UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Natalie Drass
Assignment Date: January 26, 2016
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Florida Hospital Tampa
1 PATIENT INFORMATION
Patient Initials: B.W. Age: 67 Admission Date: January 20, 2016
Gender: Female Marital Status: Married Primary Medical Diagnosis with ICD-10 code:
Primary Language: English Pleural effusion, J90
Level of Education: Associates Degree Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired from criminal justice N18.3 Chronic kidney disease, stage 3
Number/ages children/siblings:
Brother-64 Sister-60 Daughter-39 Son-41

Served/Veteran: No Code Status: Full

Living Arrangements: Lives with husband in a one story house Advanced Directives: Yes
If no, do they want to fill them out?
Surgery Date: Unknown Procedure: Possible
Transjugular Intrahepatic Portosystemic Shunt
Culture/ Ethnicity /Nationality: American
Religion: Baptist Type of Insurance: Medicare

1 CHIEF COMPLAINT:
Patient came to the ER on 1/20/16 with shortness of breath. Patient had fluid drained from her lungs via thoracentesis last
month at Florida Hospital Wesley Chapel. Four liters of fluid were removed. Patient states I had trouble breathing last
month and there was fluid in my lungs. I knew that the same thing was happening because I had the exact same
symptoms. The patient reported that her chest had felt tight and that she could not stop coughing.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The shortness of breath started a week prior to admission
The shortness of breath is affected the lungs
Shortness of breath was constant
Patient states when I had trouble breathing my whole chest felt tight
Patient says nothing really makes it worse
The chest tube has alleviated some of the discomfort, sitting up in bed
Treatment is insertion of a chest tube to drain fluid

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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
Birth Birth defect, hole in diaphragm
Childhood Measles
Patient says ~ age 40 Hypertension
Patient says age 36 Hysterectomy
or 37
Patient says ~ age 40 Type II diabetes
Patient says ~ age 40 Hypercholesterolemia

(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

Seizures
Arthritis
Anemia

Asthma

Kidney
HISTORY
Cancer

Tumor
Stroke
Death Gout
(if
applicable)
Father 47 Heart attack
Mother 91
Brother 64
Sister 60
Daughter 39
Son 41

Comments: Include age of onset

Neither patient or husband remember the date of onset for any family member

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations U
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Date) Patient went to a free flu shot drive in fall, U
Pneumococcal (pneumonia) (Date)
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 Have you had any other vaccines given for international travel or
occupational purposes? Please List

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Codeine Nausea
Erythromycin Nausea
Penicillin Hives
Medications
Keflex Nausea
Floxin Patient says she feels very sleepy
Atarax Nausea
Environmental/seasonal
Itchy nose, watery eyes, headaches
allergies
Other (food, tape,
latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Accumulation of fluid within the pleural space is considered a pleural effusion. Fluid buildup impairs the lungs
ability to fully expand. Dyspnea and chest pain are the most common symptoms with a pleural effusion. A
cough may sometimes be present with a pleural effusion but not always. Disease in any organ system can result
in a pleural effusion. For this patient, the liver caused the pleural effusion. This patient has cirrhosis of her liver
and a hole in her diaphragm. Fluid is backing up from her liver and spleen into her chest. Pleural effusions can
be detected with a chest x-ray or physical examination. It is important to distinguish if the pleural fluid is
exudative or transudative. An exudative effusion will be due to inflammatory conditions or underlying health
problems that need to be evaluated. Transudative effusions do not require further clinical evaluation because
these types of effusions are associated with clinically apparent conditions (Bouros, 2004).
If the liver causes the pleural effusion, the patient may have ascites. Transudative effusions form due to the
movement of fluid along a pressure gradient from the peritoneal space into the pleural space. The development
of hepatic hydrothorax in a patient with cirrhosis and ascites is the movement of ascetic fluid from the
peritoneal space to the pleural cavity through a defect in the diaphragm. A transjugular intrahepatic portal-
systemic shunt (TIPS) may effectively manage hepatic hydrothorax (Bouros, 2004). TIPS is a procedure by
which communication between the portal and the hepatic vein is created. A stent connects hepatic and portal
systems. Blood will be shunted to the hepatic vein to decompress the portal venous system (Gins, Arroyo,
Rods, & Schrier, 2005). A pleural effusion can be treated with thoracentesis, chest tube drainage, or a
pleurectomy.

