UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: AO
Assignment Date: 2/7/2017
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: LRMC
 1 PATIENT INFORMATION
Patient Initials: AS Age: 34 Admission Date: 2/6/2017
Gender: Female Marital Status: Single Primary Medical Diagnosis: DVT right leg
Primary Language: English
Level of Education: High School Diploma Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Secretary
Number/ages children/siblings: two children (boys, 10 and 12)

Served/Veteran: Code Status: Full

If yes: Ever deployed? Yes or No
Living Arrangements: One story home, 4 step walk up Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: N/A Procedure: N/A
Culture/ Ethnicity /Nationality: White
Religion: Baptist Type of Insurance: Cigna

 1 CHIEF COMPLAINT:
Patient complains of pain in the right leg. Patient states, “I can’t keep dealing with this. It keeps me from working and
taking care of my kids.”

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is a 34-year-old morbidly obese female admitted to the emergency department with recurrent right lower
extremity DVT. Patient has a past medical history of chronic DVT and reports that she ran out of Coumadin two weeks
ago. Patient reports that she also has not been taking the medication because she dropped her insurance briefly, which left
her unable to refill her prescription. She reports that over the past three days she has had increased swelling to the right
lower extremity. She reports intermittent pain and cramping sensation in popliteal area of right lower extremity. The pain
began to become sever two days prior to admission. The pain is highest in the calf and radiates up the leg. The pain is
constant and is described as aching and throbbing. Patient reports that the pain is aggravated with even slight activity, and
is best relieved by remaining stationary. She reports she occasionally uses Tylenol for pain but has not used anything over
the past 24 hours. She denies chest pain, shortness of breathe, nausea/vomiting, heart palpitations, diaphoresis,
fever/chills, and syncope/dizziness.

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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
3/6/10 Morbid obesity
2/28/15 hypercholesterolemia
6/17/11 hypertension
12/19/12 Pulmonary embolism
4/28/13 Hypothyroidism
12/8/16 Protein C + protein S deficiency
8/13/16 Chronic non-healing ulcers

2

(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 66
Mother 66
Brother
Sister
Son
10
Son
12
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 n/a
Adult Diphtheria (Date)
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 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

 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Morphine Rash
Vancomycin Hives, dizziness
Medications

Tape Itching
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 deep venous thrombosis (DVT) is described as a clot that forms in the deep veins, commonly in the legs. Virchow’s
triad, which is used to explain the formation of DVT’s, includes venous stasis, endothelium damage, and
hypercoagulability. Stasis of the blood occurs when a patient is in surgery or when they are on continuous bed rest.
Endothelium damage can occur due to surgery, trauma, inflammation, or infection. Hypercoagulability occurs when there
is a deficiency in antithrombin III and in proteins C and S. The signs and symptoms of DVT’s can vary from patient to
patient and may not even manifest themselves until the development of a pulmonary embolism. While some patients may
not report any discomfort at all, others may report warmth, pain, redness, tenderness, and edema. The deep veins of the
calf are where DVT’s most typically start. Diagnostic tests for DVT’s include duplex ultrasounds, CT scans, D-dimers,
and MRI’s. Medical management includes the use of anticoagulants, such as heparin, low molecular weight heparin,
thrombin inhibitors, and oral warfarin. In order to prevent pulmonary embolism from occurring, surgical interventions
may be required. Though not commonly performed, a thrombectomy may be required. Another surgical intervention
would be vena cava interruption, which is done by inserting a filter device into the inferior vena cava that captures
thrombi but still allows the blood to flow through it. In regards to nursing management, the encouragement of early
ambulation, assisting the patient with active and passive range of motion exercises, elevating the extremity, graduated
compression stockings, and venous foot pumps all aid in DVT prophylaxis and prevention (Osborn et al., 2014).

 5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: enoxaparin (Lovenox) Concentration: 40mg/0.4mL Dosage Amount: 40mg

Route: subcutaneous injection Frequency: q12h

Pharmaceutical class: low molecular weight heparin Home Hospital or Both
Indication: prevention of venous thromboembolism and/or pulmonary embolism
Adverse/ Side effects: bleeding, anemia, hyperkalemia, edema
Nursing considerations/ Patient Teaching: monitor for hematoma and other blood thinning drug-drug interactions

Name: warfarin (Coumadin) Concentration: 15mg/tab Dosage Amount: 30mg

Route: oral Frequency: daily

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Pharmaceutical class: anticoagulant Home Hospital or Both
Indication: used to treat or prevent blood clots in veins or arteries
Adverse/ Side effects: cramps, nausea, bleeding, fever
Nursing considerations/ Patient Teaching: monitor stool and urine for occult blood before and periodically during therapy. Monitor INR.

