UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Danielle Finethy

MSI & MSII PATIENT ASSESSMENT TOOL .

Assignment Date: 10/13/15

Agency: BMC

1 PATIENT INFORMATION
Patient Initials: J. S.

Age: 43

Admission Date: 10/12/15

Gender: Female

Marital Status: Married

Primary Medical Diagnosis: Hidradenitis

Suppurativa

Primary Language: English

Level of Education: Some college

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Disabled, prev. Customer support

tech.
Number/ages children/siblings: 3 non-biological sons 18, 20, 22

None known

Served/Veteran: No
If yes: Ever deployed? No

Code Status: Full code

Living Arrangements: Extended stay hotel, first floor with ramp for
handicapped access.

Advanced Directives: No
If no, do they want to fill them out? No, confident
her partner knows what she wants.
Surgery Date: none this admission

Culture/ Ethnicity /Nationality: Caucasian

Religion: Shamanistic/Celtic/Wicken

Type of Insurance: Coventry Medicare HMO

1 CHIEF COMPLAINT:
Flare up of my hidradenitis

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is a 43 year old female presenting to the hospital to be admitted for a flare up of hidradenitis suppurativa (HS),
a condition she has been dealing with for many years. She has an extensive past medical history including diabetes
mellitus type 2, hypertension, previous MI, osteoarthritis, asthma, and MRSA, The affected areas of current flair up are
mainly suprapubic and labia, these areas are painful for the patient and require medical management to decrease pain and
infection. The pain is dull and constant with occasional episodes of sharp and stabbing like pain, medication and
distraction make the pain bearable and stress and movement with activity make the pain worse. Patient states her pain is
7/10 at any given time. This is a problem which has required multiple hospitalizations and surgeries to manage. The
patient states she was able to tell that an infection was coming on because of the increased amount of pain she having
around her pubic and labial folds. She saw her primary care physician who is new to her and not yet familiar with her
entire history, this physician sent her to Bayfront. Patient has been started with IVPB vancomycin 2000mg/500mL Q12H
for the infections present, this has worked for previous episodes requiring hospitalization; she is also receiving IVPB
Levaquin 500mg/100mL daily. The patients pain is being controlled with IV dilauded 1mg Q3H prn.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease

Father
Mother

48
47

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable
)

Environmental
Allergies

Operation or Illness
DM2 (dx:10 years ago, insulin for 7 years)
Htn (metoprolol and amlodipine
Hidradenitis Suppurativa (multiple hospitalizations, multiple I&D, skin graft, NSAIDS for
inflammation and pain, abx therapy as needed for flare up)
MRSA - abscess on groin (treated with Vancomycin)
Osteoarthritis hips and knees (NSAIDS, rest)
Degenerative disk disease C5, C6 (untreated)
MI thrombotic event from L PICC after hospitalization for HS flare up.
Asthma due to allergies avoids allergens
Tonsillectomy as child

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Date
2005
2005
2006, 2011, 201315
2014
2010
2014
2015
Unk
Unk

MI
MI

Brother
Sister
relationship
relationship
relationship

Comments: Include age of onset

Patient unsure on exact details of parents previous health problems. Father was a bilateral above knee amputee from complications
from diabetes, states that he exhibited depression after that happened. Both parents died of heart attacks, patient states father had
kidney issues for years after his first heart attack.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Received with Tetanus shot
Adult Tetanus (Date) Is within 10 years? Pt unsure of exact date, but
w/in last 10 years.
Influenza (flu) (Date) Is within 1 years?
Pt refused

YES

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NO

Pneumococcal (pneumonia) (Date) Is within 5 years? Pt refused

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
OR ADVERSE
REACTIONS

Medications

Other (food, tape,

latex, dye, etc.)

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Penicillin
Doxycycline
Keflex