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name Cetirizine (Zyrtec) Concentration Dosage Amount 10mg

Route PO Frequency daily

Pharmaceutical class antihistamines, piperazines Home Hospital or Both
Indication allergies

Adverse/ Side effects Dizziness, drowsiness, fatigue, pharyngitis, dry mouth

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Nursing considerations/ Patient Teaching Avoid driving until medication response is known, avoid alcohol and other CNS depressants with
this drug, good oral hygiene

Name Valsartan (Diovan) Concentration Dosage Amount 160mg

Route PO Frequency daily

Pharmaceutical class angiotensin II receptor antagonists Home Hospital or Both
Indication high blood pressure
Adverse/ Side effects dizziness, fatigue, headache, edema, hypotension, hyperkalemia, angioedema, back pain, abdominal pain, diarrhea,
nausea, sinusitis
Nursing considerations/ Patient Teaching Take at the same time each day, take missed doses as soon as possible, avoid salt substitutes, get up
slowly to avoid orthostatic hypotension, avoid driving until medication response is known, notify health care professional if swelling
occurs

Name Simvastatin (Zocor) Concentration Dosage Amount 40mg

Route PO Frequency QHS

Pharmaceutical class hmg coa reductase inhibitor Home Hospital or Both
Indication hypercholesterolemia
Adverse/ Side effects abdominal cramps, constipation, diarrhea, heartburn, nausea, rashes, hyperglycemia, rhabdomyolysis, dizziness,
confusion, headache, weakness
Nursing considerations/ Patient Teaching Avoid drinking more than 1 qt of grapefruit juice a day, exercise and diet changes, notify health care
professional if unexplained muscle pain, wear sunscreen

Name Ondansetron (Zofran) Concentration Dosage Amount 4mg

Route IV push Frequency Q6H

Pharmaceutical class antiemetics Home Hospital or Both
Indication nausea
Adverse/ Side effects headache, dizziness, drowsiness, fatigue, weakness, constipation, diarrhea, dry mouth, abdominal pain,
extrapyramidal reactions
Nursing considerations/ Patient Teaching Take as directed, notify health care professional of involuntary movement of eyes, face, or limbs

Name Acetaminophen (Tylenlol) Concentration Dosage Amount 650mg

Route PO Frequency Q4H

Pharmaceutical class nonopiod analgesics Home Hospital or Both
Indication mild pain
Adverse/ Side effects renal failure, neutropenia, rash, urticarial, toxic epidermal necrolysis
Nursing considerations/ Patient Teaching Do not take more than the recommended dose, discontinue if rash develops, may alter blood glucose
in diabetic patients

Name Albuterol ipratropium (Duoneb) Concentration Dosage Amount 3 ml

Route Inhalation Frequency Q4
Pharmaceutical class bronchodilators Home Hospital or Both
Indication Dyspnea
Adverse/ Side effects dizziness, headache, nervousness, bronchospasm, cough, hypotension, nausea, rash
Nursing considerations/ Patient Teaching Instruct patient in proper use of nebulizer, rinse mouth after using

Name Insulin lispro (Humalog) Concentration Dosage Amount sliding scale

Route SubQ Frequency A.C. (before meals)
Pharmaceutical class pancreatics Home Hospital or Both
Indication Type II diabetes

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Adverse/ Side effects hypoglycemia, pruritis, erythema, swelling anaphylaxis
Nursing considerations/ Patient Teaching Instruct proper technique for administering insulin, rotate sites, insulin is not a cure, teach signs and
symptoms of hypoglycemia and hyperglycemia, carry source of sugar, proper testing glucose

