
siblings. of the lesser toe on the right foot.

Served/Veteran: No. Code Status: Full

If yes: Ever deployed? N/A
Living Arrangements: Lives alone in at home. (House with a porch Advanced Directives: Yes
to get inside.) If no, do they want to fill them out? N/A
Surgery Date: Procedure:
Culture/ Ethnicity /Nationality: Caucasian ORIF of right ankle on 3/19/17
Religion: Catholicism Type of Insurance: Blue Cross Blue Shield

1 CHIEF COMPLAINT:
I got hit by a car.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
On 3/18/17, a MVC occurred between the patient and a vehicle, the patient reported he was clipped by a car that ran over
his right foot, and he fell and hit the back of his head. The patient was intoxicated at this time, and was admitted into the
ED at Tampa General Hospital. Orthopedic trauma and internal medicine consulted with the patient before beginning a
Surgical procedure on 03/19/17 at 2:00 PM. The surgery was an ORIF on the right ankle and manipulation under
anesthesia. The surgery was completed without any reported complications. Patient was transferred to Orthopedic Trauma
and has been there since the surgery. Onset: 03/18/17 after MVC with vehicle. Location: Right ankle Duration: the pain
was reported to have a constant duration. Characteristics: The patient described the pain as an aching pain, and as if
theres pins and needles. Aggravating: Movement makes the pain worse. Relieving: Rest decreases the pain the patient
has been having. Treatments: Rest and pain medication. Severity: 6/10 pain rated on a 0-10 scale.

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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
2010 Chronic bilateral neuropathy from frostbite.
Unknown Hepatitis C
05/14/2012 Nasal fracture surgery
05/14/2012 Clavicle surgery
02/05/2017 Syncope
02/06/2017 Gracepoint Alcoholic abuse/withdrawal.
02/15/2017 Elbow laceration; left
02/15/2017 Alcohol intoxication with unspecified complication
03/18/2017 Right ankle fracture, bimalleolar, closed
03/19/2017 ORIF Right angle fracture and manipulation under anesthesia.
03/19/2017 Scalp abrasion from initial encounter
03/19/2017 Alcohol intoxication

(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 64 Lung Cancer
Mother 80
Brother
Sister
relationship

relationship

relationship

Comments: The patients father was a heavy smoker. Died from lung cancer when was 64. The patients mother is currently living in a
ALF. The patient has no siblings or children. The patient didnt remember much of the information about extended family.

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
Keflex
Hives and breathing issues.
(Cephaloxine)

Medications

No other known
allergies.
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) The primary medical issue the patient presented with was a closed right ankle fracture and was
bimalleolar, which means both malleolus are fractured. A fracture is a break in the continuity of a bone. A break occurs
when force is applied that exceeds the tensile or compressive strength of bone. (Huether and McCance, 2012, p. 978).
The disease, in this case, was caused by a MVC resulting in the ankle fracture and a lesion to the right scalp. There are
some disease that can predispose to fractures, like osteoporosis, but they do not appear to be a cause the case for this
patient. The clinical manifestations of include unnatural alignment (deformity), swelling, muscle spasm, tenderness,
pain and impaired sensation, and decreased mobility, (Huether and McCance, 2012, p. 980). All of these can contribute
to the diagnosing of a fracture, along with an X-Ray of the fractured site. In terms of treatment, there is essentially a
realignment of the bone s to the normal anatomical position. (Huether and McCance, 2012, p. 978).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.] (Vallerand, A. H., Sanoski, C. A., & Deglin, J. H., 2015)

Name Chlordiazepoxide (Librium) Concentration 25 mg x 1 cap Dosage Amount 25 mg (1 cap)

Route PO Capsule Frequency Every 6 hours PRN
Pharmaceutical class Benzodiazepines Home Hospital or Both
Indication Alcohol dependence/withdrawal
Adverse/ Side effects SE: Drowsiness, confusion, nausea, constipation, libido changes, dizziness, and incontinence. Serious AE:
Respiratory depression, seizures, suicidal ideation, syncope, blood dyscrasias, and hepatic impairment.
Nursing considerations/ Patient Teaching Avoid alcohol and other CNS depressants while taking.

