UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Ashley Joseph
Assignment Date: 10/20/2016
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: LRH
 1 PATIENT INFORMATION
Patient Initials: AN Age: 69 Admission Date: 10/17/2016
Gender: male Marital Status: divorced Primary Medical Diagnosis
Primary Language: English Post-operative abdominal abscess LUQ
Level of Education: high school graduate Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): shop supervisor -FLOW components Iron deficiency anemia, leukocytosis (17.8)
Number/ages children/siblings: Sister - 74
2 kids – girl: 46 boy: 47
Served/Veteran: yes Code Status: full code
If yes: Ever deployed? Yes or No
Living Arrangements: lives with girlfriend of 20 years in a 1 story Advanced Directives: yes
house with no stairs and no pets If no, do they want to fill them out?
Surgery Date: Procedure:
Culture/ Ethnicity /Nationality: white non-Hispanic
Religion: none Type of Insurance: Medicare part A
Tricare for life

 1 CHIEF COMPLAINT:
“I had surgery on my stomach on September 27th and last Monday I had diarrhea so I called my primary care provider.
I was told to go to the ER and had a CAT scan and I had a sac with pus in it. They put a catheter into it to drain out the
Pus. It was partly from my antibiotics”
 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient is a 69-year-old male who was recently admitted to LRH for an ulcer surgery. Since discharge, patient has had a
Decrease in appetite with poor intake and weight loss. He had a low grade fever around 100 degrees according to his
Girlfriend. They noticed erythema around the midline inscision staples. CT scan reveals an abscess. Patient has
Experienced frequent liquid bowl movements over the last day or 2. Patient denies vomiting, constipation, shortness of
Breath, and black stool.

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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
6 years ago COPD
1 year ago Had cataracts removed
9/27/16 Perforated ulcer surgery
In his 30s hemorrhoids
Couple years ago hypertension
Years ago Macular degeneration

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 89 MI
Mother 90
Brother
Sister
grandma 92 Unknown
relationship

relationship

Comments: Include age of onset

Father had colon cancer

 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) U
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years? 9/27/16
Pneumococcal (pneumonia) (Date) Is within 5 years? 9/27/16
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
NKDA

Medications

NONE
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)
An abdominal abscess is a “localized collection of pus that are confined in the peritoneal cavity by an inflammatory
Barrier” (Medscape). This patient’s abscess is caused by an infection of his previous ulcer surgery and from the antibiotics
He was taking. It was diagnosed by a CT scan of the abdomen. “If untreated, the process continues until bacteremia
Develops, which then progresses to generalized sepsis with shock” (Medscape). The patient is given antibiotics to treat
The infection and has an 8 French catheter to drain it. “Risk factors for morbidity and mortality include the following:
Multiple surgical procedures, age older than 50 years, multiple organ failure, complex reccurent abscesses” (Medscape).

 5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name pantoprazole Concentration 40 mg/1 tablet Dosage Amount 40 mg
Route oral Frequency daily
Pharmaceutical class proton pump inhibitor Home Hospital or Both
Indication used when body is making too much stomach acid
Adverse/ Side effects allergic reaction, bloody stool, nasal congestion, pharyngitis, nausea/vomiting, jaundice, peripheral edema, chest pain, bone pain
Nursing considerations/ Patient Teaching do not chewtablets, med used for about 8 weeks, do not use if you have liver disease

Name ferrous sulfate (Feosol) 325 mg/1 tablet 325 mg

Oral bid
Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name ondansetron (Zofran) 4 mg/2 mL 4 mg

INJ IV push Q4h PRN
Selective 5-HT3 receptor antagonist Home Hospital or Both

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Indication prevent nausea and vomiting
Adverse/ Side effects allergic reaction, dizziness, constipation, fast/uneven heartbeat, blurred vision
Nursing considerations/ Patient Teaching avoid if PKU or liver disease, report constipation or diarrhea, take with water

Name levofloxacin 500 mg/100 mL 500 mg

INJ IVPB Q24h
Synthetic fluoroquinolone anti-bacterial Home Hospital or Both
Indication: treat infections
Adverse/ Side effects tendon problems, diarrhea, abdominal pain, insomnia, headache, rash, pruritis, Achilles tendon rupture
Nursing considerations/ Patient Teaching – avoid if myasthenia gravis,

Name fluconazole 400 mg/200 mL Dosage Amount 400 mg

Route INJ Q24h

Bis-triazole antifungal Home Hospital or Both
Indication decrease abdominal abscess infection
Adverse/ Side effects nausea, itching, anorexia, dark urine, jaundice, fever, chills, rash

