UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Morgan McMahon

Assignment Date: 2/09/17

MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: LRH
1 PATIENT INFORMATION
Patient Initials: J.F. Age: 24 Admission Date: 02/06/17

Gender: Male Marital Status: Single Primary Medical Diagnosis Fracture of left
superior and inferior pubic rami, as well as closed
left acetabular fracture
Primary Language: English
Level of Education: Completion of High School Other Medical Diagnoses: (new on this admission)
Acute alcohol intoxication

Occupation (if retired, what from?): Recently fired this week from
automobile relocator systems job
Number/ages children/siblings: Patient has one brother who is 27
years old

Served/Veteran: Code Status: Full Resuscitation

If yes: Ever deployed? No

Living Arrangements: Patient lives at apartment by himself. Advanced Directives: None

He may be living with parents after discharge. If no, do they want to fill them out? No
Surgery Date: Procedure:

Culture/ Ethnicity /Nationality: American/Caucasian/Irish

Religion: Christian Type of Insurance: Blue Shield

1 CHIEF COMPLAINT: I fell out of a tree trying to get a football that got stuck. I dont remember what
happened after I fell, I just woke up here. I think I fractured my pelvis in a couple of places and hit my ribs too.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) The patient was admitted to the ER 02/06/17 after losing consciousness from falling 20 feet from a tree. A CT of
the Chest/Abdomen/Pelvis confirmed a nondisplaced fracture proximal to the mid left sacrum associated with a displaced
fracture of the distal pubic ramus left and proximal aspect of the left anterior acetabulum. A CT of the head confirmed that
there is no acute intracranial abnormalities. The patient states that he was climbing a tree to retrieve a football and fell 20
feet. He lost consciousness on impact, and does not remember anything from the point of the fall until he woke up in the
hospital. The overall time of unconsciousness is approximately four hours according to the nurse. Upon awakening, the
patient felt severe pain in his pelvic region, and RUQ of abdomen. The pain is constant in both regions. The pain is a
stabbing and stinging sensation in the RUQ when breathing deeply, and the pain in the pelvic region is a throbbing
sensation with episodes of stabbing pain. Moving aggravates the pain in both regions and the only relief from the pain
comes from the acetaminophen-oxycodone and dilaudid. The pain medication was the only treatment the patient utilized
University of South Florida College of Nursing Revision September 2014 1
 to treat the pain. Upon awakening, the patient states that his pain was a 10 on a pain scale of 0-10. After the pain
medication, his pain decreases to a 5 on a scale of 0-10.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
2012 Right hip surgery due to car accident

(angina, MI, DVT etc.)

Stomach Ulcers
Cause
Environmental

FAMILY

Mental Health
Age (in years)

Heart Trouble
Bleeds Easily

Hypertension
of
Alcoholism

MEDICAL

Glaucoma
Death

Problems

Problems
Allergies

Diabetes
Arthritis

Seizures
HISTORY
Anemia

Asthma

Kidney
Cancer

(if

Tumor
Stroke
Gout
applicable
)
Patient
states
that he
Father N/A
does
not
know
Patient
states
that he
Mother N/A
does
not
know
Brother 27 N/A
Sister None N/A
relationship

relationship

relationship

Comments: Include age of onset

Patient states that his father became an alcoholic when he was a teenager as well as his brother. The patients mom has had
environmental allergies to pollen since she was a child, and she developed stomach ulcers in her thirties.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
University of South Florida College of Nursing Revision September 2014 2
 Adult Diphtheria (Date) Patient does not remember, and it is not in
patients chart.
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Patient does not
have any known
medication allergies
Medications