Name Nicotine (Nicoderm CQ) Concentration 14 mg/24 hr patch Dosage Amount 1 patch
Route Transdermal Frequency Every 24 hours
Pharmaceutical class Smoking deterrent Home Hospital or Both
Indication Adjunct therapy in the treatment of nicotine withdrawal.
Adverse/ Side effects Headache, insomnia, burning at patch site, erythema and pruritus.
Nursing considerations/ Patient Teaching Apply patch at same time each done, and removing the other patch before administration.

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Name Ondansetron (Zofran) Concentration 1 x 4 mg tablet Dosage Amount 1 tablet
Route PO Tablet Frequency Every six hours PRN
Pharmaceutical class 5-HT3 antagonists Home Hospital or Both
Indication Nausea/Vomiting
Adverse/ Side effects Headache, dizziness, drowsiness, fatigue, weakness, constipation, and diarrhea. EPS, and torsade de
pointes can also occur.
Nursing considerations/ Patient Teaching Monitor cardiac function (ECG) and for other adverse reactions like EPS.

Name Docusate sodium (Colace) Concentration 1 x 100 mg capsule Dosage Amount 1 Capsule (100 mg)
Route PO Capsule Frequency 2x Daily
Pharmaceutical class Stool softeners Home Hospital or Both
Indication Prevention of constipation.
Adverse/ Side effects Throat irritation, mild cramps, diarrhea and rashes.
Nursing considerations/ Patient Teaching Take with a full glass of water.

Name Enoxaparin (Lovenox) Concentration 40 mg Dosage Amount 40 mg injection

Route SubQ injection Frequency 1x daily
Pharmaceutical class Antithrombotic Home Hospital or Both
Indication Prevention of venous thromboembolism in surgical and medical patients.
Adverse/ Side effects Some side effects could be dizziness, headache, insomnia, constipation, nausea, vomiting, urinary
retention, alopecia, ecchymosis, pruritus, rash, urticaria, and pain at injection site. Adverse effects are bleeding, anemia,
eosinophilia, thrombocytopenia and osteoporosis.
Nursing considerations/ Patient Teaching Assess for signs of bleeding and hemorrhage. Protamine sulfate is the antidote in case of
overdose. Monitoring CBC.

Name Famotidine (Pepcid) Concentration 1 x 20 mg Dosage Amount 1 tablet (20 mg)

Route PO Tablet Frequency 2x daily
Pharmaceutical class Histamine H2 Antagonists Home Hospital or Both
Indication Treatment of heartburn, acid indigestion, or prevention and treatment of stress-induced upper GI bleeding.
Adverse/ Side effects Side effects include: confusion, dizziness, drowsiness, hallucinations, headache, constipation, and
reproductive issues. Adverse effects could be arrhythmias, agranulocytosis, aplastic anemia, anemia, neutropenia,
thrombocytopenia, and hypersensitivity reactions.
Nursing considerations/ Patient Teaching Monitor CBC with differential because of potential blood dyscrasias.

Name Thiamine Concentration 1 x 100 mg tablet Dosage Amount 1 tablet (100 mg)
Route PO tablet Frequency 1x daily
Pharmaceutical class Water soluble vitamins Home Hospital or Both
Indication Treatment of thiamine deficiencies and prevention of Wernickes encephalopathy.
Adverse/ Side effects Restlessness, weakness, tightness of the throat, nausea, sweating, tingling, and warmth. Adverse reactions
associated with large doses or IV administration include vascular collapse, hypotension, GI bleeding, angioedema,
pulmonary edema and respiratory distress.
Nursing considerations/ Patient Teaching Assess nutrition throughout therapy.

Name Gabapentin (Neurontin) Concentration 1 x 100 mg capsule Dosage Amount 1 capsule (100 mg)
Route PO Capsule Frequency 3x daily
Pharmaceutical class Analgesic adjunct, anticonvulsants Home Hospital or Both
Indication Neuropathic pain and adjunct treatment for seizures.