Hives that look like giant ringworm

Severe nausea & vomiting
Numb lips

Strawberries
Dust/pollen

Mild itching states has gotten better with time

Itchy nose & throat, runny nose

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)
Hidradenitis Suppurativa (HS) is a chronic, progressive skin disease involving frequents cysts, infections, and scarring. The
pathophysiology of HS is not completely understood yet, but the distinct patterns of the clinical manifestations in patients have been
well documented. This disease is characterized by occlusion of hair follicles and typically occurs on areas of the body containing
apocrine sweat glands such as axillae and groin (Prens & Deckers, 2015). The development of HS was typically thought to be due to
apocrine glands becoming occluded and causing follicular involvement in infections, but recent research shows that though the
follicular occlusion is the cause of lesions in HS patients that the apocrine gland is not directly involved in the formation of cysts or
lesions (Prens & Deckers, 2015). The pathogenesis of HS usually will start with one or several instances of follicular occlusion which
becomes painful, tender, and inflamed. These occluded follicles essentially are comedones within the hair follicle and will fill with
bacteria and debris which caused occlusion; eventually they rupture and cause a severe localized inflammatory response to the bacteria
and fluid discharge (Prens & Deckers, 2015). The early signs of HS include one or more occasions of an inflamed lesion, usually
about the size of a pea, the later signs include lesions that are larger, may have a malodorous discharge, are chronic in nature, and
create sinus tracts and tunneling often requiring surgical interventions (Beshara, 2010). As the disease progresses it may require
repeated surgeries since the lesions will recur even after resection. Patients diagnosed with HS may have various other problems
resulting from HS including depression, social isolation, chronic pain, and sexual dysfunction (Gooderman & Papp, 2015).
The age of onset is typically between puberty, when apocrine glands develop, and through menopause for women who are affected
more than men. The disease is seen worldwide with higher frequency in places with hot and humid climates. Risk factors include
being overweight, being female, having acne prone skin, and smoking which has been linked to HS. Since the exact pathophysiology
is not understood with HS, there are many possible factors that may contribute to the disease but are not definite. As described by
Prens and Deckers (2015), smoking has been epidemiologically linked to HS and is thought to play a part due to the chemicals
released into the body through cigarette smoke. Another factor that may contribute are hormones, especially sex hormones, due to
their involvement in follicular proliferation. A genetic link is thought to be a possibility in risk for developing HS but has not been
proven.
To be diagnosed with hidradenitis suppurativa the patient must meet certain criteria as outlined by Beshara (2010), the patient must
have at least one of the following: one or more active primary lesions in a specific site, axilla or groin and a history of three or more
discharging or painful lumps in designated sites since puberty; in absence of current active lesions must have history of five or more
painful or draining abscess-like lumps since puberty. The disease is categorized by three clinical stages and the nature of the disease,
having periods of exacerbation and remission, may delay a definitive diagnosis in some patients. The first stage is having initial
lesions that have not left scarring or tracts under the skin. The second includes having recurrent infections under the skin and with
single or multiple separated lesions causing sinus tracts and scarring. According to Beshara (2010), most often the second stage is
when people will be diagnosed and may require a surgery referral. The third stage is severe and can affect large portions of skin
across the body. Its clinical requirements for staging as defined as diffuse, broad involvement with multiple interconnecting sinus
tracts and abscesses across a broad area of the body. At this stage, scarring and oozing lesions are common (Beshara, 2010, p. 330).
Other tools that may aid in diagnosing HS are various lab tests including platelet counts, c-reactive protein assay, comprehensive

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metabolic panel, thyroid and anemia panels.

The prognosis for patients diagnosed with HS depends of their severity of disease when determining quality of life. There is no cure
for the disease only management of symptoms. Treatment often includes antibiotic therapy, oral is preferred but intravenous may be
needed to handle more severe infections. Antibiotics of choice are typically the same type used for acne control such as doxycycline,
tetracycline, and erythromycin as described by Beshara (2010). Along with management of symptoms, patients will often require
incisions and drainage of large nodules or lesions that have tracked and tunneled under the skin; this is cause for pain both
preoperatively and postoperatively. Nonsteroidal anti-inflammatory drugs (NSAIDS) are a first choice for management of multiple
symptoms including the inflammation and pain associated. Pain is a significant problem for patients with HS with most reporting both
nociceptive and neuropathic pain of some degree. There are several different options for pain control in patients with hidradenitis
which may include use of serotonin norepinephrine reuptake inhibitors (SNRI) or selective serotonin reuptake inhibitors (SSRI) for
neuropathic pain and can also treat underlying depression. In a study by Horvath, Janse, and Sibbald (2015), the differences in pain
management are attributed to the different types of pain experienced as well at the timing of pain related to acute exacerbations or
chronic pain from scarring or previous surgery. Patients should be started on NSAIDS for chronic pain and see how they manage with
that, acetaminophen can be given for acute pain and depending on patient outcome may need to be changed to include antiepileptic
medications such as gabapentin for neuropathic pain, or opioids for severe unrelieved pain.

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name Metoprolol succinate (Toprol XL)

Concentration

Dosage Amount 50 mg, 1 tab

Route PO

Frequency Daily

Pharmaceutical class Beta blocker

Home

Hospital

or

Both

Indication Hypertension, angina, prevention of MI, management of heart failure due to ischemic, hypertensive, or cardiomyopathic origin. May also be used for
ventricular arrhythmias or anxiety (situational).
Adverse/ Side effects Fatigue, weakness, dizziness, drowsiness, insomnia, hypotension, blurred vision, bronchospasm, wheezing, constipation, diarrhea, dry mouth,
erectile dysfuntion, decreased libido, hyper/hypo-glycemia. Bradycardia, heart failure, or pulmonary edema.
Nursing considerations/ Patient Teaching: check blood pressure and pulse prior to administration, hold medication if pulse <50 and contact provider. Advise patient that
they may experience some side effect when changing positions, advise to sit up and stand up slowly when changing position. Make sure patient knows not to stop taking
medication abruptly to avoid rebound hypertension. Have patient alert nurse of any side effects they have experienced after taking medication.
Name levofloxacin (Levaquin IVPB)

Concentration 500mg/100mL

Route IV

Dosage Amount 500 mg

Frequency Daily

Pharmaceutical class Floroquinolone

Home

Hospital

or

Both

Indication Treatment of bacterial infections, including urinary tract infections, cystitis, pyelonephritis, and prostatitits. Uncomplicated and complicated skin and skin
structure infections.
Adverse/ Side effects Nausea, abdominal pain, diarrhea, vomiting, hypersensitivity reactions, peripheral neuropathy, hepatotoxicity, hyperglycemia/hypoglycemia,
phlebitis at IV site. Elevated ICP, seizures, pseudomembranous colitis, Stevens-Johnson syndrome.
Nursing considerations/ Patient Teaching Monitor patient for GI symptoms after administration, assess for any signs of hypersensitivity reaction and/or rash. Monitor
patient for signs of hypoglycemia or hyperglycemia, especially for diabetics. Check labs for changes in LFTs. Advise patient of potential side effects and instruct to make
them known to nurse if occurring.
Name amlodipine (Norvasc)