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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?
Diet patient follows at home?
24 HR average home diet:
Breakfast: Kelloggs Raisin Bran Cereal, 1 banana
Lunch: Ham and cheese sandwich with white bread, 1
serving size bag of potato chips
Dinner: Grilled steak, 1 cup of asparagus
Snacks: Large scoop of chocolate ice cream
Liquids (include alcohol): 1 cup of apple juice, 1 can of
Pepsi, 1 bottle of beer
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
How do you generally cope with stress? or What do you do when you are upset?
University of South Florida College of Nursing Revision September 2014
Analysis of home diet (Compare to My Plate and
Consider co-morbidities and cultural considerations):
The patient has hypertension so she should control the
amount of sodium she consumes. Patient is diabetic and
needs to check blood sugar throughout the day.
The 24-hour average home diet is 1933 calories. The limit
is 2000 calories. The patient is very close to going over the
2000 calorie limit.
Patient consumes 75 grams of sugar with a daily limit of 50
grams. Soda has sugar and adds extra calories. Switching to
water or tea will lower calorie intake and lower sugar
intake.
Patient went over daily sodium limit of 2300 milligrams by
1000 milligrams. It is important for the patient to lower her
sodium intake. Switching potato chips for carrots or another
type of vegetable will lower sodium intake and increase
vegetable intake.
2 ounces over protein limit. The patient should avoid eating
anymore protein. Too much protein can negatively affect
the kidneys and cause weight gain. This patients BMI is in
the overweight range so she shouldnt gain more weight.
The patients kidneys are already unhealthy (GFR 38.9).
Meets fruit requirement for the day.
1 cup under for vegetables. Eating vegetables with lunch is
a healthier choice than potato chips. Adding lettuce and
tomato onto the sandwich at lunchtime will increase
vegetable intake.
2 ounces under daily requirement for grains. It would be a
good idea to use whole wheat bread for her sandwich at
lunch.
2 cups under dairy limit. 80% of daily limit for cheese is
consumed. 20% of daily limit for milk and yogurt is
consumed. Adding yogurt to the diet will increase the
amount of dairy eaten.
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.
6
When I am stressed I like to color and snuggle with my pets. I have a few coloring books with me right now.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I have been anxious. I want to go home.

+2 DOMESTIC VIOLENCE ASSESSMENT

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

Have you ever felt unsafe in a close relationship? _________No______________________________________________

Have you ever been talked down to?__No__________ Have you ever been hit punched or slapped? _____No_________

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

Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
Integrity is a sense of integrity and fulfillment; willingness to face death; wisdom and despair is the
dissatisfaction with life; denial of or despair over prospect of death (Halter, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient is in the ego integrity stage. The patient had a successful career. The patient states I loved my job
and I am happy that I was able to help people. The patient enjoys talking about her family. The patient states I
have the smartest grandkids. I teach them to put school first and they are doing very well. I got to be a mother
and a grandmother. That is all I ever wanted.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The patients condition has had no impact on the patients developmental stage of life.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The doctor says that my birth defect caused it. Fluid from my liver is going into my lungs or something.

What does your illness mean to you?

It means that I cant be home. I miss my pets.

+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

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possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record

Have you ever been sexually

active?_________Yes___________________________________________________________
Do you prefer women, men or both genders?
____Men_________________________________________________________
Are you aware of ever having a sexually transmitted
infection? ________No_______________________________________
Have you or a partner ever had an abnormal pap
smear?__________No___________________________________________ Have you or your partner received the
Gardasil (HPV) vaccination? ___________No________________________________

Are you currently sexually active? ___Yes________________________ If yes, are you in a monogamous relationship?
________Yes____________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _____Nothing_____________________________

How long have you been with your current partner? Since I was 20.___________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? ____No______________________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life? _Religion is everything to me. I pray every day
and I go to church every Sunday. God has given me a beautiful family and amazing doctors to take care of
me.____________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
___I wish I could go to church. My faith keeps me strong and I will get over all of these health issues. I have a
lot of people praying for
me.___________________________________________________________________________________________________
______________________________________________________________________________________________________

+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? 37 years
Cigarettes 2 packs a day (age 30 thru 67 )

If applicable, when did the

Pack Years: 74
patient quit?
4 months ago
Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit? Yes, nothing
so, what, and how much? No If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? 1 bottle For how many years? 42
Beer Volume: 24 fluid ounces (age 25 thru 67 )
Frequency: every few days
If applicable, when did the patient quit?

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

Is the patient currently using these drugs?