Name: acetaminophen Concentration: 325mg/tab Dosage Amount: 650mg

Route: oral Frequency: q4h, PRN

Pharmaceutical class: analgesic/antipyretic Home Hospital or Both
Indication: mild pain, fever
Adverse/ Side effects: hepatotoxicity, hypotension, constipation, nausea, vomiting
Nursing considerations/ Patient Teaching: Advise patient to avoid alcohol. Stop taking medication if rash occurs.

Name: nitroglycerin Concentration: 0.4mg/tab Dosage Amount: 0.4mg

Route: oral Frequency: q5min, PRN

Pharmaceutical class: antianginal; vasodilator Home Hospital or Both
Indication: acute and long-term prophylactic management of angina pectoris.
Adverse/ Side effects: dizziness, headache, restlessness, weakness, hypotension, tachycardia, syncope
Nursing considerations/ Patient Teaching: Acute angina attacks: sit down and use medication. If pain does not subside, repeat dose and call EMS.

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

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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Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Regular Consider co-morbidities and cultural considerations):
24 HR average home diet: The patient is well over her daily food group targets of
refined grains and protein, at 272% and 145% respectively.
She is under her targets for vegetables and cheese, and has
absolutely no intake of fruits at all. In addition, she is also
1,013 calories over the daily caloric limit of 2,000.
Recommendations for this patient can include reducing her
intake of refined grains by substituting her morning toast
with various fruits, thereby increasing her intake of fruit.
The patient can be instructed to eat proteins such as meat
more in moderation, and substitute vegetables with meals
whenever possible. The patient can also substitute her usual
snack options with something healthier, such as cheese and
crackers, which would help her to meet her daily food
group target for dairy. With the patient’s elevated intake of
saturated fat and sodium, it can be recommended that she
decrease this intake by eating lean meats, avoiding frying
foods, and avoiding excessive salt usage. Co-morbidities
associated with such a diet can include type-2 diabetes,
hypertension, cardiovascular disease, and stroke.
Breakfast: eggs, bacon, toast

Lunch: chicken tenders, French fries

Dinner: cheeseburger, pizza, hot dogs

Snacks: Doritos, pretzels, chocolate chip cookies

Liquids (include alcohol): fruit punch, coca cola, coffee,

whiskey

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?
“My mother.”
How do you generally cope with stress? or What do you do when you are upset?
“I usually just lock myself in my room until I feel better. Also, there’s nothing better than a shot of whiskey to calm the
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nerves.”

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“No. I feel okay right about now.”

+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? ______________________

Are you currently in a safe relationship?

“I’m about as single as they come.”

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s 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 Erickson’s developmental stage for your
patient’s age group:
“The capacity to commit himself to concrete affiliations and partnerships and to develop the ethical strength to abide by
such commitments. Isolation is the avoidance of intimacy” (Treas & Wilkinson, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
In the patient’s current state, she feels that she has been unsuccessful in developing her relationships in both her personal
life and work life. At 34, she feels as though her window of opportunity to find the love of her life is narrowing. This has
affected her relationships at home and at work, as she’s noticed her frustrations are beginning to show in her lashing out
against the people around her. She’s also noticed that these feelings have gotten in the way of her productivity, and her
performance at work has suffered. Her commitment to her work has faltered because of her lack of ability to commit to a
significant other. Bouts of depression have plagued the patient since she was about 27 years old after having had her heart
broken by a man she thought she’d one day marry.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The patient’s current hospitalization has opened her eyes to the reality that she must take initiative in order to cause a
beneficial change in her life.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“I know I don’t take care of myself. It’s just what I grew up with. It’s hard to change things now.”
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What does your illness mean to you?
“It means I really need to swallow my pride and try this whole exercise thing.”

+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? ____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?_____single___________________________________________________

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?
“I go to church because my mom thinks I should. I’ve never been big into religious things, but I guess it does give me hope when
things are going wrong.”
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_”No, I don’t think so.
_____________________________________________________________________________________________________
______________________________________________________________________________________________________

+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? X years
(age thru )

If applicable, when did the

Pack Years:
patient quit?

Does anyone in the patient’s 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?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Whiskey How much? For how many years?
Volume: 8 oz (age 16 thru present)
Frequency: every 2/3days
If applicable, when did the patient quit?