Concentration

Dosage Amount 5 mg, 1 tab

Route PO

Frequency Daily

Pharmaceutical class Calcium channel blocker

Home

Hospital

or

Both

Indication Hypertension, CAD, Angina

Adverse/ Side effects Fatigue, headache, nausea, flushing, muscle cramps or weakness, palpitations dizziness. Edema or pulmonary edema may occur.
Nursing considerations/ Patient Teaching Monitor blood pressure before and after giving medication. Metabolized by the liver, may need to titrate dose in hepatic
impairment. In elderly, initiate at a lower dose.
Advise patient to sit or stand slowly when changing positions, may be caused by medication. Patient should report all side effects to the nurse, use caution with
ambulation if dizziness or weakness is occurring.
Name Hydromorphone (Dilaudid)

Concentration 1mg/ml

Route IV push

Dosage Amount 1 mg
Frequency Q3H, PRN pain scale 4-6

Pharmaceutical class Opioid analgesic

Home

Hospital

or

Both

Indication For moderate to severe pain

Adverse/ Side effects Dry mouth, palpitations, tachycardia, bradycardia, agitation, dizziness, euphoria, faintness, nervousness, seizures, constipation, nausea/vomiting,

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flushing, sweating, skin rash. Angina pectoris, cardiac arrest, respiratory depression, MI, coma, paralytic ileus, respiratory arrest.
Nursing considerations/ Patient Teaching Check blood pressure and respiratory rate and status prior to administration. Avoid giving concurrently with other CNS
depressants or other opioids. Monitor respiratory and cardiac status after administration. Opioid antagonist should be available in case of overdose/respiratory depression.
Stool softener or laxative should be given for patients receiving continuous opioid therapy to avoid constipation.
Encourage patient to express change in pain level to appropriately manage. Advise patient of potential for addiction/dependence and also of tolerance. Instruct patient to
ambulate with caution after administration when effects are the strongest. Make patient aware of common side effects including nausea and have them report to the nurse
if occurring.
Name docusate-senna (Senokot-S)

Concentration

Dosage Amount 100 mg, 1 cap

Route PO

Frequency BID

Pharmaceutical class stimulant laxative/stool softener

Home

Hospital

or

Both

Indication Treatment of constipation associated with dry, hard stools and decreased intestinal motility. Also for prevention of opioid-induced constipation.
Adverse/ Side effects fluid and electrolyte imbalances, abdominal cramps, nausea, vomiting, diarrhea, rashes, urine discoloration.
Nursing considerations/ Patient Teaching
Assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel. Asses color, consistency, and amount of stool produced.
Administer with full glass of water or juice, not within 2 hours of other laxative. Advise patient that laxatives should only be used in short term; long term may cause
electrolyte imbalance and dependence.
Encourage healthy bowel regulation with the patient, advise to increase bulk of diet, increase fluid intake and increase mobility. Advise patient to avoid straining,
especially cardiac disease.

Name vancomycin (Vancocin IVPB)

Concentration 2000mg/500mL

Route IVPB

Dosage Amount 2000 mg

Frequency Q12H

Pharmaceutical class Anti-infective

Home

Hospital

or

Both

Indication Treatment of potentially life threatening infections when less toxic medications are ineffective or contraindicated. Particularly useful in staphylococcus
infections including soft-tissue infections in patients who have allergies to penicillin or its derivatives or when sensitivity testing demonstrates resistance to methicillin.
Adverse/ Side effects Ototoxicity, hypotension, nausea, vomiting, rashes, leukopenia, back and neck pain; nephrotoxicity, and phlebitis can occur with this medication.
Hypersensitivity reactions, chills, fever, and Red man syndrome can occur with rapid infusion. Extremely irritating to veins; caution should be taken with IV infusions
to ensure extravasation does not occur possibility for necrosis of tissue.
Nursing considerations/ Patient Teaching Patient should be made aware to report any pain at the site of infusion as this may indicate too rapid of infusion or possibly
extravasation. Patient should also be aware of possibility for red man syndrome. Nurse should monitor vital signs before and throughout administration of medication,
be aware for potential of above side effects including ototoxicity. Try to avoid giving Vancomycin with other drugs excreted by the kidneys to reduce chances of
nephrotoxicity. Toxicity overdose can occur; trough levels should be drawn daily while prescribed to determine level, hold medication for level over 20 mcg/mL.
Name Ondansetron (Zofran)

Concentration 4mg/2mL

Route IV push

Dosage Amount 4mg

Frequency Q4H prn

Pharmaceutical class five ht3 antagonist (anti-emetic)

Home

Hospital

or

Both

Indication For nausea and vomiting, can be given for nausea from other medications.
Adverse/ Side effects Headache, constipation, diarrhea, dizziness, drowsiness, fatigue, weakness, abdominal pain, dry mouth, EPS reactions; may cause increased liver
enzymes, QT interval prolongation, Torsade de Pointes.
Nursing considerations/ Patient Teaching Assess patient for nausea/vomiting, and bowel sounds prior to administration. Monitor ECG in patients with hypokalemia,
hypomagnesemia, heart failure, or bradyarrhythmias. Advise patient to report symptoms of irregular heart beat or involuntary movement of eyes, face or limbs.
Name Insulin detemir (Levemir)

Concentration 1 unit = 0.01mL

Route SubQ

Dosage Amount 40 units

Frequency BID

Pharmaceutical class Pancreatics (antidiabetics)