Patient does not

have any other
Other (food, tape, known allergies.
latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
The patient had a fracture of left superior and inferior pubic rami, as well as a closed left acetabular fracture. The anatomy
of the pelvic region consists of the ischium, ilium, and pubis of each hip that form a ring with the sacrum. The rami are the
branches of the pubic bone, and the acetabulum is the socket of the hip bone where the femur connects (Hip fracture
Treatments and drugs, 2015). This region of the body needs to be stable in order for the person to walk, and due to the
structure of the bones, this region of the body usually requires a great amount of force to be damaged in an individual who
is young and healthy. Risk factors for pelvic fractures are osteoporosis, overactive thyroid, being a woman, lack of
calcium and vitamin D in diet, physical inactivity, cortisone medications, tobacco, and alcohol use, and trauma (Hip
fracture Treatments and drugs, 2015). Diagnosing a pelvic fracture can be done through diagnostic tests such as a CT or
X-ray. A fracture in the pelvic region is usually labeled unstable or stable. Stable fractures are fractures in which there is
only one break in the pelvic ring and the ends of the fractured bone line up together (Pelvic Fractures-OrthoInfo AAOS,
2016). In this specific patient, he had a stable fracture. Fractures are classified unstable when there are two or more breaks
in the pelvic ring, and the ends of the bones do not line up adequately. Unstable and stable fractures can further be
classified as open or closed. Open fractures occur when the bone fragments stick out through the skin as compared to
closed fractures in which the affected bones do not break through the skin (Pelvic Fractures-OrthoInfo AAOS, 2016).
Treatment depends on the severity of the break. Stable fractures can often be treated through nonsurgical measures
including using walking aids and medication such as anticoagulants to reduce blood clot formation. If the fracture is
unstable, the patient will most likely have a surgical treatment that will include an external fixation, skeletal traction, or
open reduction and internal fixation. Typically, stable fractures heal well. However, unstable fractures are often affected
by other complications of trauma, and do not heal as successfully as stable fractures, and the rate of success declines as
the age of the patient increases. When associated with trauma, genetic factors typically do not play a role in the
occurrence of a pelvic fracture, such as in this case. When pelvic fractures are not caused by trauma, genetic factors can
often mimic the genetic factors of osteoporosis which includes being a female, increased age, Caucasian or Asian
University of South Florida College of Nursing Revision September 2014 3
 ethnicity, having a small frame, and low body weight, and a family history of osteoporosis, smoking, and hip fractures
(Hip fracture Treatments and drugs, 2015).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name chlordiazePOXIDE (Librium) Concentration 10 mg Dosage Amount 10 mg=1 capsule

Route Oral Frequency tid

Pharmaceutical class Benzodiazepine Home Hospital or Both
Indication Relief of alcohol withdrawal from acute alcoholism and anxiety
Adverse/ Side effects drowsiness, dizziness, nausea, vomiting, headache, depression, hallucination, sleep disturbances
Nursing considerations/ Patient Teaching Do not discontinue Librium suddenly, and take Librium exactly as prescribed by the health care provider. Do not use
Librium if you are pregnant or breastfeeding. Do not drink alcohol while taking Librium. Notify your provider immediately if you are having any thoughts of
suicide while taking Librium.

Name docusate-senna (Senokot S) Concentration N/A Dosage Amount 1 tab

Route Oral Frequency BID

Pharmaceutical class stool softener and stimulant laxative Home Hospital or Both
Indication constipation from pain medication
Adverse/ Side effects mild cramps, diarrhea, rashes, electrolyte imbalances, urine discoloration
Nursing considerations/ Patient Teaching: Encourage patient to use other forms of bowel regulation such as increasing bulk in diet, increasing fluid intake, and
increasing mobility to best of abilities. Advise patient that the laxative is only for short term therapy and should not be used long-term due to risk of dependence
and electrolyte imbalances. Instruct patient to not take within 2 hours of other laxatives.