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Adverse/ Side effects Side effects include confusion, depression, dizziness, drowsiness, sedation, weight gain, anorexia,
flatulence, ataxia and altered flexes. Adverse reactions may be suicidal ideation, hypertension, rhabdomyolysis, and
multiorgan hypersensitivity reactions.
Nursing considerations/ Patient Teaching Check for any changes in behavior and for suicidal ideation.

Name Hydrocodone-acetaminophen (Narco) Concentration 5-325 mg per 1 tablet Dosage Amount 1 Tablet
Route PO Tablet Frequency Every 6 hours PRN
Pharmaceutical class Opioid analgesic/nonopioid analgesic Home Hospital or Both
combinations
Indication For moderate pain (4-6)
Adverse/ Side effects Side effects include confusion, dizziness, sedation, euphoria, hallucinations, headache, unusual dreams,
blurred vision, constipation, dyspepsia, nausea, and vomiting. Adverse reactions include respiratory depression,
hypotension, bradycardia, and dependence/tolerance. For Acetaminophen: Hepatotoxicity, Stevens-Johnson Syndrome,
toxic epidermal necrolysis, and acute generalized exanthematous pustulosis could occur.
Nursing considerations/ Patient Teaching Check vital signs like BP, pulse and respirations before and after administration. Assess
pain and bowel function routinely.

Name Morphine Concentration 2 mg Dosage Amount 2 mg

Route IV injection Frequency Every 4 hours PRN
Pharmaceutical class Opioid analgesic Home Hospital or Both
Indication For severe pain (7-10)
Adverse/ Side effects Confusion, sedation, dizziness, dysphoria, euphoria, hallucinations, headache, unusual dreams,
constipation, nausea, vomiting, and urinary retention. Adverse effects can include respiratory depression, hypotension,
physical dependence, psychological dependence, and tolerance.
Nursing considerations/ Patient Teaching Proper assessment of pain before administration. LOC, BP, pulse and respirations should
be checked before and periodically during administration. Assess for signs of respiratory depression and sedation.

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Full, no dietary restrictions.
Diet patient follows at home? No specific diet.
24 HR average home diet:
Breakfast: Cereal with 2% reduced fat milk.
(Either Cinnamon Toast Crunch or Cheerios)
Lunch: Sandwich with bread, lettuce, mayonnaise and
turkey.
Dinner: Spaghetti with meat sauce and parmesan cheese.
Snacks: Bag of Lays chips or Doritos.
Analysis of home diet (Compare to My Plate and
Consider co-morbidities and cultural considerations):
The patient, according to the foods he said he ate at home,
is consuming more than the myplate recommended daily
caloric intake for someone his age, weight, and height.
This should result in a weight gain, but there hasnt been
any reported weight gain. One area of concern regarding
the diet is the lack of fruit. The patient stated that he didnt
like fruit, so he didnt eat it. There is also a lack of
vegetables and an overconsumption of alcoholic drinks.

Liquids (include alcohol): Diet coke, water, alcoholic

beverages (usually 3x beers). (ChooseMyPlate, 2017).

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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?
God is really the one who helps me keep going.
How do you generally cope with stress? or What do you do when you are upset?
The patient brought up how praying helps him relieve stress. He also mentioned that drinking alcohol was one of the
major things that helped him relax. He states the need to take alcohol or he would feel anxious and sick. The patient stated
that listening to music has also helped him relieve stress in the past.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The patient reports feeling lonely at times, but he has been getting closer to his mother recently. He has some
feelings of being depressed, and recognizes that he has been coping with it in a negative way.

+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? Yes, but not while
in a relationship.

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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? __No._______________

Are you currently in a safe relationship? The patient is not currently in a relationship, and states that he was never in a
relationship where he felt unsafe.