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

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: 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:
Normal frequency of urination:
Post-nasal drip Other:
4x/day
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth
Diabetes Type:
2x/day
Routine dentist visits
Hypothyroid /Hyperthyroid
1x/year
Vision screening 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
Frequency of pap/pelvic exam (every 5
Emphysema Migraines
years)
Pneumonia Date of last gyn exam? 1/16/17 Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? 12 Encephalitis
last CXR February 2016 menopause age? Meningitis
Date of last Mammogram &Result:
Other: Other:
(6/30/16) no abnormal findings
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
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 Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 2/6/17 Arthritis Chicken Pox
Other: Other: Other:

General Constitution
Recent weight loss or gain
How many lbs? 20lbs
Time frame? December 2016-present
Intentional? No
How do you view your overall health? “Oh, it’s bad.”

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

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±10 PHYSICAL EXAMINATION:

General Survey: Patient Height: 5’5” Weight: 162.1 kg BMI: Pain: 7, right lower
calm with no signs of Pulse: 73 Blood Pressure: 111/73 (right arm) extremity
distress. Respirations: 18
Temperature: (route SpO2 92% 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]

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
*swelling of right calf, RLE cold to touch
Skin turgor elastic No rashes, lesions, or deformities
*discoloration of skin on RLE
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
*2+ pitting edema right lower extremity

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 / 3mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 24 inches & left ear- 24 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: no abnormal findings
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:
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
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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]
*with exception of diminished pulses in femoral and dorsalis pedis areas of RLE
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 1 DP: 1
PT: 3
No temporal or carotid bruits Edema: +2 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: right calf pitting non-pitting
Extremities warm with capillary refill less than 3 seconds
*with exception of right leg
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 2 / 6 / 17 ) 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: pale yellow Previous 24 hour output:
mLs N/A
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 ___3____ 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 Romberg’s Negative
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: +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):
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

WBC – 11.5 2/7/17 Increase (from 8.6) High. DVT is result. The
normal range is 4.5-11.
RBC – 6.3 2/7/17 Increase (from 5.5) High. DVT is result.
Normal range 4.7 to 6.1
Hgb – 15.4 2/7/17 Increase (from 15) Patient’s Hgb within
normal range. The normal
range of 12.0-15.5.
Hct – 49% 2/7/17 Increase (from 47%) High. DVT is result. The
normal range 36-48.
Plt – 550 2/7/17 Increase (from 530) High. DVT is result.
Normal range 150,000 to
450,000.
Glucose - 120 2/7/17 Decrease (from 1126) High due to stress caused
by calf pain. Normal
range is 70-99 fasting.
BUN - 12 2/7/17 Decrease (from 13) Patient’s BUN within
normal range. The normal
range of 7-20.
Na - 137 2/7/17 Decrease (from 144) Patient’s sodium within
normal range. The normal
range of 135-145
K – 3.5 2/7/17 Decrease (from 3.6) Patient’s potassium
within normal range. The
normal range 3.5-5.0.
Cl - 99 2/7/17 Decrease (102) Patient’s chloride within
normal range. The normal
range of 96-106.

+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: reduce intake of sodium and fats, drink plenty of water
Vitals: every 4 hours, it is standard protocol to take vitals every 4 hours
Activity: ambulation at least once per hour, promotes circulation and improves pain and mobility
Scheduled diagnostic tests: continued blood tests
Consults: dietary, PT, medication

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 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Pain related to inflammatory response in affected vein as evidenced by patient’s statement of, “this is the worst my leg
has ever felt.”

2. Ineffective tissue perfusion in the periphery related to decreased venous circulation in the right leg as evidenced by
swelling of the RLE, suggesting venous obstruction.

3. Risk for impaired skin integrity related to pooling of venous blood in the right leg.

4. Anxiety related to unexpected hospitalization and uncertainty about the seriousness of her diagnosis as evidenced by
patient’s statement of, “I can’t keep dealing with this. It keeps me from working and taking care of my kids.”