Name acetaminophen-oxycodone (Percocet) Concentration 325 mg/7.5 mg Dosage Amount 1 tab

Route Oral Frequency q4h PRN

Pharmaceutical class Analgesic Home Hospital or Both
Indication for pain level of 4-6 on a scale of 0-10

Adverse/ Side effects Headache, fatigue, insomnia, rash, dyspnea, somnolence, constipation, nausea, vomiting, dizziness, dry mouth, sweating, orthostatic
hypotension, euphoria, hepatotoxicity
Nursing considerations/ Patient Teaching Adults should not take more than 4 grams of acetaminophen per day. When taking Percocet, do not take any other
drug with acetaminophen in it. Take this medication exactly as prescribed by your provider.

Name enoxaparin (Lovenox) Concentration 0.3mL Dosage Amount 30 mg

Route Subcutaneous injection Frequency q12 hr

Pharmaceutical class Anticoagulant Home Hospital or Both

Indication care plan to prevent formation of DVT

Adverse/ Side effects Pain, swelling, redness and bruising at injection sites, nausea, diarrhea, swelling in the hands and feet
Nursing considerations/ Patient Teaching Contact your provider if you have any bleeding that will not stop, trouble breathing, or numbing, tingling or muscle
weakness.

University of South Florida College of Nursing Revision September 2014 4

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular Consider co-morbidities and cultural considerations):
24 HR average home diet: Patient states he almost always
eats all his meals at fast food places because he is on the Using My Plate the patient does not meet any of the
road frequently all day. target goals for refined grains, vegetables, fruits, dairy, or
protein. The patient eats approximately 2565 calories per
day which is within his limit based on his height and
weight, however, many of the calories consumed are empty
calories that do not have nutritional value. In both his
intake of saturated fat and sodium, the patient exceeded the
recommended daily limit (Choose MyPlate). The patient is
at a loss for nutrients, and states that some days he will skip
meals because the amount of beet he consumes decreases
his hunger. The patient is at risk for nutritional deficiencies.
The patient also states that he does not have enough money
to eat healthy, and he does not like to cook so he believes
that fast food is the best option for him.

Breakfast: 8 ounce coffee (black) and 1 glazed donut

Lunch: 1 burger (usually from Wendys) with everything

on it including: lettuce, tomatoes, cheese, ketchup, mustard,
pickles

Dinner: Another burger from fast food restaurant with large

fries

Snacks: Bag of chips

Liquids (include alcohol): Patient estimates that he usually

has 3 glasses of water every day, 8 ounces each. Patient has
a 6 pack of Miller Light beer every day, and he states that
he sometimes drinks up to 10 beers a day.

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?
University of South Florida College of Nursing Revision September 2014 5
Patient states, usually my mom helps me.
How do you generally cope with stress? or What do you do when you are upset?
Patient states, If Im being honest, I usually just drink alcohol, Ill try talking to friends sometimes but the alcohol does
more for me than anyone else does.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient states that he has been feeling very overwhelmed lately especially due to the recent job loss. He has periods of
time where he feels anxious and depressed, but it is not constant.

+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? Yes Have you ever been hit punched or slapped? Yes

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Yes, patient states that he was punched by ex-girlfriend If yes, have you sought help for this? No

Are you currently in a safe relationship? Patient states that he is no longer in any relationship.

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: Intimacy refers to an individuals ability to relate to another person on a personal and deep level (Treas, L. S., &
Wilkinson, J. M., 2014)
Isolation occurs when individual cannot maintain close and secure relationships. (Treas, L. S., & Wilkinson, J. M., 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 intimacy vs. isolation stage of Eriksons developmental stages. This stage was indicated due to the
patients age being 24, which is in the age range of 20-39. Along with his age, the patient indicated signs of isolation
due to his lack of ability to maintain intimate personal relationships with romantic relationships as well as familial
relationships. The patient stated that he would rather drink than share his emotions or problems with others, and he also
shared that he has episodes of his depression, and often feels lonely. The patients use of alcohol in attempt to minimize
his problems rather than seeking help from family and friends is a sign of isolation.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The patients injury will most likely cause him to move back in with his family after discharge. Moving in with his family
along with the lack of mobility could cause his ability to socialize with friends and meet new people to decline. This could
have a negative impact on forming and developing intimate relationships.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states that the cause of his illness is due to being drunk. He believes that he is not an alcoholic yet, but he probably
will be in the future because it runs in his family. He also states that drinking will probably result in more accidents like
this, and he hopes to quit one day, but he is not prepared to stop yet.