Home

Hospital

or

Both

Indication Control of hyperglycemia in patients with Type I and Type II diabetes mellitus.
Adverse/ Side effects Hypoglycemia, pruritis, erythema, and swelling at the site of injection may occur.
Nursing considerations/ Patient Teaching Assess patient for signs of hypoglycemia/hyperglycemia prior to administration. Check blood sugar levels prior to
administration and make sure food is available for patient. Other medications may mask the signs and symptoms of hypoglycemia such as beta blockers, clonidine, and
reserpine. Other medications such as corticosteroids, thyroid supplements, estrogens, isoniazid, niacin, phenothiazines, and rifampin may increase insulin requirements.
Educate patient on signs and symptoms of both hypoglycemia and hyperglycemia and what to do for each. Patients should carry a source of sugar such as candy or
glucose gel, for episodes of hypoglycemia. Regular follow ups with healthcare provider are necessary to prevent complications and manage disease. Patient should be
aware that insulin is not a cure for diabetes and that treatment will be long term.
Name Insulin Regular (Humulin R)

Concentration 1 unit = 0.01mL

Route SubQ

Dosage Amount 15 units

Frequency AC

Pharmaceutical class Pancreatics (antidiabetics)

Home

Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Indication Control of hyperglycemia in patients with Type I and Type II diabetes mellitus.
Adverse/ Side effects Hypoglycemia, pruritis, erythema, and swelling at the site of injection may occur.
Nursing considerations/ Patient Teaching Assess patient for signs of hypoglycemia/hyperglycemia prior to administration. Check blood sugar levels prior to
administration and make sure food is available for patient. Other medications may mask the signs and symptoms of hypoglycemia such as beta blockers, clonidine, and
reserpine. Other medications such as corticosteroids, thyroid supplements, estrogens, isoniazid, niacin, phenothiazines, and rifampin may increase insulin requirements.
Educate patient on signs and symptoms of both hypoglycemia and hyperglycemia and what to do for each. Patients should carry a source of sugar such as candy or
glucose gel, for episodes of hypoglycemia. Regular follow ups with healthcare provider are necessary to prevent complications and manage disease. Patient should be
aware that insulin is not a cure for diabetes and that treatment will be long term.
Name Insulin Regular (Humulin R)

Concentration 1 unit = 0.01mL

Route SubQ

Dosage Amount Sliding Scale

Frequency Q6H prn/ per sliding scale

Pharmaceutical class Pancreatics (antidiabetics)

Home

Hospital

or

Both

Indication Control of hyperglycemia in patients with Type I and Type II diabetes mellitus.
Adverse/ Side effects Hypoglycemia, pruritis, erythema, and swelling at the site of injection may occur.
Nursing considerations/ Patient Teaching Assess patient for signs of hypoglycemia/hyperglycemia prior to administration. Check blood sugar levels prior to
administration and make sure food is available for patient. Other medications may mask the signs and symptoms of hypoglycemia such as beta blockers, clonidine, and
reserpine. Other medications such as corticosteroids, thyroid supplements, estrogens, isoniazid, niacin, phenothiazines, and rifampin may increase insulin requirements.
Educate patient on signs and symptoms of both hypoglycemia and hyperglycemia and what to do for each. Patients should carry a source of sugar such as candy or
glucose gel, for episodes of hypoglycemia. Regular follow ups with healthcare provider are necessary to prevent complications and manage disease. Patient should be
aware that insulin is not a cure for diabetes and that treatment will be long term.

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? ADA
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Tries to follow diabetic diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:

*Patient stated that she tries to eat well and follow a diabetic diet
plan but it can be difficult to purchase fresh fruits and vegetables
as well as fresh meats with her fixed budget, so her diet is
typically better in the beginning of the month when she has funds
to buy healthier food. I would assume that the menu on the left is
one that she aims to stay towards but that it varies greatly
depending on availability of funding.

Breakfast: Deli turkey (3 slice) and American cheese (1

slice) sandwich on thins bread with iceburg lettuce and
slice tomato. Fruit greek yogurt (6 oz.)
Lunch: usually skip lunch
Dinner: medium chicken breast baked or grilled, 3-4 red
potatoes boiled, broccoli or green beans boiled.
Snacks: grapes, apple and popcorn with butter
Liquids (include alcohol): 32 oz. bottle of water x3/day.
Very rarely alcohol.
Analysis:

Empty Calories Limit: 258 Total Limit: 2000

Oils
Eaten: 0 tsp.
Limit: 6 tsp.

Saturated Fat
Eaten: 7g
Limit: 22g

Sodium
Eaten: 1937mg
Limit: 2300mg

Basing the analysis on this patients dietary recall for 24

hours I would say she has room for improvement. There are
multiple things to consider when creating an ideal diet plan
for her such as having type II diabetes and being on insulin,
hypertension and a previous MI. Her blood sugars while in
the hospital have been consistently high in the 190-220
range even with insulin therapy.
From the myplate.gov summary, of what she stated is a
typical diet, it shows that she is consuming under 1000
calories a day but is nearing the total amount of sodium for
a 2000 calorie/day diet plan. This indicates that she is
eating too much sodium in the amount of food she is
consuming. This patient should be cautious of how much
sodium she is taking in each day since she has htn and has

