UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Alexis Daubney

Assignment Date: 01/24/2017
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Florida Hospital Tampa
 1 PATIENT INFORMATION
Patient Initials: AS Age: 59 Admission Date: 01/23/2017
Gender: Female Marital Status: Divorced Primary Medical Diagnosis: dyspnea related to
Sarcoidosis
Primary Language: English
Level of Education: High School Other Medical Diagnoses:
Occupation (if retired, what from?): Housekeeping; currently disabled
Number/ages children/siblings: 3 brothers and 3 sisters (patient
denies knowledge of sibling’s ages); 4 children (40, 36, 35, 33 year
old children)
Served/Veteran: No Code Status: Full Resuscitation
If yes: Ever deployed? Yes or No
Living Arrangements: apartment with partner Advanced Directives: None
If no, do they want to fill them out? No
Surgery Date: Procedure:
Culture/ Ethnicity /Nationality: African American
Religion: Baptist Type of Insurance: Medicaid

 1 CHIEF COMPLAINT:
“There is a cold inside of me. It’s like lightning and thunder inside of me. I have difficulty breathing, like I’m heaving.”

 3 HISTORY OF PRESENT ILLNESS:

59 year-old female with history of Sarcoidosis, type 2 diabetes, and syphillis, was admitted to the emergency department
at Florida Hospital Tampa for progressive shortness of breath, chest congestion, and sputum production. Patient was
requiring more oxygen then her previous baseline. Onset of shortness of breath, three days prior to admission. Location of
“heaviness” is in the chest, back, and upper sides. The heaviness is sharp and constant. The weather and wind exacerbates
the shortness of breath and heaviness. Before coming to the emergency department, the patient tried Alka-Seltzer (+) for
the day and night time. Patient received an X-ray that displayed acute interstitial airspace opacities that were
superimposed on chronic reticular lung pattern. This lead to her admission for further work up. Currently, the patient is
oxygen dependent, and is awaiting a consult from respiratory to determine the next steps to take for treatment plan.

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  2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
Date Operation or Illness
1983 Sarcoidosis diagnosis via biopsy: Patient reports that they discovered this while she was pregnant
with her eldest daughter.
June 2016 Shingles on right chest cavity: Patient reports being hospitalized for a month, while they treated her
pain and burnt skin.
2016 Cholecystectomy: Patient does not report the reason for this removal.
Age (in years)

2

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma
of

Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
MEDICAL

Gout
Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Father
Mother 74
Brother
Sister
Comments:
Patient denies detailed knowledge of family medical history. Patient reports that she has no relationship with her father due to domestic
violence between him and her mother. She reports that her grandmother had type 2 diabetes, and as a result her grandmother had her
leg amputated. Patient denies knowledge of any medical history of her three brothers and three sisters.

 1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U
Adult Tetanus (Date) U
Influenza (flu) (Date) 01/20/2017
Pneumococcal (pneumonia) (Date) 01/20/2017
Have you had any other vaccines given for international travel or
occupational purposes? Please List

 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Patient denies any allergies or adverse reactions to medications or
Medications environmental allergens.

Other (food, tape,

latex, dye, etc.)

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 5 PATHOPHYSIOLOGY:
Sarcoidosis is an autoimmune disorder that can target any organ. Sarcoidosis is most commonly found in the lung tissues.
There is no known cause of Sarcoidosis, however it may have a genetic susceptibility and possible environmental antigens
may trigger the development of the disease. As the patient’s immune system develops an immune response, granulomas
and fibrosis occur within the tissues of the targeted organ Sarcoidosis attacks. Some common manifestations of the disease
include gradual signs and symptoms of malaise, fatigue, weight loss, dry cough, wheezing, and dyspnea. This may be
diagnosed through biopsy, and clinical assessment. Sarcoidosis is managed through the extent of the disease’s signs and
symptoms. The goal of management is to keep the lungs and affected organs functioning and relieve symptoms of the
disease. Medications for treatment include: corticosteroids, and immunosuppressive medications. Frequent follow-ups are
required to monitor the illness and its progression.
Referece: (Osborn, Wraa, Watson, & Holleran, 2014)