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

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No

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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 Diverticulitis Life threatening allergic reaction
Bathing routine: regularly Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy?
Other: nausea when taking medication
without nausea medication, patient has
HEENT never had a colonoscopy, edema on Hematologic/Oncologic
abdomen, hepatomegaly, splenomegaly
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: A+
Post-nasal drip Normal frequency of urination: 4 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 3 x/day Diabetes Type: 2
Routine dentist visits 1 x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Patient states that she hasnt had a
Other: Chronic kidney disease, stage 3
vision screening in a while, I have great Osteoporosis
(GFR 38.9)
vision!
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? 3 years ago Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche 14 age Encephalitis
last CXR? 1/21/16 menopause around 50 age Meningitis
Date of last Mammogram &Result: a few
Other: Other:
years ago, normal
Date of DEXA Bone Density & Result:

Patient states that she has never had an

infection of her genitalia, patient does not
have a menstrual cycle, patient has never
had a bone density test
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
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\
 Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 1/20/16 Arthritis Chicken Pox
Other: Other: Other:

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

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?
The patient has two cats, two dogs, and a bird that she misses very much

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10 PHYSICAL EXAMINATION:

General Survey: Height 167.64 cm Weight 81.9 kg BMI 29 Pain: (include rating and
Patient is a well- Pulse 64 Blood Pressure: (include location) location)
developed 67 y.o. female Respirations 128/59 Left arm
who is alert & oriented x 18 5/10, right side where the
3 chest tube is inserted
Temperature: (route SpO2 98% Is the patient on Room Air or O2 No 2/10 breathing (upon
taken?) inhalation)
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
Central access device Type: Midline Location: cephalic vein right upper Date inserted: 2/21/16
Fluids infusing? no yes - what?

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / 3 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions

Comments: No whisper test done, patient can hear

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: D LUL: CL
RML: CR LLL: CL
RLL: CR
CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab Absent
Comments: Left side expands more than right side, fremitus over right lung decreased, percussion dull over right side, no
sputum production, slight difficulty breathing, patient describes painful inhalations 2/10
Chest tube inserted 1/21/16 right lateral, fluid is yellow and cloudy, output 600cc

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Cardiovascular: No lifts, heaves, or thrills
Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
Normal sinus rhythm

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: Carotid: Brachial: Radial: 3 Femoral: Popliteal: DP: 3 PT:
No temporal or carotid bruits Edema: +1 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: abdomen pitting non-pitting
Extremities warm with capillary refill less than 3 seconds
Only radial and dorsalis pedis pulses assessed

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 1 / 25 16 ) Formed Semi-formed Unformed Soft Hard Liquid Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red

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 Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe: Hepatomegaly and splenomegaly present

GU Urine output: Clear Cloudy Color: yellow Previous 24 hour output: 550 mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness CVA punch not performed

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ____5___ RUE ___5____ LUE ____5___ RLE & ____5___ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative

Romberg not performed, stereognosis not performed, graphesthesia not performed, proprioception not performed, Babinski not performed, ankle clonus
not performed, DTR not performed

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):

Lab Dates Trend Analysis

Chest X-ray 1/20/16 1/ 21/16 1/23/16 Fluid in lungs, chest tube To check for fluid
placed correctly, less
fluid in lungs
NM liver/spleen planar 1/21/16 Hepatomegaly, Visualize changes to liver
within spleen splenomegaly, and spleen
homogenous increased
uptake throughout the
liver, increased uptake
Glomerular filtration rate The GFR is consistently The glomerular filtration
~ 38.9 rate is a test used to check
38.9 mL/min 38 mL/min 1/26/16 1/23/16 1/20/16 kidney function.
38.9 mL/min Chronic kidney disease
University of South Florida College of Nursing Revision September 2014 14
 stage 3 (GFR 30-59
mL/min per 1.73 m2)
Glucose Patients glucose levels Patient is Type II diabetic
101 91 120 are normal for her and the glucose level
baseline glucose levels needs to be monitored.
Total protein The total protein levels Total protein measures
are close to the normal the amount of protein in
5.9 g/dL 5.7 g/dL 5.9g/dL 1/26/16 1/23/16 1/20/16 range. Decreased total the blood. Albumin and
protein levels occur with globulin are included.
Normal (6-8) g/dL cirrhosis related to a The liver produces
damaged liver that cannot albumin.
synthesize adequate
amount of protein.
Creatinine The patients creatinine Creatinine is used to
levels are a little high. assess renal function.
1.4 mg/dL 1.6 mg/dL 1.6 mg/dL The values are close to Creatine is from the
the normal range. skeletal muscle, where it
Normal (0.6-1.3 mg/dL) Creatinine levels increase participates in metabolic
1/26/16 1/23/16 1/20/16 with renal disease. reactions. A small
amount of creatine is
converted to creatinine
and is excreted in the
kidneys. This level
determines the rate at
which the kidneys are
clearing creatinine from
the blood.
BUN Patients BUN levels BUN is used to assess
have been high. BUN renal function. Urea is
23 mg/dL 26 mg/dL 23 mg/dL levels are increased in formed in the liver from
patients with diabetes. ammonia and excreted by
Normal (6-20mg/dL) 1/26/16 1/23/16 1/20/16 the kidneys as an end
product of protein
metabolism. Blood urea
nitrogen levels reflect the
balance of nitrogen
ingested and excreted.