University of South Florida College of Nursing Revision September 2014

already had a heart attack this year. Increased sodium can

increase blood pressure and cause further damage to
vasculature which is already compromised for her since she
has diabetes and htn.
Another thing that is concerning with this patient and her
diet is the fact she states that she usually skips lunch. For a
diabetic who is taking multiple insulin injections a day, I
would recommend that she try to eat at least 3 meals per
day with attention given to the amount of carbs eaten at
each meal. From the analysis from MyPlate, it shows that
she is taking a normal amount of carbs (133g with 130g
being the target), however this is with eating only 955
calories out of a 2000 calorie target or limit. She should be
conscious of the carbohydrates that she is eating both in
number and the type, more complex carbs will help her
glycemic control by taking longer to metabolize instead of
turning into sugar quickly.
I would definitely recommend that this patient begin taking
a multivitamin as well as calcium with Vitamin D
supplement. From the analysis given she is falling short on
intake of fiber, potassium, iron, magnesium, calcium,
folate, and Vitamins A, D, E, and B12. If she is not able to
get it from the food she eats, a vitamin supplement is highly
recommended. I would especially encourage her to take a
calcium and Vitamin D supplement since she is over 35 and
at risk for osteoporosis.
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? Wife she is the rock in relationship
How do you generally cope with stress? or What do you do when you are upset?
Plays computer games, listens to music, watch movies distractions help. Does participate in an online support group for
her condition which is comforting to know she is not alone with her disease.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Relationship is good, states that she has good days and bad days coping with her illnesses/condition. Some days it is
difficult than others and she does have constant pain which takes a toll on her. She states that she tries to always stay
positive because if she doesnt then it would overcome her.

+2 DOMESTIC VIOLENCE ASSESSMENT

University of South Florida College of Nursing Revision September 2014

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? _Physically no, emotionally yes___________________
Have you ever been talked down to?___yes____ 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? Never
physically, was emotionally abused she got out of the relationship.
If yes, have you sought help for this? _No_____________________
Are you currently in a safe relationship? Yes, very

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
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:

Stage 7 of Eriksons psychosocial development theory: Generativity versus stagnation (40 to 65 years). The goal of this
stage is to be creative and productive. Often this is accomplished through work or relationships, such as raising healthy,
functional children or contributing to society by developing a distinguished career, for example in nursing. The person
who fails to achieve generativity (the desire and motivation to guide the next generation) may manifest stagnation in the
form of superficial relationships and self-absorption. Simply having children does not guarantee generativity. (Treas &
Wilkinson, 2014)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

This patient has reached the generativity stage of Eriksons psychosocial development theory, the seventh stage. I come to
this conclusion almost hesitantly because it is hard to include her in the textbook definition of this stage as she has been
disabled from working for many years and when she was employed it was a customer service representative, a job I do not
feel that most would associate as distinguished career. However, I do feel that this patient has reached the generativity
stage from what she explained to me regarding her disease and her outlook on life. She was in good spirits and spent time
coloring intricate designs of mandalas and other drawings. She told jokes whenever I would enter the room and she
explained to me that she has to laugh at things or else what is the point of anything? She explained that dealing with her
health problems can be quite troublesome at times but she chooses to see the good parts of her life and enjoy it to the best
of her ability. When speaking about her wife she seemed to have much happiness from that relationship and it was
evident that she was content with that part of her life. From her feelings towards her life and family it tells me that she has
reached the positive side of this stage in Eriksons theory even though her work career never had a chance to go very far.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

I would say that her disease has had quite an impact on all aspects of her life, especially her developmental with regards to
work or career. Her disease causes her a lot of physical pain and has left her with disfigurement which is cause for some
depression and sadness. She has required multiple hospitalizations for HS as well as heart problems. She is aware that she
will likely be in and out of the hospital in future times to manage her problems but she states to me that she tries to be
positive and see the good in life. She is on a fixed income due to disability from her health problems which would affect
her ability to reach generativity in some sense, but she stays positive and is content with what has become of her and her
family.

University of South Florida College of Nursing Revision September 2014

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Diabetes and my environment, a lot is hereditary
What does your illness mean to you?
It feels that since I do have this disease [hidradenitis], it is destined that I will face hard conditions. Ive accepted that I
will be overwhelmed and that it is uncontrollable, it can be hard to deal with sometimes but I try to keep a positive
attitude. I always try to laugh and make others laugh with me because if I cant laugh then whats the point?

+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?___Yes______________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___No___________________________________
Are you currently sexually active? __When it is possible___________________ 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?_____12 years_____________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _Yes, having surgery has hindered
sex life, especially because of the area that is affected most by infections. __________________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision September 2014

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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?
It gives me balance and validity in my life. __________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
They dont anymore. The shamanistic side of my religion, which comes from my great grandfather who was a shaman, teaches me to
accept what becomes and to try and be at peace with it. That is how I deal with my condition as far as religion is concerned.
______________________________________________________________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)
Cigarettes
pack per day

Yes
No
For how many years? 20 years
(age 23 thru 43

If applicable, when did the

patient quit?

Pack Years: 10

Does anyone in the patients household smoke tobacco? If

Has the patient ever tried to quit? Yes
so, what, and how much?
If yes, what did they use to try to quit? Cold turkey
Yes, all members of household (Total 5 people) cigarettes, - 1 ppd
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What?
How much? 1-2 drinks
Wine, beer, or rum
Frequency: very rarely
If applicable, when did the patient quit?

No
For how many years?
(age 21 thru 43

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

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?
N/A

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 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF: 30
Bathing routine: every other day
Other:

Be sure to answer the highlighted area

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
2 x/day
Routine dentist visits
<1 x/year
Vision screening 1 year ago last exam
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? Never done
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: A positive
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

7 x/day

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
Type: 2
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing (allergy induced)
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 2 years ago
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
8/15
CAD/PVD
CHF
Murmur
Thrombus (from a PICC line)
Rheumatic Fever
Myocarditis
Arrhythmias

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Does not
complete
Frequency of pap/pelvic exam
2-3 years
Date of last gyn exam?
3 years ago
menstrual cycle
regular
irregular
menarche
age? 9
menopause
age?
Date of last Mammogram &Result: n/a
Date of DEXA Bone Density & Result: n/a
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

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12

Last EKG screening, when? 8/15

Other:

Arthritis
Other:

Chicken Pox
Other: Shingles in 2011

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health? Poor but managed.