Nursing considerations/ Patient Teaching do not use with synthroid, Xanax, with hemodialysis, renal dysfunction, and causes hepatotoxicity

Name vancomycin Concentration 125 mg/1.25 mL Dosage Amount 125 mg

Route oral suspension Frequency q6h
Pharmaceutical class bactericidal glycopeptide antibiotic Home Hospital or Both
Indication fights infection of abscess
Adverse/ Side effects allergic reaction, dry mouth, muscle cramps, bloody urine, fatigue, diarrhea
Nursing considerations/ Patient Teaching report ringing of ears or dizziness, do not stop taking even if feeling better

Name lisinopril Concentration 10 mg/ 1 tablet Dosage Amount 10 mg

Route oral Frequency daily
Pharmaceutical class ACE inhibitor Home Hospital or Both
Indication lower blood pressure to treat hypertension
Adverse/ Side effects cough, depressed mood, dizziness, orthostatic hypotension, rash, blurred vision, fatigue, diaphoresis
Nursing considerations/ Patient Teaching get up slowly when changing positions, continue taking even when feeling better, report muscle/joint pain or cough

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? regular Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Patient does not eat breakfast

Lunch: Usually eats at restaurant or fast food place, usually subway

Also likes eating burger or chili dog
Dinner: Spaghetti or meatloaf with potatoes or rice, sometimes peas
Occasionally eats various fruits or veggies
Snacks: No snacks

Liquids (include alcohol): Diet pepsi, water, lemonade, iced tea, alcohol before bed

Breakfast is the most important meal, so the patient should be

encouraged to try and eat something. It is recommended to eat 2
cups of fruit and 2.5 cups of vegetables according to myplate.gov
but this patient said he only eats a couple fruits or veggies
occasionally. He eats out a lot at places that usually have high-
sodium foods, which worsens his hypertension. He should be
having 3 cups of dairy, but he does not consume any dairy. The
patient might get enough protein from the meats he eats. It is
recommended that he consumes at least 4 ounces of grains, so if
the rice and pasta are whole grains then this might be fulfilled.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
“my girlfriend”
How do you generally cope with stress? or What do you do when you are upset?
“I don’t carry stress around. I leave my home at home and my work at work. It’s a state of mind. If you separate them
Then you’re okay, there is no need to get stressed over things.’ If I’m upset I will figure it out and keep going.”

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“I feel stressed out and I have anxiety because of what’s going on right now. There’s a hole in my stomach and if
They can’t fix this infection I’ll die. I don’t know what’s going on with this thing”

+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_______

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
____”yes, my ex-wife used to slap me. She’s an ex for a reason”___ If yes, have you sought help for this? ___yes_____

Are you currently in a safe relationship? yes

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 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: “It is during this time we contemplate our accomplishments and are able to develop integrity if we see ourselves
Leading a successful life. Wisdom enables a person to look back on their life with a sense of closure and completeness” (simplypsych)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
Patient stated that if the doctors and nurses are not able to fix his infection then he will die, but we all will eventually die.
He seemed very accepting of death if it were to happen, and he was proud of the life he had lived. He did not seem to have
Any regrets about his life, and he had many accomplishments to look back at.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The disease is making the patient get anxious because he does not fully understand what is happening, but he has
Accepted that he might die from this. He is becoming more contemplative of his life.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”

“no idea”

What does your illness mean to you?

“if they can’t fix it I’ll die. You can’t live forever, especially with an infection”

+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? _______no____________________________________
Have you or a partner ever had an abnormal pap smear?___________”not that I know of”_________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___________________________________________

Are you currently sexually active? ______”it’s been a while”______________ 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? None.
How long have you been with your current partner?_____________20 years___________________________________

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, we are both past the age of pregnancy and we have not strayed away from each other”

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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?
_____________________”on a scale of 1-10, I would have to say about a 7.”_______________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
______________________”No, my religion has nothing to do with this” ___________________________________________
______________________________________________________________________________________________________

+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? 51 years
Currently e-cigarettes, and previously Previously 2.5 packs a day (age 14 thru 65 )
Regular cigarettes
If applicable, when did the
Pack Years: 77
patient quit?
Quit reg cigarettes 5 years ago
Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? yes
so, what, and how much? no If yes, what did they use to try to quit? E-cig