What does your illness mean to you?

Patient states, the illness means that I should probably quit drinking and stop climbing trees.
University of South Florida College of Nursing Revision September 2014 6
+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? No
Have you or your partner received the Gardasil (HPV) vaccination? No

Are you currently sexually active? No If yes, are you in a monogamous relationship? No
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? Patient states that he uses condoms to prevent pregnancies and acquiring an STD.

How long have you been with your current partner? N/A
Have any medical or surgical conditions changed your ability to have sexual activity? No

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

University of South Florida College of Nursing Revision September 2014 7

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Patient states, Religion is a big part of my life. My family is Baptist, and even though I dont go to church all the time, it was a really
big part of growing up for me.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
Patient states that sometimes he will pray when he is in pain or going through depressing days.
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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? Currently smokes cigarettes How much?(specify daily amount) For how many years? 10 years
Patient smokes a pack of cigarettes a
(age 14 thru currently )
day

If applicable, when did the

Pack Years: 10 year pack history
patient quit? N/A

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit? No
so, what, and how much? Yes, the patients father smokes If yes, what did they use to try to quit? N/A
cigarettes. Patient states that his father smokes a pack a day
for the last 30 years.
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
How much? 6 pack of Miller Light
What? Patient usually drinks miller light For how many years? 8 years
and
as well as vodka and rum on occasions. Volume: 1 can = 12 ounces (age 16 thru currently )
Frequency: Drinks 6 pack of beer
every day
If applicable, when did the patient quit?
N/A

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
Patient states that he has used marijuana,
How much? For how many years? 3 years
cocaine, heroin, ecstasy, and pain killers.
He used smoked marijuana
about once a week. He used the
other street drugs with friends (age 15 thru 18 )
and at parties, which were
about 2 or 3 times a month.

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No
After he graduated from high
school (at age 18) he quit all
street drugs

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient states, Well I guess you could say that secondhand smoke from my father my whole life is an environmental
hazard, but it does not matter since I smoke now too.

5. For Veterans: Have you had any kind of service related exposure? N/A
University of South Florida College of Nursing Revision September 2014 8
 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: Patient
Diverticulitis Life threatening allergic reaction
does not use any sunscreen
Bathing routine: Once a day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy?
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known:
Post-nasal drip Normal frequency of urination: 6x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2 x/day Diabetes Type:
Routine dentist visits 1 x/year Hypothyroid /Hyperthyroid
Vision screening 1x/year Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? 2/06/2017 menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Infection of male genitalia/prostate?
Hypertension Patient never had infection of male Depression
genitalia/prostate
Frequency of prostate exam? Patient
Hyperlipidemia Schizophrenia
never had a prostate exam
Chest pain / Angina Date of last prostate exam? N/A 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
University of South Florida College of Nursing Revision September 2014 9
 Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? Patient
does not know, and I could not find it in Arthritis Chicken Pox
the chart.
Other: Other: Other:

General Constitution
Recent weight loss or gain None
How many lbs? N/A
Time frame? N/A
Intentional? N/A
How do you view your overall health? Patient states that he feels bad about his overall health and attributes it to his injuries and his
inability to get around by himself for now.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
None

Any other questions or comments that your patient would like you to know?
None

University of South Florida College of Nursing Revision September 2014 10

10 PHYSICAL EXAMINATION:

General Survey: Patient Height 178 cm Weight 83.9 kg BMI 26.48 Pain: (include rating and
is a 24 y.o. Caucasian kg/m2 location)
male who is A&O x3. He Pulse 78 bpm Blood Pressure: (include location)
appears to be in pain and Respirations 128/72 in right arm 7 in pelvic region
when asked, pain is a 7 18
out of 10 on a scale of 0-
10.
Temperature: (route SpO2 95% Is the patient on Room Air or O2
taken?) 98.8 Oral Room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]

awake, calm, relaxed, interacts well with others, judgment intact
Patient becomes agitated without pain medication
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