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: Isolation is the avoidance of intimacy. The task at this stage is is to develop a commitment to work and
relationships, (Treas, L. S., & Wilkinson, J. M., 2014, p. 164).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient is currently in the intimacy vs isolation stage of Ericksons stage of psychosocial development. Hes at this
stage because of his lack of relationships throughout his life. The patient confirms that has been feeling lonely, and
only just started talking to his mother again. He presents with a lack of social and intimate relationships, with his most
recent marriage resulting in a divorce. He never had a strong relationship with his parents growing up, and said he didnt
have any children.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The current hospitalization seems to be a result of the patients developmental stage. It seems the patient has been turning
to alcohol for much of his problems, which has resulted in a few hospital admissions in the past, most currently being
the current admission. The fractured ankle will likely lead to more isolation now that he is away from work.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
It was that guy that ran over me.

What does your illness mean to you?

The patient views the illness as something that prohibits him from getting to work. The patient already feels frustrated for
not being able to move around as well as he could, and believes that this would cause him to have some issues getting up
his porch to get into his house.
+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? The only infection he is aware of is Hepatitis C._
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? _____Yes.____________________ If yes, are you in a monogamous relationship?
_________No._________ 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?___N/A_______________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? _No.________________________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No.
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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Religion plays a major role in the patients life. I pray every day. The patients religion one of the things that really helps him cope
with through tough times.
Do your religious beliefs influence your current condition?
Religion helps the patient keep going despite his current situation. The patient reports finding comfort in talking to God. He didnt
believe that his religion influence his condition, but rather it helps him cope.

+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? 20 years
Cigarette 1 pack a day (age 38 thru 58 )

If applicable, when did the

Pack Years: 20 Pack years patient quit? Since hospital
admission. (3/18/17)

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? If yes, what did they use to try to quit?
No, the patient lives alone.

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? 3-12 For how many years? 2
Budweiser or other beers. Volume: 355 mL (Per one can) (age 56 thru 58 )
Frequency: 2-3 times a week for (On and off with drinking, but
heavy drinking, but usually a few currently has been drinking for 2
cans per day. years.)
If applicable, when did the patient quit?
N/A. The patient had quit back in 2013, but picked back up again around 2015.

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
The patient denies the use of any street drugs. How much? For how many years?
(age thru )

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
The patient mentioned that welding was his only risky exposure, but that he has been doing it for a long time and knows
how to keep safe.

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

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 10 REVIEW OF SYSTEMS NARRATIVE
The patient got agitated after the other patient in his room had a bowel movement and he wanted to leave the room. At this
point he didnt wish to discuss anymore and was more focused about getting away from the odor. Because of this, I was
unable to ask the next few questions and everything below Immunologic on the ROS, though I have filled out what I
already knew from the patient as best I could.

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 (Keflex) Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen - No SPF: Diverticulitis Life threatening allergic reaction
Bathing routine: Showers usually every
Appendicitis Enlarged lymph nodes
morning.
Other: Patient had previous rash on elbow, Abdominal Abscess Other: Patient had some signs of alcohol
and currently has lesion on scalp. Last colonoscopy? Hasnt had one. withdrawal.
HEENT Other: Patient has hepatitis C. 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: 10/day Other: No reported hematologic/oncologic
Oral/pharyngeal infection Bladder or kidney infections issues.
Dental problems Many cavities Metabolic/Endocrine
Routine brushing of teeth On and
Diabetes Type:
off, but sometimes 1/day
Routine dentist visits No routine
Hypothyroid /Hyperthyroid
visits. Goes every few years.
Vision screening Believes to be about
Intolerance to hot or cold
5 years ago.
Other: No reported issues with vision or Osteoporosis
hearing. Other: The records showed no issues in
Pulmonary metabolic function.
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? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? The patient doesnt know
menopause age? Meningitis
when he had his last CXR.
Other: There was no documented cases of
Other: The patient has had no issues with any of the CNS issues, though if it was
DIB, asthma, COPD, or other pulmonary Date of last Mammogram &Result: asked, the patient may have brought up
issues. seizures or tremors/other signs of alcohol
withdrawal.
Date of DEXA Bone Density & Result:
University of South Florida College of Nursing Revision September 2014 9
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Frequency of prostate exam? Hasnt
Hyperlipidemia Schizophrenia
had one.
Chest pain / Angina Date of last prostate exam? n/a. Anxiety
Myocardial Infarction BPH Bipolar
Other: The patient had previously stated
CAD/PVD Urinary Retention having some issues with depression
and anxiety.
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness - RLE Measles
Rheumatic Fever Pain Right angle. Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? Arthritis Chicken Pox
Other: The patient stated he had the
Other: The patient doesnt recall any Other: Patient has obtained right ankle
vaccines for most of the childhood
issues with his cardiovascular health. fracture
diseases.