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years? 35
Nightcaps (bourbon or beer) Volume: 2 (age 35 thru 70 )
Frequency: every night before bed
If applicable, when did the patient quit?
NA

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?
Deployed to Vietnam and wounded, but not exposed to much

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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: 30-35 Diverticulitis Life threatening allergic reaction
Bathing routine: once every day Appendicitis Enlarged lymph nodes
Other: sunscreen for long time In sun Abdominal Abscess currently Other:
Be sure to answer the highlighted area Last colonoscopy? 3-4 years ago
HEENT Other: Hematologic/Oncologic
Difficulty seeing (wears glasses) Genitourinary Anemia (iron deficiency)
Cataracts (removed year ago) nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: A-
Post-nasal drip Normal frequency of urination: 7 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems (false teeth) Metabolic/Endocrine
Routine brushing of teeth 1-2 x/day (hemorrhoids were when he was in his 30s Diabetes Type:
Routine dentist visits 4 x/year Ulcer was 9/27/26 – perforated, had black Hypothyroid /Hyperthyroid
Vision screening every 6 months Stool previously) Intolerance to hot or cold
Other: macular degeneration Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive (occasional) WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema (COPD 6 yrs ago) 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? 1 year ago menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? 1/yr Schizophrenia
Chest pain / Angina Date of last prostate exam? 1.5 yr ago Anxiety (from current health status)
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur (mild) Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 3 wk ago Arthritis many years Chicken Pox
Other: Other: Other: had these at very young age
University of South Florida College of Nursing – Revision September 2014 8
General Constitution
Recent weight loss or gain
How many lbs? 12-15 pounds
Time frame? 3 weeks
Intentional? No, from diarrhea and loss of appetite
How do you view your overall health? “well I was in good health until a hole blew out in my stomach”

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?

“Not right now”

University of South Florida College of Nursing – Revision September 2014 9

±10 PHYSICAL EXAMINATION:

General Survey: Patient Height 5’6” Weight 58.1 kg BMI 20.66 Pain: (include rating and
is a 69 year old male who Pulse 90 Blood Pressure: 113/65 left arm location) currently 0
is A&O times 3 Respirations 18
Temperature: (route SpO2 99 Is the patient on Room Air or O2
taken?) 36.4 oral
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 surgical incision on the abdomen – pink, well-approximated, with serous drainage

Central access device Type: 20 gauge IV Location: R AC Date inserted: 10/19

Fluids infusing? no yes - what? 0.9% NS

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 2/ mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 2 inches & left ear- 2 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: patient has fake teeth
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 patient has COPD – barrel chest
RML CL LLL D
RLL D

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

University of South Florida College of Nursing – Revision September 2014 10

 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: 2 Carotid: 2 Brachial: 2 Radial: 2 Femoral: 2 Popliteal: 2 DP: 2 PT: 2
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: 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 10 / 20 / 16 ) Formed Semi-formed Unformed Soft Hard Liquid Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other – Describe:

GU Urine output: Clear Cloudy Color: yellow Previous 24 hour output: mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges 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 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

±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):

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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 10/17 – 17.8 down The elevated WBC count
10/18 – 14.1 is an indicator of
10/19 – 10.9 infection, and the patient
10/20 – 7.2 came in due to an
infection so it makes
sense that it was so
elevated. The fact that it
is trending down is a
good sign because it
means that the infection
is decreasing.
platelet 10/17- 961 down The patient’s platelet
10/18 – 881 count is abnormally high,
10/19 – 714 which increases the risk
10/20 - 715 of blood clots and
bleeding complications.
The fact that it is trending
down is a good sign.
neutrophil 10/17 – 15.21 down The normal neutrophil
10/18 – 11.37 count is around 15, so the
10/19 - 8.46 patient is becoming
10/20 -4.73 neutropenic. This means
that his body will not be
able to fight off infections
as well as it should. For
this patient, a low
neutrophil count can lead
to an increased infection
duration and the
possibility that his
abdominal abscess can
get worse.
Deep wound culture 10/17 Kleb. Pneumoniae, The patient has an
moderate yeast abdominal abscess that
has multiple infections.
The yeast is from the
antibiotics he was on, so
he must be prescribed a
new antibiotic.
Stool: C-diff unknown positive Patient currently has a C-
diff infection causing
diarrhea. This is easily
spread through contact,
University of South Florida College of Nursing – Revision September 2014 12
 so he must remain in an
isolated room with
contact precautions.
CT scan abdominal 10/17 Frank pus – needs 8 The abscess in the
French drainage catheter patient’s abdomen has
pus in it, and it needs a
catheter to drain it
because it is too much.