+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.)
Respiratory therapy to improve breathing pattern, heart healthy diet, accu check Q4, surgery consult for possible
TIPS procedure, gastroenterologist consult to evaluate liver, chest tube

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 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Ineffective breathing pattern r/t pain as evidenced by patient stating that is hurts to breath

2. Excess fluid volume r/t compromised regulatory mechanisms of liver as evidenced by fluid in the lungs

3. Impaired gas exchange r/t respiratory fatigue secondary to pleural effusion as evidenced by patient stating that is difficult
to breath

4. Acute pain r/t chest tube and excess fluid volume as evidenced by patient stating pain 5/10 at her chest tube site and 2/10
upon inhalation

5. Disturbed body image r/t chest tube as evidenced by patients stating, I am embarrassed that I have a tube coming out of
my chest.

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 15 CARE PLAN
Nursing Diagnosis: Ineffective breathing pattern r/t pain as evidenced by patient stating that is hurts to breathe
Patient Goals/Outcomes
By end of hospitalization
patient will report ability to
breathe comfortably
Identify and avoid factors that
exacerbate episodes of
University of South Florida College of Nursing Revision September 2014
Nursing Interventions to
Achieve Goal
Monitor vital signs
Monitor respiratory rate, depth, To evaluate changes compared
and ease of respirations
Auscultate breath sounds
Relaxing environment
Elevate head of patients bed
Consult respiratory therapy
Administer medication*
Rationale for Interventions
Provide References
To evaluate patients baseline
compared to new data, how is
dyspnea affecting vital signs
to patients baseline
Abnormal breath sounds
(absent, crackles, and wheezes) Crackles on right side didnt
indicate respiratory pathology
associated with an altered
breathing pattern
Decrease anxiety associated
with acute dyspneic state
An upright position facilitates
lung expansion
Breathing treatments can
relieve dyspnea
Prescribed medications might
prevent episodes of ineffective
Evaluation of Goal on Day
Care is Provided
Vital signs consistent
throughout shift, dyspnea
causes tachycardia for a few
minutes and then resolves
Respiratory rate consistently
18, ease of respirations
increased throughout day
resolve by the end of the day
Light turned off in room,
patient colored pictures in her
coloring books, breathing
comfortably
Patient reported breathing is
easier in the Fowlers position
Patient reported dyspnea
resolved after breathing
treatment
Patient felt that she could
breathe better after having pain
17
ineffective breathing pattern by
end of shift
Demonstrate ability to perform
pursed-lip breathing and
controlled breathing
Maintain normal oxygen
saturation level throughout shift
Demonstrate a breathing pattern
that supports blood gas results
within the clients normal
parameters
University of South Florida College of Nursing Revision September 2014
Elevate head of patients bed
Teach patient how to perform
pursed-lip breathing
Administer supplemental
oxygen as needed
Consult respiratory therapy
Monitor respiratory rate, depth,
and ease of respirations
Pursed lip-breathing
Monitor respiratory rate, depth,
and ease of respirations
Elevate head of patients bed
breathing pattern
An upright position facilitates
lung expansion
Pursed-lip breathing results in
increased use of intercostal
muscles, decreased respiratory
rate, increased tidal volume,
and improved oxygen
saturation level
Supplemental oxygen can assist
in raising O2 saturation if it
lowers <95%
Breathing treatments can
relieve dyspnea and improve
oxygen saturation
To evaluate changes compared
to patients baseline
Pursed-lip breathing results in
increased use of intercostal
muscles, decreased respiratory
rate, increased tidal volume,
and improved oxygen
saturation level
To evaluate changes compared
to patients baseline
An upright position facilitates
lung expansion
medication, pain aggravated
dyspnea
Patient reported that she
becomes short of breath laying
down, elevating head of bed
increased ease of respirations
Patient was able to demonstrate
pursed-lip breathing and
controlled breathing, patient
reported that it helped with her
dyspnea
Patient did not require any
supplemental oxygen, O2
saturation 98% throughout shift
Breathing treatments resolved
dyspnea, O2 remained 98%
Oxygen saturation did not
change, ease of respirations
improved throughout shift
Patient was able to demonstrate
pursed-lip breathing and
controlled breathing, patient
reported that it helped with her
dyspnea
Respiratory rate consistently
18, ease of respirations
increased throughout day
Patient reported breathing is
easier in the Fowlers position
18
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge
teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