 5 MEDICATIONS:
Name albuterol-ipratropium bromide Concentration Dosage Amount 3 mL

Route solution; nebulizer treatment Frequency every 4 hours

Pharmaceutical class anticholinergic Home Hospital or Both
Indication bronchodilator utilized to open up the alveoli to promote more effective breathing and gas exchange
Adverse/ Side effects cough, nervousness, nausea, bronchospasm, anaphylaxis, hypersensitivity
Nursing considerations/ Patient Teaching monitor for hypersensitivity reaction, monitor respiratory rate, monitor oxygen saturation

Name dextromethorphan/guaifenesin Concentration Dosage Amount 100 mg

Route capsule, PO Frequency every 12 hours

Pharmaceutical class antitussive and expectorant combination Home Hospital or Both
Indication dextromethorphan is an antitussive for suppressing cough, guaifenesin is an expectorant for loosening phlegm and thinning secretions
Adverse/ Side effects abdominal pain, dizziness, nausea, rash, abuse potential, nephrolithiasis, serotonin syndrome
Nursing considerations/ Patient Teaching monitor for hypersensitivity reaction, ensure that MAOI have been discontinued within 14 days prior to initiation of this
medication due to fatal drug interactions, monitor for effectiveness of therapy (monitor secretions, auscultate lung sounds)

Name insulin glargine Concentration Dosage Amount 25 units

Route injection Frequency twice daily

Pharmaceutical class insulin, long acting Home Hospital or Both
Indication treatment of hyperglycemia, maintaining continuous insulin levels
Adverse/ Side effects hypoglycemia, hypokalemia, anaphylaxis, injection site reaction, rash
Nursing considerations/ Patient Teaching monitor blood glucose levels, teach patient that this injection establishes the basal rate of insulin and cannot be discontinued,
ensure that patient maintains blood glucose levels with another source for short acting insulin, teach patient regarding Somogyi effect and Dawn phenomenon

Name insulin lispro Concentration Dosage Amount correction dosage

Route injection Frequency sliding scale, as needed for correction

Pharmaceutical class insulin, short acting Home Hospital or Both
Indication treatment of hyperglycemia
Adverse/ Side effects hypoglycemia, hypokalemia, anaphylaxis, injection site reaction, rash
Nursing considerations/ Patient Teaching monitor blood glucose levels, teach patient that if medication is used to cover a meal that they must have their food
immediately after the injection to not risk hypoglycemia

Name methylprednisolone Concentration Dosage Amount 40 mg

Route REC injection Frequency every 8 hours

Pharmaceutical class corticosteroids, systemic Home Hospital or Both
Indication anti-inflammatory action, inhibits inflammatory cytokines
Adverse/ Side effects sodium and fluid retention, hypokalemia, increased blood pressure, rash, weight gain, anaphylaxis, adrenal insufficiency, Cushing syndrome,
infection
Nursing considerations/ Patient Teaching monitor electrolytes, monitor blood pressure, monitor weight, teach patient signs and symptoms of infection to report

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Name prednisone Concentration Dosage Amount 5 mg

Route PO Frequency once daily

Pharmaceutical class corticosteroids, systemic Home Hospital or Both
Indication anti-inflammatory action, inhibits inflammatory cytokines
Adverse/ Side effects sodium and fluid retention, hypokalemia, increased blood pressure, rash, weight gain, anaphylaxis, adrenal insufficiency, Cushing syndrome,
infection
Nursing considerations/ Patient Teaching monitor electrolytes, monitor blood pressure, monitor weight, teach patient signs and symptoms of infection to report

Name diazepam Concentration Dosage Amount 5 mg

Route tablet, PO Frequency three times a day, as needed for anxiety

Pharmaceutical class benzodiazepine Home Hospital or Both
Indication treatment of anxiety, seizure disorders
Adverse/ Side effects drowsiness, fatigue, ataxia, confusion, respiratory depression, seizures, medication dependence, bradycardia, severe hypotension
Nursing considerations/ Patient Teaching monitor respiratory rate, monitor sedation utilizing a valid scale such as the Glasgow Coma Scale, teach patient that this
medication is utilized for short term use, monitor for drug interactions, teach patient alternatives to medication therapy for stress relief such as guided imagery or deep
breathing exercises

Name acetaminophen/hydrocodone (Norco) Concentration Dosage Amount 5 mg/ 300 mg

Route tablet, PO Frequency twice daily

Pharmaceutical class opioid combination Home Hospital or Both
Indication pain relief
Adverse/ Side effects lightheadedness, dizziness, sedation, nausea, vomiting, respiratory depression, hepatotoxicity, blood dyscrasia
Nursing considerations/ Patient Teaching monitor respiratory rate and respiratory depression, monitor sedation, monitor creatinine at baseline, monitor pain levels have
patient report pain on a scale of 1-10