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:
Height 61 inches
Weight 115.45 kg
BMI 48
Pain: (include rating and
Pleasant obese Caucasian Pulse 88
location)
Blood Pressure: (include location)
female in no acute
7 has chronic pain in areas
135/65
Right
arm
Respirations 18
distress, sitting in bed
of groin, axilla, abdomen,
drawing when entered
knees, and hips.
the room. Calm and
cooperative with exam.
Temperature: (route
SpO2: 98%
Is the patient on Room Air or O2:
Room Air
taken?) 97.5 Temporal
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
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: single lumen PICC
Location: Right arm
Date inserted: 10/12/15
Fluids infusing?
no
yes - what? NS @ 75 ml/h
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 3/ mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 48 inches & left ear48 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Molar missing on lower left and right side.
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
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

Chest expansion

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

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 1 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 2
DP: 3
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: lower abdomen/pubic area
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 10/11 /15 )
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: pt reports nausea after receiving antibiotics and pain medication
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe: Patient has diffuse swelling around genitalia. Hard and tender nodules palpated on right inguinal area as
well as right labia. Erythema and tenderness noted on exam. Lesions have no drainage. Lesions are constantly painful even
with rest per patient.
GU
Urine output:
Clear
Cloudy
Color: yellow
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Previous 24 hour output:

without assistance

or

mLs N/A

with assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ___4____ RUE ___4____ LUE ____5 __ RLE & _____5__ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: +2

Biceps: +2

Brachioradial: +2

Patellar: +2 Achilles:

+2 Ankle clonus: negative Babinski: negative

Patients gait is affected due to pain, walks with short, slow steps. Symmetric length of stride.

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15

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
WBC

Dates

10.1
12.4 H
Normal range (4.5-11.1)

(10/13/15)
(10/12/15)

CRP
2.68 H
Normal range (0-1.0)

Glucose (laboratory):
189 H
174 H
Accuchecks (capillary):
212, 195
211, 218
Normal range (70-100)

(10/12/15)

(10/13/15)
(10/12/15)
(10/13/15)
(10/12/15)

Vancomycin Trough level

Normal (5-15)

Ultrasound Pelvic
Limited

(10/12/15)

Trend
The patients white blood
cell count was elevated on
admission and has returned
to normal limits on second
day of treatment.

Analysis
Upon admission the patient
had multiple abscesses
requiring treatment with IV
anti-infectives. Since starting
treatment the levels have
returned to normal limits.
C-Reactive Protein level
This value being elevated is an
was drawn on first day of
indication that a non-specific
admission to hospital and
inflammatory response is
was elevated above normal
occurring in the body. An
range.
elevated range would be
expected in this patient due to
her disease process involving
inflammation.
Patients blood glucose level This patient has diabetes type
has been elevated for the
II and is on insulin therapy.
first two days of admission. She is ordered Levemir 40
units BID, and Humilin 15
units AC, as well as a sliding
scale for Humilin Q6H. Basing
analysis on current blood sugar
readings, her sugar is not being
controlled on current regimen
and it is important for her to
have this under good control to
help with the healing of
abscesses and infection.
Has not been drawn yet,
This will need to be drawn
treatment was started on
prior to administering next
10/13/15.
dose of medication to monitor
for toxicity. Nurse should hold
dose for level above 20 and
contact provider.
No trending available, only Findings show no drainable
done on admission. No
abscesses. Solid isoechoic
other prior studies to
nodule measuring 2.0x1.7x0.9
compare.
cm. in inferior portion of right
labia. A thin anechoic area is
seen centrally likely

University of South Florida College of Nursing Revision September 2014

16

representing minimal fluid.

Similar 1.2x1.1x0.5 cm nodule
in upper portion right labia.
Multiple lymph nodes are in
right groin area, measuring up
to 2.5 cm.
These findings show that
treatment may not need
surgical intervention at this
time and can be treated with
medication for infection
present.
*All normal lab values
obtained from nursing
central.
+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.)
Medical care is under Dr. McRae patient seen daily.
Nursing care on medical surgical floor includes physical assessment Q shift, administer scheduled and prn
medications as needed.
Diet ADA, regular.
Vitals Q4H and Accucheck AC/HS.
Lab work daily.
Activity ad lib as tolerated.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Acute pain R/T biological injury from disease process AEB reported pain of 8/10 on a 0-10 scale.
2. Impaired tissue integrity R/T disease process and treatments AEB current infection and scar tissue from previous
episodes of exacerbation.
3. Imbalanced nutrition: more than body requirements R/T intake more than metabolic needs AEB weight 20% over ideal
for height and frame.
4. Risk for unstable glucose levels R/T physical health status.
5. Risk for constipation R/T use of opioid pain medication.
6. Disturbed body image R/T illness and surgeries AEB verbalization of negative thoughts of self.
7. Risk-prone health behavior R/T smoking AEB identification of potential health risks.
8. Sexual dysfunction R/T actual limitations imposed by disease AEB altered body function and pain.