General Constitution
Recent weight loss or gain None reported.
How many lbs?
Time frame?
Intentional?
How do you view your overall health? The patient wasnt directly asked this question.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
The patient did not bring up any medical problems that havent already been addressed.

Any other questions or comments that your patient would like you to know?
The patient didnt want to continue the conversation, so he didnt seem to have any questions.

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10 PHYSICAL EXAMINATION:

General Survey: The Height 177.8 cm Weight 76 kg BMI 24.1 Pain: Constant 6/10 aching
patient is a 58 y/o male Pulse 68 Blood Pressure: 134/79 right arm. pain on the right ankle
with an ankle fracture Respirations 15 related to previous fracture.
and is in no sign of Pain started from the ankle
distress. fracture, and is aggrevated
Temperature: (route SpO2 99% Is the patient on Room Air or O2: by movement. Pain
taken?) 97.4 F orally Room air. medication and rest have
helped with the pain.
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Patient was not clean initially. The was initially in jeans and a t-shirt, which had to be removed due to him voiding himself.
Patient has no obvious signs of handicaps and maintains eye contact.
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Patient was AOx4, and was able to interact with others without major issues. He eventually got agitated and no longer wanted
to talk, but only after a situation with the patient in the bed beside him.
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
The patients speech was mostly clear, however the patient did mumble at times.
Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other: The patient started out cooperative, but got agitated as the day went by. He was rather quiet and apathetic at times
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
The patient has been having some issues with diaphoresis. His skin was moist when I performed the assessment. He also had
voided in the bed, which was cleaned and dried after it was discovered. The patient had a lesion on the back of his scalp, on
the right side. No drainage was found from the wound.
Central access device Type: Location: Date inserted:
Fluids infusing? no yes - what?
Patient had a peripheral line inserted on 03/18 on the left arm. No IV fluids were infusing at time of assessment.
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 / 4 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 12 inches & left ear- 12 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: The patient has been having issues with cavities in the past. Many teeth have a yellow color to them.
Comments: The patient had no complaints about HEENT.

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 - No sputum production.
Color: white pale yellow yellow dark yellow green gray light tan brown red No sputum production.
Lung sounds:
RUL - Clear LUL - Clear
RML - Clear LLL - Clear
RLL - Clear

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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
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: Not checked Popliteal: 3 DP: 3
for LLE, unable to check for right. PT: 3 for LLE, unable to check for right.
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: No 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 03/20/2017 ) 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: Last one was described as yellow with some food.
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe: The patient was cleaned after voiding his bed.

GU Urine output: Clear Cloudy Color: Yellow Previous 24 hour output: N/A Not
collected
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 2 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
Some paresthesia and pain on the patients right ankle.
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 Unable to
preform due to ankle fracture.
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride -
Unknown.
DTR: (Not preformed) [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 12