+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.)
Regular diet, gastroview today to see GI tract– UGI/ SM bowel (pending results),
vitals q8h because of hospital policy

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

1. impaired skin integrity related to abdominal wound as evidenced by abscess, infection of surgical site, and
Imbalanced nutritional state
2. anxiety related to fear of abdominal infection as evidenced by patient stated feelings of anxiety due to not
Understanding what is happening and feelings of impending death and change in health status
3. social isolation related to contact percautions as evidenced by c-diff diagnosis, patient is alone with no human
Interaction, and feelings of embarrassment when seeing nurse in special gown and gloves.
4.

5.

University of South Florida College of Nursing – Revision September 2014 13

± 15 CARE PLAN
Patient Goals/Outcomes
Patient will regain integrity of
Skin surface by time of discharge
And maintain skin integrity
Nursing Diagnosis: impaired skin integrity
Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Nurse will monitor surgical site Inspecting skin can insure that Infection seems to be decreasing
At least once a day for color infection does not worsen According to WBC
Changes, redness, swelling, pain,
Or other signs of infection

Nurse will ensure that the abscess Proper drainage will help with Wound is continuing to drain
Is being properly drained q4h Wound healing and improve With no problems
Skin integrity
Patient will demonstrate under-Nurse will demonstrate how to Proper cleaning of wound will
Standing of plan to heal skin Properly clean wound and change Ensure skin healing
And prevent reinjury by time ofDressing by time of discharge
discharge Nurse will minimize exposure of Minimizing exposure to skin will No skin exposure to diarrhea or to
skin to wound drainage and improve wound healing and wound drainage
diarrhea q6h prevent further impairment
Nurse will educate patient about Patient must understand the
Importance of proper nutrition to Importance of proper nutrition to
Include a minimum of one Ensure proper skin healing Ensure compliance of diet
Long term goal per care plan Nurse will monitor patient’s
nutritional status and diet during Proper nutrition will help the body
each shift Have the strength to heal skin
±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
X PT/ OT
□Pastoral Care
□Durable Medical Needs
X F/U appointments
X Med Instruction/Prescription

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  □ are any of the patient’s medications available at a discount pharmacy? X Yes □ No
□Rehab/ HH
□Palliative Care

University of South Florida College of Nursing – Revision September 2014 15

 References

Abdominal Abscess. (n.d.). Retrieved October 25th, 2016, from

http://emedicine.medscape.com/article/1979032-overview

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

B.C. (n.d.) (used for all my med information). Retrieved October 25, 2016 from https://www.drugs.com/

McLeod published 2008, updated 2013, S. (1970) Erik Erikson. Retrieved October 25, 2016 from
http://www.simplypsychology.org/Erik-Erikson.html

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

 Patient Goals/Outcomes
Patient will identify, verbalize, and
Demonstrate techniques to control
Anxiety by time of discharge
Patient will have gestures, facial
Expressions, and activity levels
That reflect decreased distress
At the end of each shift
Include a minimum of one
Long term goal per care plan
University of South Florida College of Nursing – Revision September 2014
Nursing Interventions to Achieve
Goal
Nurse will encourage patient to
Use positive self-talk at each shift
Nurse will use therapeutic touch
and healing touch techniques as
needed by patient
Nurse will suggest activites for
patient to do in order to decrease
stress, such as music, distraction,
or deep breathing exercises
Nurse will assess patient’s level
Of anxiety and physical reactions
To anxiety at beginning of shift
Nurse will explain all procedures,
issues, and diagnosis in calm and
slow speech when new information
is received about patient
Nurse will use empathy to
encourage client feelings of anxiety symptoms and problems of anxiety
are normal
Nursing Diagnosis: anxiety
Rationale for Interventions Evaluation of Goal on Day Care
Provide References is Provided
Changing thoughts will help
Change behaviors and decrease
Anxiety feelings
Healing touch is a very useful tool
to help decrease anxiety by
bringing healing energy
Music, deep breathing and Unable to assess use of these
distraction can help reduce stress techniques
and anxiety
Assessing anxiety will help with Patient currently very anxious
Figuring out how to intervene
Patient is afraid because of Explaining reason for contact
knowledge deficit of diagnosis and precautions helped put patient’s
procedures, so explanation will mind somewhat at ease
decrease anxiety
Supporting patient will reduces
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