Name morphine Concentration Dosage Amount 2 mg

Route injection Frequency four times a day, PRN

Pharmaceutical class opioid Home Hospital or Both
Indication producing analgesia and sedation, pain relief
Adverse/ Side effects somnolence, constipation, nausea, vomiting, respiratory depression, apnea, respiratory arrest, circulatory depression, severe hypotension
Nursing considerations/ Patient Teaching monitor for signs and symptoms of respiratory depression, monitor creatinine levels, monitor pain levels,

Name nitroglycerin Concentration Dosage Amount 0.4 mg

Route sublingual Frequency every 5 minutes, for a maximum of 3 sublingual tablets

Pharmaceutical class vasodilator, nitrate Home Hospital or Both
Indication as needed for chest pain
Adverse/ Side effects headache, lightheadness, dizziness, severe hypotension, paradoxical bradycardia, syncope
Nursing considerations/ Patient Teaching monitor blood pressure, monitor respiratory rate, monitor for signs on myocardial infarction, teach patient that headache is a
side effect of nitroglycerin, teach patient proper administration and timing of nitroglycerin

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Con Carb (60-75 g) Heart Healthy Analysis of home diet

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Diet patient follows at home? Patient would benefit from nutritional teaching with regards
24 HR average home diet: to food choices, and how to balance meals. Patient
Breakfast: corn flakes, 2% milk, grapes/peaches currently consumes more than the daily requirements of
fruit and does not consume adequate amounts of vegetables
Lunch: Lean cuisine, fruit and dairy. Teaching regarding the differences between
grains would be beneficial to increase patient’s whole grain
Dinner: baked chicken, salad, fried rice consumption. Patient currently solely consumes grains from
refined sources. Dietary teaching should focus on balancing
Snacks: fruit the diet among all the food groups, ensuring that enough
calories are consumed, and decreasing the amount of
Liquids: apple juice, water, Kool Aid, soda (Diet Pepsi) sodium consumed from processed sources.

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
“My boyfriend does.”
How do you generally cope with stress? or What do you do when you are upset?
“I just watch TV. It is a good way to distract myself you know? I particularly love the crime shows.”

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“None that I can think of.”

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+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? “No. Well a long time ago, my dad would talk loud. But it was okay as
long as them bills were paid. He never hit me or nothing.”

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?
“No.” If yes, have you sought help for this? “He left so I didn’t need to worry. God was with me.”

Are you currently in a safe relationship? “Yes, I am.”

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your
patient’s age group:
Generativity vs. self-absorption occurs at the approximate stage of “middle adulthood (35-65 yr)”. Developmental task is
“fulfilling life goals that involve family, career, and society; developing concerns that embrace future generations”.
Successful competition of this stage is “ability to give and to care for others”. Unsuccessful resolution of crisis leads to
“self-absorption; inability to grow as a person”. (Varcarolis & Halter, 2014, p. 23)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
This patient is currently in the stage of generativity versus stagnation. This stage tends to be present in the middle adult
years. During this stage, it is important to create and nurture things that will outlast them. She currently resides in the
generativity stage. This finding is presented in the way in which she regards her well being in: it is “coming soon…you
know death. I’m trying to get things done.” This statement displays her need to leave things behind and in order for her
family.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
Her current condition is exacerbating an area of the stage that she had not experienced for a short while. Since she was
hospitalized last year due to an exacerbation of shingles, she revisited the stage of standing still. She is unable to do
everything she has wanted to do, since she is in the hospital with a condition that is progressively getting worse. This
hospitalization due to her Sarcoidosis is greatly impacting her psychosocial stage and the development to successfully
progress through the stage.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
“Well we have a family history of it, on my mama’s side. My grandmother had it, the diabetes.”

What does your illness mean to you?

“Coming soon…you know death. I’m trying to get things done. Never been better off. It’s about moving on.”

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+3 SEXUALITY ASSESSMENT

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? “I had syphilis in ’82. They found it when I was pregnant.
They fixed it.”
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? “Every now and then.” 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? “A condom. But I don’t need to worry about that anymore.”