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):
The patient had multiple lab tests performed, all of which are listed below. An x-ray was performed on the 18th
of March on the RLE, which found bimalleolar, closed right ankle fracture and phalanx fracture on the RLE.
Lab Dates Trend Analysis
Complete Metabolic 03/18/17 Na 144 The only lab value high
Panel K 4.3 on admission was
Cl 111 chloride, which was only
CO2 26 111 mEq/L.
BUN 7
Glu 95
Creat 0.9
Ca 8.5
Complete Metabolic 03/21/17 Na 134 The lab values have
Panel K 3.9 remained relatively
Cl 104 consistent for the CMP.
C02 25
BUN 8
Glu 102
Creat 0.8
Ca 8.8
Magnesium Levels th th st
19 , 20 , 21 of March 3/19/17 1.8 The patients magnesium
3/20/17 1.8 level remained consistent.
3/21/17 1.8 This test was probably
performed because there
could be a decrease in
alcohol seen with
alcoholics.
CBC 03/21/2017 WBC 5.01 The most significant
RBC 3.26 findings of this test would
Hbg 10.4 be the low hemoglobin,
Hct 31.7 hematocrit, and platelet
MCV 97.2 counts. This may lead to
MCH 31.9 issues getting oxygen
MCHC 32.8 throughout the body
Plt cnt 98 because there is a
MPV 10.4 decrease in oxygen
RDW 12.6 carrying capacity.
BAL 03/18/2017 339 This test was done
because the patient was
reportedly intoxicated. It
shows that he had a high
blood alcohol level at
admission.
University of South Florida College of Nursing Revision September 2014 13
+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.)
Vital signs were being conducted every four hours by Patient Care Technicians throughout the day. This is
important because the patient is on several medications that can cause changes in his overall status, and the
patient was previously detoxing form alcohol. There are no current dressing changes scheduled for the nurse, as
there is a cast covering the RLE. The right scalp lesion is small and healing on its own. Physical therapy was
scheduled to work with the patient, and has been helping him move to his chair. The patient is on no dietary
restrictions, and doesnt have a consult with a dietitian.

University of South Florida College of Nursing Revision September 2014 14

 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) (Ackley, B. J., & Ladwig, G. B., 2014.)

1. Risk of infection r/t inadequate primary defenses, smoking, inadequate vaccination, and invasive procedures AEB:
surgical incision site on RLE, OLIF surgery, 20 pack years, and a lack of vaccinations.
2. Risk for falls r/t narcotics, decreased lower extremity strength, impaired physical mobility and postoperative conditions
AEB: the patient currently taking opioids and a right ankle fracture.
3. Risk-prone health behavior r/t excessive alcohol, inadequate social support, and smoking AEB: 3-12 beers a day, a stated
lack of social support/friends, and 20 pack years of smoking.
4.

5.

Nursing Diagnosis: Risk for infection r/t inadequate primary defenses, smoking, inadequate vaccination, and
invasive procedures AEB: surgical incision site on RLU, OLIF surgery, 20 pack years, and a lack of vaccinations.
(Ackley, B. J., & Ladwig, G. B., 2014.)
Patient Goals/Outcomes Nursing Interventions Rationale for Evaluation of Goal on
to Achieve Goal Interventions Day Care is Provided
Provide References
Patient will identify signs of Teach the client the A majority (2/3) of The patient wasnt
symptoms of infection, importance of hand infections occur after educated on hand
maintain a clean hygiene in preventing discharge, so practicing hygiene, but sometimes
environment, and practice postoperative good hand hygiene could demonstrated (4)
infection control strategies. infections. help prevent infection. maintaining a clean
Rated on a 0-5 scale: 1 = environment by helping
never demonstrated, 2 = to clean himself up after
rarely demonstrated, 3 = voiding and wanting to
sometimes demonstrated 4 be removed from the
= often demonstrated, 5 = room after a patients
consistently demonstrated. BM.
The patient will remain free Oral thermometers Assessing temperature, lab The patients
from symptoms of infection used to assess values, and skin can help temperature was 97.4 F
temperature. determine if there is an and the skin was warm
infection. Using appropriate and moist before
Note and report hand hygiene can help cleaning. There is
laboratory values. prevent health-care currently no sign no
associated infections. infections.
Assess skin for color,
moisture, texture, and
turgor.

Use appropriate hand

hygiene.