University of South Florida College of Nursing Revision September 2014

17

 15 CARE PLAN
Nursing Diagnosis: Impaired tissue integrity R/T disease process and treatments AEB current infection and scar tissue from previous exacerbations.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will report altered sensation 1. Assess patient for pain and
1. Systematic inspection can
1. Patient was assessed for pain or
or pain at site of tissue impairment altered sensation at site Q4H.
identify impending problems early sensory changes multiple times
if occurring anytime during
on. Ayello & Braden, 2002;
through the shift, she reported
hospitalization.
Rastinehad, 2006; WUWHS, 2007. considerable pain and no changes
(As cited by Ackley & Ladwig,
in sensation. Patient received pain
2011, p. 842)
medication for management of
2. Advise patient to report pain at
tissue compromise.
site and that medication is available 2. Self-report is considered the
to manage pain.
single most reliable indicator of
pain presence and intensity. APS,
2008 (As cited by Ackley &
Ladwig, 2011, p. 601)
Patient will acknowledge
1. Assess the clients nutritional
1, 2. The benefit of nutritional
1. Patient has maintained adequate
nutritional changes that will
status daily including blood
evaluation and intensive nutritional nutrition on day of assessment,
improve healing times within 1
glucose readings prior to meals.
support in clients at risk for and
eating ADA diet. Blood glucose
week of admission.
with pressure ulcers is not
readings have been high throughout
2. Refer to a dietary consult and/or supported by rigorous clinical
the day even with insulin therapy.
institute use of dietary supplements trials. Despite this lack of evidence, Patient has not yet been referred for
the National Pressure Ulcer
dietary consult.
Advisory Panel endorses the
application of reasonable
nutritional assessment and
treatment for clients at risk for and
with pressure ulcers. NPUAP,
2009. (As cited by Ackley &
Ladwig, 2011, p. 843)
Patient will experience a wound
1. Assess the site of impaired tissue 1. The etiology or cause of the
1. The site has been assessed
that decreases in size by time of
integrity and determine the cause
wound must be determined before
during start of shift and
discharge.
(chronic dermatologic lesions).
appropriate interventions can be
documented findings include color
implemented. This provided the
of tissue, patient report of pain,
University of South Florida College of Nursing Revision September 2014

18

2. Determine the size and depth of

the wound. Document findings
starting with first assessment to
track changes.

*Patient will describe measures to

protect and heal tissue by time of
discharge.

basis for additional testing an

evaluation to start the assessment
process. Langemo & Brown, 2006;
Baranoski & Ayello, 2008. (As
cited by Ackley & Ladwig, 2011, p.
842)
2. Serial wound assessments are
more reliable when performed by
the same caregiver, with the client
in the same position, and using the
same techniques. Ankrom et al,
2005; Black, 2005; Romero,
Treston, & OSullivan, 2006. (As
cited by Ackley & Ludwig, 2011)

3. Monitor the site of impaired

tissue integrity at least once daily
for color changes, redness,
swelling, warmth, pain, or other
signs of infection.

3. Systematic inspection can

identify impending problems early.
Ayello & Braden, 2002;
Rastinehad, 2006; WUWHS, 2007.
(As cited by Ackley & Ladwig,
2011, p. 842)

1. Monitor the status of the skin

around the wound. Monitor the
clients skin care practices, noting
type of soap or other cleansing
agents used, temperature of water,
and frequency of skin cleansing.

1. Individualize the plan according

to the clients skin condition,
needs, and preferences. Avoid
harsh cleansing agents, hot water,
extreme friction or force, or toofrequent cleansing. Bergstrom et al,
1994; Rodeheaver, 2007. (As cited
by Ackley & Ladwig, 2011, p. 842)

2. Avoid massaging the site of

impaired tissue integrity and over
bony prominences.

2. Panel for the Prediction and

Prevention of Pressure Ulcers in
Adults, 1992. (As cited in Ackley
& Ladwig, 2011, p. 843)

palpable nodules and areas of

inflammation.
Size and depth of wounds are
difficult to measure without
diagnostic tests, an ultrasound of
patients pelvis has been obtained
and nodule measurements
documented.

1. Patient is able to recognize

differences in signs and symptoms
of infection and is able to report
them to healthcare providers for
treatment. Patient expresses that
she baths usually once every other
day, this increases risk for bacteria
to grow on skin further risk for
infection in any open lesions.
Patient avoids touching the areas of
inflammation due to pain at the
site, so she is aware to avoid
massaging the area.

3. Teach skin and wound

University of South Florida College of Nursing Revision September 2014

19

*Patient will effectively consult

with other healthcare providers
(dermatology) who can help to
manage her disease process within
1 month of discharge.

assessment and ways to monitor for 3. Early assessment and

signs and symptoms of infection,
intervention help prevent serious
complications, and healing.
problems from developing.
(Ackley & Ladwig, 2011, p. 844)
1. Consultation with other health
1. Consider referring to a dietitian,
care disciplines provides a
physical therapist, occupational
thorough, comprehensive
therapist and social worker as
assessment.
needed. (Ackely & Ladwig, 2011,
p. 844)
2. Initiate a consultation in a case
assignment with a wound specialist
or wound, ostomy, and continence
nurse to establish a comprehensive
plan as soon as possible. Plan case
conferencing to promote optimal
wound care.

2. Case conferencing ensures that

cases are regularly reviewed to
discuss and implement the most
effective wound care management
to meet client needs. (Ackely &
Ladwig, 2011, p. 844)

1. Patient has not yet been referred

to any specialty providers. I would
recommend a dermatologist to
follow her closely as well as a
dietician. She has an interest in
managing her health and is
optimistic in care.