How long have you been with your current partner? “7-8 years. But we knew each other 20 years before that.”

Have any medical or surgical conditions changed your ability to have sexual activity? “I have no pleasure in it anymore.”

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

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±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
“I want to know God first. I want to know everything about Him. That’s why I read the Bible.”
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
“Not really, I just want to read it.”
______________________________________________________________________________________________________

+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?
(age thru )

If applicable, when did the

Pack Years:
patient quit?

Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years?
Volume: 1 cup (age thru )
Gin
Frequency: on the weekend “It was only when I was young. I
don’t drink anymore now.”
If applicable, when did the patient quit? Patient denies specific ages for
starting and stopping drinking.
“It was hurting me. It got dead to me, I found no pleasure in it.”

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, not that I know of.”
5. For Veterans: Have you had any kind of service related exposure?

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 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin: due to
GERD Cholecystitis Fever
shingles outbreak last year
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Hemorrhoids: patient reports, “those
Dandruff started after I had my children” Lupus
Blood in the stool
Psoriasis Yellow jaundice Hepatitis C Rheumatoid Arthritis
Sarcoidosis: patient reports “I have that
Hives or rashes Pancreatitis
in my lungs and liver.”
Skin infections Colitis Tumor
Use of sunscreen SPF: Diverticulitis Life threatening allergic reaction
Bathing routine: shower every other day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy
HEENT Other: cholecystostomy Hematologic/Oncologic
Difficulty seeing: corrective glasses 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: 4/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems: dentures Metabolic/Endocrine
Routine brushing of teeth: once a day Diabetes Type: 2
Routine dentist visits: 1 or every 2
Hypothyroid /Hyperthyroid
years
Vision screening Intolerance to hot or cold
Other: brushes and soaks dentures over
Osteoporosis
night
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Infection of the female genitalia:
Asthma Dizziness
syphillis
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia: patient reports, “I have had
Date of last gyn exam? 03/2016 Seizures
that in the past”
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche 13 age Encephalitis
menopause: patient did not report
last CXR? Meningitis
knowledge of exact onset of menopause
Date of last Mammogram & Result: 35
Other: Other:
years old, no abnormal findings
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
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 CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Injuries or Fractures: left ankle
Murmur
fractured in four locations
Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? Arthritis Chicken Pox
Other: Other: Other:

General Constitution
Recent weight loss or gain
“I lost 100 pounds when I was in the hospital with shingles. This wasn’t intentional, but it did help me lose weight that I have wanted
to lose for a while. My health was very poor at this time!”

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
“Nothing, other then my shingles last year.”

Any other questions or comments that your patient would like you to know?
“Nothing, right now.”

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±10 PHYSICAL EXAMINATION:

General Survey: 59 year Height 169 cm Weight 81.64 kg BMI 28.58 Pain: Patient is in no acute
old female, resting in Pulse 84 Blood Pressure: 147/70 Right arm pain at the time of the
chair, patient does not Respirations 18 assessment
appear to be in any
distress at the time of
assessment
Temperature: 98, oral SpO2 90% Is the patient on Room Air or O2?
Patient is on nasal cannula oxygen, 5 L
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
Notes:

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: Location: Date inserted:
Fluids infusing? no yes - what?
Peripheral IV site Type: 20 gauge Location: Right AC Date inserted: 01/23/2017
no redness, edema, or discharge
Fluids infusing? no yes

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- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Teeth are uniform, clean, and without abnormalities
Comments: Whisper test was not conducted due to patient’s appropriate response to questions in previous assessment

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: CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent
RUL CR LUL CR
RML CR LLL CR
RLL CR
Notes: patient is currently on oxygen therapy; patient was admitted with sputum production; sputum production currently
absent
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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

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: Radial: 2 Femoral: Popliteal: DP: 2 PT: 2
No temporal or carotid bruits Edema: [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: pitting non-pitting
Extremities warm with capillary refill less than 3 seconds

GI Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly palpated

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 01 / 23 / 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: Previous 24 hour output: mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

Musculoskeletal:  Full ROM intact in all extremities without crepitus

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

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

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±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS

Diagnostic Exam Date Finding

Time
XR chest 2V 01/23/2017 Indication: cough
1529 Finding: abnormal exam mixed with acute interstitial, airspace opacities
superimposed on chronic reticular lung pattern. No pneumonia present.
CT chest PE w 01/23/2017 Indication: hypoxia, tachypnea, evaluation pulmonary embolism,
contrast 1551 pneumonia
Finding: end stage fibrosis in apices of lungs and elsewhere. Normal
tissue at bases. No mass consolidation. Acute inflammation in septal
around fibrosis. No pulmonary embolism, no cardiac abnormalities.
Splenomegaly noted.