University of South Florida College of Nursing Revision September 2014 15

Nursing Diagnosis: Risk for falls r/t narcotics, decreased extremity strength, impaired physical mobility, and
postoperative condition AEB: the patient currently taking opioids and a right ankle fracture. (Ackley, B. J., &
Ladwig, G. B., 2014.)
Patient Goals/Outcomes Nursing Interventions to Rationale for Evaluation of Goal on
Achieve Goal Interventions Day Care is Provided
Provide References
The patient will have fall Teach the client have to Using walking aids can The patient often
prevention behavior as safely ambulate, help prevent further falls. demonstrated (4) safe
evidenced by the use of including safety measures transfer techniques when
handrails and grab bars as such as hand rails in working with physical
needed, using assistive bathroom. therapy to transfer from
devices correctly, and his bed to his seat.
uses safe transfer
procedures. Rated on a 0-
5 scale: 1 = never
demonstrated, 2 = rarely
demonstrated, 3 =
sometimes demonstrated,
4 = often demonstrated, 5
= consistently
demonstrated.
The patient will remain Carefully assist a mostly This method of helping a The patient was transferred
free of falls. immobile client up. Be patient ambulate is the to the seat with help from
sure to lock the bed and way provided that can physical therapy without
wheelchair and have help prevent the risk of complications. There was
sufficient personnel to falls. no further ambulation by
protect the client from the patient.
falls. When raising from a
lying position, have the
client change positions
slowly, dangle legs, and
stand next to the bed prior
to walking to prevent
orthostatic hypotension.

University of South Florida College of Nursing Revision September 2014 16

 15 CARE PLAN

Nursing Diagnosis: Risk-prone health behavior r/t excessive alcohol, inadequate social support, and smoking
AEB 3-12 beer per day, a stated lack of social support/friends, and 20 pack years of smoking. (Ackley, B. J., &
Ladwig, G. B., 2014.)
Patient Goals/Outcomes Nursing Interventions to Rationale for Evaluation of Goal on
Achieve Goal Interventions Day Care is Provided
Provide References
Patient will have risk Refer to community A study showed that While the resources
detection as evidenced resources. Provide community belonging werent brought up by
recognizing signs and general and contact could contribute to a myself, referring the
symptoms that indicate information for ease of change in behavior. patient to resources like
risks, identifying personal use. AA may have helped with
health risks, and obtaining the patients alcohol
information about issues. The patient is at a
changes in health 1 (never demonstrated)
recommendations. Rated because he doesnt
on a 0-5 scale: 1 = never acknowledge any issues
demonstrated, 2 = rarely with drinking beer. He
demonstrated, 3 = views this current
sometimes demonstrated, situation as the fault of
4 = often demonstrated, 5 the driver of the vehicle.
= consistently
demonstrated.
The patient will request Use open-ended questions A study showed that The patient never
assistance in altering to allow the client free using open-ended requested assistance in
behaviors to adapt to expression. questions can help altering his health for his
change. develop a stronger nurse- alcohol addiction.
client relationship.
The patient will state Use motivational For studies related to The patient was initially
acceptance of change in interviewing to help the substance abusers, use of not forthcoming of
health status. client identify and change this technique was helpful information, which may
unhealthy behaviors. in reducing the use of have been due to it being
those substance. the morning and his
condition with alcohol
withdrawal. He
eventually opened up and
was able to talk about his
situation until he got
agitated again. In the end,
he still didnt view
drinking beer as a
problem.
University of South Florida College of Nursing Revision September 2014 17
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 * - Patient will need PT for the right ankle fracture.
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-prone health behavior r/t excessive alcohol, inadequate social support, and smoking
AEB 3-12 beer per day, a stated lack of social support/friends, and 20 pack years of smoking. (Ackley, B. J., &
Ladwig, G. B., 2014.)

University of South Florida College of Nursing Revision September 2014 18

 References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning

care. Maryland Heights, MO: Elsevier.

ChooseMyPlate. (n.d.). Retrieved April 3, 2017, from https://www.choosemyplate.gov/

Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (5th ed.). St. Louis, MO: Elsevier.

Treas, L. S., & Wilkinson, J. M. (2014). Basic Nursing: Concepts, Skills & Reasoning (1st ed.). PA: F.A. Davis

Company.

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2015). Davis's Drug Guide for Nurses (14th ed.).

Philadelphia: F. A. Davis Company.

University of South Florida College of Nursing Revision September 2014 19