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± 15 CARE PLAN
Patient Goals/Outcomes
Patient will describe ways in which
to manage unrelieved pain by end
of stay.
Nursing Diagnosis: Pain related to inflammatory response in affected vein
Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Discuss the client’s fears of “Clients often have multiple fears Patient demonstrates understanding
undertreated pain, side effects, and and misconceptions regarding pain of pharmacologic and non-
addiction. and its treatment; therefore, pharmacologic methods in order to
education about how pain and side manage unrelieved pain.
effects can be controlled safely and
effectively and correction of myths
and misconceptions about the use
of opioids should be included as
part of the treatment plan (Ackley,
2014, p. 481).”
In addition to administering “Cognitive-behavioral strategies
analgesics, support the client’s use can restore the client’s sense of
of non-pharmacological methods to self-control, personal efficacy, and
help control pain, such as active participation in his or her
distraction, imagery, relaxation, own care (Ackley, 2014, p. 481).”
and application of heat and cold.

Patient will report a pain level of 3
or lower by end of shift.
Assess pain intensity level in a
client using a valid and reliable
self-report pain tool, such as the 0-
10 numerical pain rating scale.
Assess the client for pain presence
routinely; this is often done at the
same time as when a full set of
vital signs is obtained, and during
activity and rest. Also assess for
pain with interventions or
procedures likely to cause pain.
“Simple–dimension pain ratings Patient reports having a pain level
are valid and reliable as measures of 1 on a scale of 0-10.
of pain intensity level (Ackley,
2014, p. 481).”
“Acute pain should be reliably
assessed both at rest (important for
comfort) and during movement
(important for function and
decreased client risk of
cardiopulmonary and
thromboembolic events (Ackley,
2014, p. 481).”

University of South Florida College of Nursing – Revision September 2014 16

Include a minimum of one
Long term goal per care plan
±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
 □ are any of the patient’s medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing – Revision September 2014 17

University of South Florida College of Nursing – Revision September 2014 18
15 CARE PLAN
Nursing Diagnosis: Ineffective tissue perfusion in the periphery related to decreased venous circulation in the right leg
Patient Goals/Outcomes Nursing Interventions to Achieve
Goal
Patient will verbalize knowledge of If the client smokes, aggressively
treatment regimen, including counsel the client to stop smoking
appropriate exercise and and refer to the physician for
medications and their actions and medications to support nicotine
possible side effects by end of stay. withdrawal and a smoking
withdrawal program.
If the client is overweight,
encourage weight loss to decrease
venous disease.
Rationale for Interventions Evaluation of Goal on Day Care
Provide References is Provided
“A Cochrane review found that use Patient verbalizes and demonstrates
of the medication varenicline appropriate knowledge on
(Chantix) increased the rate of prescribed medications and
smoking withdrawal two to three exercise regimen.
times more than smoking
withdrawal without use of
medications (Ackley, 2014, p.
481).”
“Obesity is a risk factor for
development of both DVT and
pulmonary embolism (Ackley,
2014, p. 481).”

Patient will demonstrate adequate
tissue perfusion as evidenced by
palpable peripheral pulses, warm
and dry skin, adequate urine
output, and absence of respiratory
distress by end of stay.
Check the brachial, radial, dorsalis
pedis, posterior tibial, and popliteal
pulses bilaterally. If unable to find
them, use a Doppler stethoscope
and notify the physician
immediately if new onset of
absence of pulses along with a cold
extremity.
Note skin color and feel the
temperature of the skin.
“Diminished or absent peripheral Patient demonstrates palpable
pulses indicate arterial peripheral pulses, warm and dry
insufficiency with resultant skin, adequate urine output, and no
ischemia (Ackley, 2014, p. 481).” respiratory distress.
“Skin pallor or mottling, cool or
cold skin temperature, or an absent
pulse can signal arterial
obstruction, which is an emergency
that requires immediate
intervention (Ackley, 2014, p.
481).”

University of South Florida College of Nursing – Revision September 2014 19

Include a minimum of one
Long term goal per care plan
±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
 □ are any of the patient’s medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing – Revision September 2014 20

 References

Ackley, B. J. (2014). Nursing diagnosis handbook (10th ed.), St. Louis, MO: Elsevier Mosby

Food Tracker. (n.d.). Retrieved October 24, 2016, from

https://www.supertracker.usda.gov/foodtracker.aspx

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

MO: Elsevier Mosby.

Kee, J. L., Hayes, E. R., McCuistion, L. E. (2015). Pharmacology: a patient-centered nursing

process approach (8th ed.). St. Louis, MO: Elsevier Saunders.

Osborn, K. S., & Osborn, K. S. (2014). Medical-surgical nursing: preparation for practice.

Boston: Pearson.

Treas, L. S., Wilkinson, J. M. (2014). Basic nursing concepts, skills & reasoning. Philadelphia,

PA: F.A Davis Company.

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University of South Florida College of Nursing – Revision September 2014 22