Skin is intact except for small abrasions to right palm, nose, above the left eyebrow, left knee, and a small puncture wound to
left hip; Patient has first degree sunburn across upper chest

Central access device None Type: N/A Location: N/A Date inserted: N/A
Fluids infusing? no yes - what? N/A

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 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 12 inches & left ear- 12 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Arrangement of the teeth are symmetric and straight
Comments: Nose has abrasion on the left side and nose is without discharge

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 I forgot to percuss lung fields with this
patient
Sputum production: None thick thin Amount: None scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: Clear and no adventitious breath sounds without any crackles, wheezes, rhonchi or stridor auscultated
RUL CL LUL CL
RML CL LLL CL

University of South Florida College of Nursing Revision September 2014 11

RLL CL

CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent

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

N/A

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: I did not find this pulse on the patient
Popliteal: I did not find this pulse on the patient DP: 3 PT: 2
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: right wrist 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 I forgot to percuss the patient
Abdomen non-tender to palpation
Last BM: (date 02 / 08 / 2017 ) Formed Semi-formed Unformed Soft Hard Liquid
Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe:

GU Urine output: Clear Cloudy Color: Hematuria, urine is red Previous 24 hour output:
mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

Musculoskeletal: ! Full ROM intact in all extremities without crepitus Patient does not have full ROM in both legs due
to injuries
Strength bilaterally equal at _____5__ RUE ____5___ LUE ____3___ RLE & ____3___ 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
Patient is using crutches due to injury
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: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive
negative
Patient refused DTR in bracioradial, patellar, Achilles, and ankle because it might hurt

University of South Florida College of Nursing Revision September 2014 12

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS
(Common laboratory tests and what they mean, 2014).

Lab Dates Trend Analysis

WBC 12.2 k/mcL 02/06/2017 Upon admit, the patients Number of infection
15.5 k/mcL 02/07/2017 WBC were elevated and fighting cells. Because
12.0 k/mcL 02/08/2017 continued to elevate into there were no other signs
9.8 k/mcL 02/09/2017 the next day, indicated of infection, and the
infection or inflammation. patients injury caused
The WBC started to drop, tissue damage, the WBC
and are now in normal was most likely due to
limits. inflammation in response
to the trauma.
Total CK 02/07/2017 Lab only taken once CK is the enzyme
484 unit/L creatine phosphokinase
which is primarily found
in the brain, heart, and
skeletal muscles. The
elevated Total CK
indicates release of CK
from and/or the brain,
heart, and skeletal
muscles. In this case, the
CK is most likely raised
due to the traumatic fall
and damage to skeletal
muscle tissue.
UA RBC Auto 02/07/2017 Lab only taken once The number of RBC in
too numerous to count urinary output. The
patient had blood in his
urine, indicating that his
kidneys could have been
bruised or damaged in
the fall. Other labs to
watch would be
creatinine and BUN
levels, which were both
in normal range.
Ethanol 02/06/2017 Lab only taken once The amount of alcohol in
0.282 gm/dL the blood. The critical
high amount starts at