Include a minimum of one

Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
University of South Florida College of Nursing Revision September 2014

20

 are any of the patients medications available at a discount pharmacy? Yes No

Rehab/ HH
Palliative Care

15 CARE PLAN
Nursing Diagnosis: Risk for constipation R/T use of opioid pain medication
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Patient will maintain passage of
1. Assess usual pattern of
1. There often are multiple reasons Patient was asked about bowel
soft, formed stool every 1 to 3 days defecation, including time of day,
for constipation; the first step is
habits and last bowel movement
without straining while taking
amount, frequency and consistency assessment of the usual patterns of which was the day before being
opioids.
of stool. Ask about bowel habits
bowel elimination. Bleser et al,
admitted to hospital. Patient states
and history, personal remedies for
2005. (As cited by Ackley &
that it is normal for her to go three
constipation, surgeries, diseases
Ladwig, 2011, p. 259)
days before a bowel movement.
that affect bowel motility, and
Patient has been receiving dilaudid
present bowel regimen. Perform
Q3H consistently throughout the
this assessment on admission to
2. Opioids lead to constipation
day, ordered along with pain
obtain baseline.
because they decrease propulsive
medications is Senokot-S for
movement in the colon and
constipation. Goal for interventions
2.* Recognize opioids are
enhance sphincter tone making it
has been met.
especially problematic. If the client difficult to defecate. Senokot-S is
is receiving temporary opioids,
recommended to prevent
request an order for routine stool
constipation when opioids are
softeners from the primary care
given round the clock. Kyle, 2007.
practitioner, monitor bowel
(As cited by Ackley & Ladwig,
movements, and request a laxative 2011, p. 259)
if the client develops constipation.
If client is receiving round the
clock opiates, request an order for
Senokot-S and institute a bowel
regimen.
Patient will recognize feelings of
1. *Teach clients to respond
1. A study of male volunteers
Patient was asked regarding need
fullness or discomfort prior to
promptly to the defection urge.
determined that the defecation urge for a bowel movement and
becoming extremely constipated
can be delayed and that delaying
instructed to let nurse know if she
Patient Goals/Outcomes

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21

and express need for aid to nurse.

Patient will identify measures that

prevent or treat constipation before
discharge from hospital to home.

defecation decreased bowel

movement frequency, stool weight
and transit time. Klauser et al,
1990. (As cited by Ackley &
Ladwig, 2011, p. 261)
2.* Encourage fluid intake of 1.5 to
2 L/day, unless contraindicated
because of renal insufficiency.

2. When dehydrated, the body

absorbs additional water from
stools resulting in dry, hard stools
that are difficult to pass. Sykes,
2006. (As cited by Ackley &
Ladwig, 2011, p. 260)

3. Provide laxatives, suppositories,

and enemas only as needed if other
more natural interventions are not
effective, and as ordered only;
establish a client goal of
eliminating their use.

3. Use of stimulant laxatives

should be avoided because they
result in laxative dependence and
loss of normal bowel function.
Merli & Graham, 2003. (As cited
by Ackley & Ladgwig, 2011, p.
261)
1. Larger stools move through the
colon faster than smaller stools and
dietary fiber makes stools bigger
because it is undigested in the
upper intestinal tracts. Fiber
fermentation by bacteria in the
colon produces gas. Vuksan et al,
2008. (As cited by Ackley &
Ladwig, 2011, p. 260.)

1. *Encourage fiber intake of 20

g/day ensuring that the fiber is
palatable to the individual and that
fluid intake is adequate. Add fiber
gradually to decrease bloating and
flatus.

2. *Encourage clients to resume

walking and activities of daily
living as soon as possible if their
mobility has been restricted.

2. Bed rest and decreased mobility

lead to constipation, but additional
exercise does not help the
constipated person who is already
mobile. When client has
diminished mobility even minimal

University of South Florida College of Nursing Revision September 2014

felt constipated or very full in the

abdomen. Patient is receiving IV
fluids and has been encouraged to
drink more water. No laxative were
needed on day of assessment, but
patient is aware that it is available.

Patient has been educated that fluid

intake will help decrease
constipation. Increased fiber intake
has not been addressed with the
patient on this day of assessment.
Patient will benefit from dietary
input on an overall diet to help
manage disease as well as
constipation.
Client is ad lib for activities while
in hospital, however is in acute
pain and does not get up much.
More education is needed to meet
goal.

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activity increases peristalsis, which

is necessary to prevent
constipation. Joanna Briggs
Institute, 2008; Kyle, 2007; Sykes,
2006. (As cited by Ackley &
Ladwig, 2011, p. 260.)

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

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References

Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.
Beshara, M. A. (2010). Hidradenitis suppurativa: A clinicans tool for early diagnosis and treatment. Advances
in Skin and Wound Care, 23(7), 328-332. http://doi: 10.1097/01.ASW.0000363559.53350.84.
Gooderham, M., & Papp, K. (2015). The psychosocial impact of hidradenitis suppurativa. Journal of the
American Academy of Dermatology, 73(5), S19-S22. http://doi:10.1016/j.jaad.2015.07.054
Horvath, B., Janse, I. C., & Sibbald, G. R. (2015). Pain management in patients with hidradenitis suppurativa.
Journal of the American Academy of Dermatology, 73(5), S47-S51.
http://doi:10.1016/j.jaad.2015.07.046
Prens, E., & Deckers, I. (2015). Pathophysiology of hidradenitis suppurativa: An update. Journal of the
American Academy of Dermatology, 73(5), S8-S11. http://doi:10.1016/j.jaad.2015.07.045
Treas, L. S., & Wilkinson, J. M. (2014). Basic Nursing. Concepts, Skills & Reasoning. Philadelphia, PA: F. A.
Davis

doi: 10.1016/j.jaad.2015.07.045.

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