Lab Dates Trend Analysis

WBC White blood cell counts WBC well within normal
8.2 01/23/2017 trending down. Well range. This value was
5.4 01/24/2017 within normal range. obtained through typical lab
Normal work up.
4.5-11

RBC Red blood cell counts This low RBC count may
4.05 L 01/23/2017 trending down. Lower be related to the patient’s
3.46 L 01/24/2017 than normal range. diagnosis of Sarcoidosis,
Normal which may present with
4.3-5.5 anemia. This should be
monitored for potential
need for blood transfusion.
HGB Hemoglobin trending This low HGB count may
12.0 01/23/2017 down. Latest value be related to the patient’s
10.3 L 01/24/2017 lower than normal diagnosis of Sarcoidosis,
Normal range. which may present with
12-16 anemia. This should be
monitored for potential
need for blood transfusion.
HCT Hematocrit trending This low HCT count may be
38.4 01/23/2017 down. Latest value related to the patient’s
32.8 L 01/24/2017 lower than normal diagnosis of Sarcoidosis,
Normal range. which may present with
38-54 anemia. This should be
monitored for potential
need for blood transfusion.
Platelet Platelet count trending This low platelet count may
162 01/23/2017 down. Latest value be related to the patient’s
120 L 01/24/2017 lower than normal diagnosis of Sarcoidosis,
Normal range. which may present with
150-450 anemia. This should be
monitored for potential
need for blood transfusion.
University of South Florida College of Nursing – Revision September 2014 13
Na Sodium consistent Na well within normal
141 01/23/2017 trend. Within normal range. This value was
141 01/24/2017 range. obtained through typical lab
Normal work up.
135-145

K Potassium trending This may be related to

3.4 L 01/23/2017 upward. First blood insulin therapy initiated at
3.6 01/24/2017 draw was lower than the hospital. Since the
Normal normal ranges, and then patient has not previously
3.5-5.0 returned to normal utilized insulin to care for
range after protocol her type 2 diabetes, the
was enacted. insulin may be causing a
drive of potassium into her
cells leading to decreased
levels in the blood.
Chloride Chloride consistent Chloride well within normal
98 01/23/2017 trend. Within normal range. This value was
98 01/24/2017 range. obtained through typical lab
Normal work up.
98-106

CO2 Carbon dioxide Carbon dioxide well within

30 01/23/2017 consistent trend. Within normal range. This value
30 01/24/2017 normal range. was obtained through
Normal typical lab work up.
23-39

BUN Blood urea nitrogen BUN well within normal

11 01/23/2017 consistent trend. Within range. This value was
12 01/24/2017 normal range. obtained through typical lab
Normal work up.
8-21

Creatinine Creatinine levels Creatinine well within

0.9 01/23/2017 consistent trend. Within normal range. This value
1.0 01/24/2017 normal range. was obtained through
Normal typical lab work up.
0.8-1.3

Blood Glucose Blood glucose levels Blood glucose levels higher

137 H 01/23/2017 trending up. Higher than normal range due to
162 H 01/24/2017 than normal range. type 2 diabetes. Higher
Normal blood glucose levels may be
65-110 due to stress levels in the
hospital, and changes in
treatment of diabetes.
Calcium Calcium levels trending Patient does not exhibit
8.7 L 01/23/2017 down. Lower than signs and symptoms of
8.5 L 01/24/2017 normal range. calcium deficiency. This
University of South Florida College of Nursing – Revision September 2014 14
 Normal level would require
9-11 monitoring from the nurse.
Pre-Op Prothrombin, INR, and
Prothrombin Prothrombin levels aPTT levels well within
13.5 01/23/2017 trending up. Within normal range. These values
14.4 01/24/2017 normal range. were obtained through
Normal typical lab work up.
11-14
INR INR levels trending up.
1.00 01/23/2017 Within normal range.
1.09 01/24/2017
Normal
0.9-1.2
aPTT aPTT levels trending
33 01/23/2017 up. Levels within
38 01/24/2017 normal range.
Normal
20-40