University of South Florida College of Nursing Revision September 2014 13

 0.250. The elevated level
indicates acute alcohol
intoxication at the time of
the injury.
ABO Rh Interp 02/06/2017 Lab only taken once Patients blood type
A+ using ABO and Rh
analysis. Patients blood
type is found during
traumas in case they will
need blood transfusions
due to loss of blood or in
surgery.
AST 02/07/2017 Lab only taken once Amount of aspartate
61 unit/L aminotransferase enzyme
in the blood. This lab
tests for liver damage.
The elevated lab value
indicates possible
damage to the liver due
to excessive alcohol
consumption.
CT Chest/Abd/Pelvis w/ 02/06/2017 Test only done once CT confirmed a
Contrast nondisplaced fracture
proximal to the mid left
sacrum associated with
displaced fracture of the
left distal pubic ramus
and proximal aspect of
the left anterior
acetabulum.
No compression
deformity of lumbar
spine
No free air or fluid
CT Head w/ Contrast 02/06/2017 Test only done once CT confirmed no acute
intracranial abnormalities
CT Spine w/ Contrast 02/06/2017 Test only done once CT confirmed no
abnormalities of cervical
spine
USN Doppler Venous 02/08/2017 Test only done once Doppler confirmed no
Bilateral Lower DVTs in lower
extremities
DIA Chest portable 02/07/2017 Test only done once Test confirmed no acute
cardiopulmonary disease
DIA right wrist 02/07/2017 Test only done once Test done due to swelling
of the right wrist. The
test showed no evidence
of acute fracture or joint
space malalignment.

University of South Florida College of Nursing Revision September 2014 14

+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.)
Current healthcare treatments and procedures include routine vitals every eight hours, pain management consult,
physical therapy consult, weight bearing with left toe touch, and Lovenox 30 mg every 12 hours. The patient has
a pain management consult to be informed on how to decrease pain when he leaves the hospital. The patient also
has a physical therapy consult to help him mobilize without further injuring his fracture. The patient is weight
bearing with a left toe touch in order to allow him to ambulate with the assistance of an ambulatory device as
much as possible without added stress on the fracture. The patient also has Lovenox injections in order to prevent
DVTs from forming due to the amount of bed rest and immobility since the fall.

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

1. Impaired walking r/t fracture of left superior and inferior pubic rami and left acetabular fracture and temporary absence
of full weight bearing AEB toe touch weight bearing for left lower extremity, need for ambulatory device, and pain during
movement.
2. Imbalanced nutrition: less than body requirements r/t poor dietary habits AEB consumption of excessive empty calories
and alcohol as well as meeting none of the daily requirements of protein, carbohydrates, fruit, dairy, and vegetables.
3. Ineffective coping r/t use of alcohol to cope with life events AEB patient states, If Im being honest, I usually just drink
alcohol, Ill try talking to friends sometimes but the alcohol does more for me than anyone else does.
4. Anxiety r/t loss of control, withdrawal, future living arrangements, and loss of job AEB patient states, Im trying to get
out of moving back home while my hip gets better because I know Ill hate it. But I cant afford to live alone with no job.
Im not sure what Im going to do.