Nursing Diagnosis: Excess fluid volume r/t compromised regulatory mechanisms of liver as evidenced by fluid in the lungs
Patient Goals/Outcomes Nursing Interventions to Rationale for Interventions Evaluation of Goal on Day
Achieve Goal Provide References Care is Provided
Patient maintains clear lung Listen to lung sounds for Abnormal breath sounds Patient breathing easier
sounds by end of shift crackles, monitor respirations for (absent, crackles, and wheezes) throughout the day, crackles
effort, and determine the indicate respiratory pathology on right side do not resolve by
presence and severity of associated with an altered end of shift
orthopnea breathing pattern

Maintain body weight
appropriate for the client by
end of hospitalization
Monitor intake and output
Monitor daily weight for sudden
increases; use same scale and
type of clothing at same time
Accurately measuring intake
and output is important for the
client with fluid volume
overload
It is important to weigh patient
with fluid overload to ensure
Patient had 300ml urine output
in 10 hours, normal output
Patient weight has not
changed since 1/20/16

University of South Florida College of Nursing Revision September 2014 19


Patient and family will describe
signs and symptoms of excess
fluid volume and actions to
take if they occur by end of
shift
Explain actions that that are
needed to treat or prevent
excess fluid volume including
fluid and dietary restrictions,
and medications by end of shift
Effusion resolves by end of
hospitalization
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
University of South Florida College of Nursing Revision September 2014
each day
Restrict fluid intake
Patient education about fluid
excess
Provide a restricted-sodium diet
as appropriate if ordered*
Restrict fluid intake
Monitor for the development of
conditions that increase the
clients risk for excess fluid
volume
Monitor chest tube
that fluid is not being retained
Fluid restriction may decrease
intravascular volume
Educate patient and their
family to contact a health care
professional if fluid excess
returns
Restricting sodium in the diet
will favor the renal excretion
of excess fluid
Fluid restriction may decrease
intravascular volume
Many clients with fluid
overload have acute kidney
disease, and fluid balance is an
important indicator of
outcomes, with increased
morbidity and mortality in
clients with fluid overload
Record chest tube output to
ensure that is it working
efficiently
Patient is compliant to
restricting her fluid intake
Patient and family know to
contact health care
professional if weight
increases by 2 pounds in a day
and if shortness of breath
comes back
Patient started on heart healthy
diet
Patient is compliant to
restricting her fluid intake
Patient has chronic kidney
disease and cirrhosis of her
liver
600cc output from chest tube
20
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014 21

 References

Ackley, B. (2010). Nursing Diagnosis Handbook: An Evidence-based Guide to Planning Care (9th Ed). Maryland Heights, Missouri:

Mosby.

Bouros, D. (2004). Pleural disease. New York: Marcel Dekker, Inc.

Food Tracker. (n.d.). Retrieved November 4, 2015, from https://www.supertracker.usda.gov/foodtracker.aspx

Gins, P., Arroyo, V., Rods, J., & Schrier, R. (2005). Ascites and Renal Dysfunction in Liver Disease: Pathogenesis, Diagnosis, and

Treatment, Second Edition. Malden, MA: Blackwell Publishing.

Halter, M. (2014). Varcarolis' foundations of psychiatric mental health nursing: A clinical approach. (7th ed., p. 23). St. Louis,

Missouri: Elsevier.

Unbound Medicine. (2014). Nursing Central (Version 1.24 (414)) [Mobile application software]. Retrieved

from: http://nursing.unboundmedicine.com/nursingcentral

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