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

Scheduled Procedure/Surgery: None scheduled at this time
Scheduled diagnostic tests: None scheduled at this time
Consults: Respiratory
Oxygen dependent on 5 L of O2
Diet: Heart health con carb diet
Vitals:
01/24/2017 0700
HR: 84 RR: 19 BP: 147/70 Temp: 98 BG: 144 O2: 97% via 5 L
01/24/2017 1200
HR: 79 RR: 20 BP: 149/58 Temp: 98.2 BG: 206 O2: 100% via 5 L
01/24/2017 1700
HR: 66 RR: 19 BP: 150/62 Temp: N/A BG: 298 O2:100% via 5 L
Activity: ambulates independently

 8 NURSING DIAGNOSES
1. Ineffective airway clearance related to Sarcoidosis present in lung tissues as evidenced by crackles in all lung
fields, and increased respiratory rates.
2. Activity intolerance related to Sarcoidosis present in lung fields as evidenced by exertional dyspnea, exertional
discomfort, verbal response of fatigue, and decreased oxygen saturation.
3. Ineffective peripheral tissue perfusion related to Sarcoidosis present in lung tissues as evidenced by decreased
oxygen saturation with out oxygen therapy and ineffective airway clearance.
4. Risk for impaired liver function related to Sarcoidosis present in liver.
5. Risk for infection related to secretions present in lungs and immunosuppression through corticosteroid
administration.

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

± 15 CARE PLAN
Nursing Diagnosis: Ineffective airway clearance related to Sarcoidosis present in lung tissues as evidenced by crackles in all lung fields, and
increased respiratory rates.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will maintain a patent Nurse will monitor respiratory A normal respiratory rate without Patient maintains respiratory rate
airway at all times throughout patterns, including rate, depth and dyspnea is 10-20. However, with within range of 10-20, with oxygen
current shift. effort. secretions in the airway the saturation above 95% by the end of
respiratory rate will increase to the shift.
compensate for decreased
exchange of gases.
Nurse will note areas of decreased Breath sounds should be clear. No Patient has decreased crackles upon
or absent ventilation and presence lung sounds indicates a blocked auscultation by the end of shift.
of adventitious sounds. airway and requires immediate
attention.
Patient will demonstrate effective Nurse will instruct patient how to This technique prevents the glottis Patient describes, and demonstrates
coughing and clear breath sounds cough effectively, through the from closing during the cough, and back effective “huff cough” by the
by the end of shift. forced expiratory technique of the helps to remove secretions. end of the shift.
“huff cough”.
Nurse will note areas of decreased Breath sounds are normally clear. Patient has decreased crackles upon
or absent ventilation and presence Presence of crackles indicates fluid auscultation after demonstrating
of adventitious sounds, prior to within the airway, and wheezes and utilizing effective coughing
coughing and follow up later indicate airway obstruction. within a day of teaching.
during shift.
Patient will explain methods useful Nurse will encourage fluid intake, Fluids help minimize mucosal Patient drinks 2500 mL/day, and
to enhance secretion removal prior and instruct patient how fluids drying and increase ciliary action describes to the nurse why fluids
to discharge. increase secretion removal. to move secretions are needed to remove secretions.
Nurse will teach the client how to Controlled coughing using Patient demonstrates effective deep
deep breathe effectively. diaphragmatic muscles, making breathing and teaches back
coughs more forceful and effective. knowledge to nurse prior to
discharge.
Care Plan Reference: (Ackley, & Ladwig, 2014)