University of South Florida College of Nursing Revision September 2014 15

 15 CARE PLAN
Nursing Diagnosis: Impaired walking r/t fracture of left superior and inferior pubic rami and left acetabular fracture and temporary absence of full
weight bearing AEB toe touch weight bearing for left lower extremity, need for ambulatory device, and pain during movement (Ackley & Ladwig
Patient Goals/Outcomes
Patient will demonstrate correct
transfer and ambulation techniques
and proper use of ambulatory aids
by discharge.
Long term goal: Patient will regain
ability to ambulate without any
ambulatory assistance devices and
without pain in 8 weeks.
University of South Florida College of Nursing Revision September 2014
2011).
Nursing Interventions to Achieve
Goal
1.) Nurse will teach patient
how to correctly use
crutches.
2.) Nurse will have patient
demonstrate how to use
crutches by going down the
hallway and back while
using the crutches.
1.) Nurse will give resources
for physical therapy that is
under patients health
insurance.
2.) Nurse will educate and
encourage the patient to
perform strengthening
exercises given by hospital
physical therapist every
day for 30 minutes when
discharged. Nurse will also
have the patient
demonstrate the exercises
before discharge.
3.) Nurse will teach the patient
to use crutches for the
amount of time given by
health care provider.
Rationale for Interventions Evaluation of Goal on Day Care
Provide References is Provided
The nurse will want the patient to Patient correctly used his crutches
demonstrate the use of crutches in to aid in ambulatory process down
order to evaluate if the patient the hallway and back.
understands the correct way to use
his crutches according to the
nurses patient education.
The nurse will want to educate the If the patient adheres to the health
patient on following the health care provider and the physical
care provider and the physical therapists orders for after
therapists orders in order to discharge, he will most likely be
regain ability to walk without any able to walk without any
assistance or pain by scheduled ambulatory assistance in 8 weeks.
time. The nurse will want the
patient to demonstrate the
exercises provided by the physical
therapist to make sure that the
patient understands the exercises
before returning home.
16
Nursing Diagnosis: Imbalanced nutrition: less than body requirements r/t AEB consumption of excessive empty calories
and alcohol as well as meeting none of the daily requirements of protein, carbohydrates, fruit, dairy, and vegetables.
Patient Goals/Outcomes
Patient will identify three
nutritious meals that he can cook
at home that will meet his daily
requirements for nutrients. Patient
will also identify two alternatives
to fast food restaurants.
Long term: Patient will display
desire to quit drinking, and will
seek help to quit drinking by two
months following discharge.
University of South Florida College of Nursing Revision September 2014
Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
1.) Nurse will educate By having the patient make a My If the patient adhered to the plan,
patient on healthy diet, Plate account, the patient will be the patient identified three healthy
and help patient make able to see if he is meeting his meals to make at home using My
a My Plate account to daily goal for nutrition. By Plate as well as finding two
track daily intake. finding three nutritious meals to alternatives to fast food
2.) Nurse will encourage cook at home, and finding restaurants. The patient identified
and aid patient in alternatives to fast food, the healthier options on menus of his
finding three nutritious patient will identify healthier favorite fast food restaurants in
meals that he is easily eating habits and gain more order to meet his daily goals for
able to make at home. independence with cooking. By each nutrient.
Nurse will also help identifying healthier options on
patient find alternatives the fast food menus, the patient
to fast food restaurants. can easily make a change in diet
3.) Nurse will find menus that does not affect his daily
of patients favorite routine.
fast food restaurants
and help the patient
pick out the healthiest
options on the menu.
1.) Nurse will educate the The nurse will want to have the If the patient adhered to the plan,
patient of the affect of patient repeat the information the patient would have decided to
alcohol on the body, about how alcohol affects the quit drinking and is now meeting
and have the patient body back to the nurse in order to all his daily nutritional
repeat the information ensure that the patient understood requirements.
back after teaching. the information. The nurse will
2.) Nurse will give give the patient resources to stop
resources to the patient drinking in order provide
on quitting drinking information that he can use after
alcohol. discharge. Because the patient
uses alcohol as a coping
17
 3.) Nurse will teach the mechanism, the nurse can teach
patient effective coping coping techniques such as
skills to use instead of meditation to give the patient
drinking. alternatives to drinking when
under stress.

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

University of South Florida College of Nursing Revision September 2014 18

 References

Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.

Choose MyPlate. (n.d.). Retrieved February 23, 2017, from https://www.choosemyplate.gov/

Common laboratory tests and what they mean. (2014). Retrieved February 23, 2017, from
http://www.cpmc.org/learning/labtests.html

Dunn, J. (2012, April 30). Pelvis Injuries - The American Association for the Surgery of Trauma. Retrieved
February 18, 2017, from http://www.aast.org/pelvis-injuries

Hip fracture Treatments and drugs. (2015, March 11). Retrieved February 18, 2017, from
http://www.mayoclinic.org/diseases-conditions/hip-fracture/basics/treatment/con-20021033

Pelvic Fractures-OrthoInfo - AAOS. (2016, February). Retrieved February 18, 2017, from
http://orthoinfo.aaos.org/topic.cfm?topic=a00520

Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing: Concepts, skills, & reasoning. Philadelphia, PA: F.A.
Davis Compan

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University of South Florida College of Nursing Revision September 2014 20