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

 Nursing Diagnosis: Activity intolerance related to Sarcoidosis present in lung fields as evidenced by exertional dyspnea, exertional
discomfort, verbal response of fatigue, and decreased oxygen saturation.
Patient Goals/Outcomes Nursing interventions to achieve Rationale for Interventions Evaluation of Goal on Day Care
goal Provide References is Provided
* Patient will maintain normal skin Nurse will ensure that patient has Oxygen therapy improves exercise Patient has continuous oxygen
color, and skin is warm and dry oxygen saturation testing with ability. Continuous oxygen saturation with normal skin color
with activity by the end of the shift. exercise. And additional saturation monitoring will ensure while ambulating and completing
supplemental oxygen is utilized to that the oxygen levels are exercises with physical therapy by
keep oxygen saturation 95% or addressed accordingly. the end of the shift.
above.
Nurse will observe and document Cyanosis and pallor are signs of Patient maintains normal skin
skin integrity several times a day, decreased oxygen saturation, and color, which is warm and dry with
noting cyanosis or pallor with require immediate intervention. If prescribed activity by the end of
activity. patient does not engage in shift.
prescribed activities, resulting
immobility may lead to pressure
ulcers. Mechanical pressure,
moisture, friction, and shearing
forces all predispose a patient for
the development of pressure ulcers.
Patient will state symptoms of Nurse will instruct client to stop These are signs of angina, and are Patient states symptoms of adverse
adverse effects of exercise and activity immediately and report to signs of temporary insufficiency of effects of exercise/additional
verbalizes to report onset of physician if client is experiencing coronary blood supply. If movement and verbalizes an
symptoms immediately, by the end the following symptoms: new or symptoms last longer than 5-10 understanding to report such
of the shift. worsened intensity and increased minutes, a provider should evaluate symptoms by the end of the shift.
frequently of discomfort; tightness the client.
or pressure in chest, back, neck,
should, and/or arm; palpitations;
weakness; excessive air hunger.
Nurse will teach patient regarding These are all signs of respiratory Patient states signs and symptoms
signs and symptoms of respiratory intolerance, which indicate adverse of respiratory intolerance and
intolerance, such as increased effects of exercise. These signs verbalizes an understanding to
difficulty breathing, skin tone require immediate intervention. report such symptoms by the end of
changes. the shift.
* Nurse will monitor patient’s These are all signs of respiratory Patient does not demonstrate signs
response to activity by observing intolerance, which indicate adverse and symptoms of respiratory
for symptoms of respiratory effects of exercise. These signs intolerance by then end of shift.
University of South Florida College of Nursing – Revision September 2014 17
 intolerance such as increased
dyspnea, loss of ability to control
breathing rhythmically, use of
accessory muscles, nasal flaring,
skin tone changes such as pallor
and cyanosis.
* Patient will verbalize feelings of Nurse will have patient rate her
increased ability to move, with less difficulty breathing on a scale of 0-
difficulty breathing within 7 days. 10.
Nurse will monitor oxygen
saturation, and respiratory rate
while patient ambulates. Nurse will
address changes in oxygen
saturation accordingly with
increased oxygen while
ambulating.
Care Plan Reference: (Ackley, & Ladwig, 2014)
require immediate intervention.
The 0-10 scale is reliable reference
to score levels. When this is used
the nurse is able to see the rate at
which the patient finds breathing
more difficulty, comparing resting
to ambulating to the bathroom.
Monitoring oxygen saturation and
respiratory rate will reflect the
extent of effort the patient requires
while ambulating. Adjusting
oxygen flow accordingly will
increase oxygen saturation, and
decrease difficulty breathing.
Patient demonstrates a decreased
level of difficulty when ambulating
to the bathroom within 7 days.
Patient does not require increased
oxygenation while ambulating to
the bathroom, and verbalizes
feelings of increased ability to
ambulate to the bathroom within 7
days.

±2 DISCHARGE PLANNING:
Consider the following needs:
SS Consult
Dietary Consult – Patient would benefit from education regarding well balanced meals to help manage her type 2 diabetes and overall health
PT/ OT- Patient would benefit from PT and OT due to difficulty ambulating related to exertional dyspnea
Pastoral Care
Durable Medical Needs
F/U appointments – Patient should follow up with primary care to ensure
Med Instruction/Prescription – Patient requires medication instructions for proper administration as per hospital protocol
Are any of the patient’s medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing – Revision September 2014 18

 References

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

(10th ed.). Maryland Heights, MO: Mosby Elsevier.

Epocrates. (2014). Epocrates Reference Tools for Healthcare Professionals (16.8) [Mobile application software].

Retrieved from http://itunes.apple.com

Osborn, K. S., Wraa, C .E., Watson, A. B., & Holleran, R. (2014). Medical-surgical nursing: Preparation for

practice (2nd ed.). Upper Saddle River, NJ: Pearson Education.

SuperTracker: My Foods. My Fitness. My Health. Retrieved September 26, 2016, from

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

Varcarolis, E. M., & Halter, M. J. (2014). Foundations of psychiatric mental health nursing: A clinical

approach (7th ed.). St. Louis, MO: Saunders/Elsevier.

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