UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Kristina Maldonado

Assignment Date: 2/7/2017
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Sarasota Memorial Hospital
 1 PATIENT INFORMATION
Patient Initials: T.S. Age: 84 years Admission Date: 2/6/17
Gender: Male Marital Status: married Primary Medical Diagnosis: SOB
Primary Language: English
Level of Education: PhD in Psychology Other Medical Diagnoses: (new on this admission)
Influenza A
Occupation (if retired, what from?): retired clinical psychologist and
researcher
Number/ages children/siblings: No siblings.

Served/Veteran: No. Code Status: Full Code

If yes: Ever deployed? Yes or No
Living Arrangements: Lives with wife. Advanced Directives: Did not find this document
in chart.
If no, do they want to fill them out?
Surgery Date: N/A Procedure: N/A
Culture/ Ethnicity /Nationality: German
Religion: Judaism Type of Insurance: Medicare

 1 CHIEF COMPLAINT: Increased SOB over the last week on exertion and at rest accompanied with
wheezing.

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Onset: one week ago
Location: RML, LUL, LLL
Duration: SOB and wheezing constantly
Characteristics: wheezing on expiration
Aggravating: Patient states that everything made it worse, and he noticed that chocolate aggravated his symptoms as well.
Relieving: nothing
Treatment: Advair Diskus and Proventil HFA 90 mcg
Pain: 0

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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
Asthma
2011 Aortic valve replacement
Positive prostate cancer
Bilateral hernia repair
L3-L4 disk surgery
Left rotator cuff surgery
Ligament repair on left knee

2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause
Alcoholism

MEDICAL

Glaucoma

Problems

Problems
Allergies

of
Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY
Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father
Mother
Brother
Sister
relationship

relationship

relationship

Comments: Include age of onset

 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)
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
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 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS

Medications

Pollen & ragweed Nasal congestion and wheezing

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):
Influenza virus can be divided into two groups: Influenza A and Influenza B. This patient was diagnosed with
influenza A. Influenza A undergoes major antigenic variation where the viral surface antigens are changing due
to mutations. The human body protects itself from the influenza by making antibodies against the HA and NA
antigens. Hemagglutinin (HA) and neuraminidase (NA) are two surface proteins essential to the spread of the
influenza virion. HA aids in entering the cells and NA are responsible for the release of virions from infected
cells. Influenza A can infect birds and mammals and there are many distinct subtypes specific to influenza A.
Influenza is highly contagious and is transmitted through aerosols or body fluids. Symptoms begin to present
themselves 1-4 days after infection and may present themselves as: chills, fever, sore throat, muscle aches,
headaches, coughing, malaise, nausea, and vomiting. Symptoms can lead to the contraction of pneumonia.
Young children and older adults are at risk. Influenza can be fatal. (Huether & McCance , 2017)
Oseltamivir, an antiviral drug, is the primary treatment for influenza A. Oseltamivir can impede viral replication
and can improve the patient’s survival prospect. This drug should be given with 48 hours within the onset of
symptoms. Aquatic birds are the primary reservoirs for influenza A. “Bird flu” and “swine flu” are subtypes of
influenza A. Influenza A is not spread between people, but primarily through animal contact. To diminish one’s
chance of contracting influenza A, exposure to infected poultry (dead or alive) should be avoided and handled
with the utmost caution. Those who handle bird carcasses are at risk. (World Health Organization, 2016)
The influenza cannot be diagnosed and confirmed through symptoms alone. Symptoms can differ from person
to person depending on age and other comorbidities. For some individuals, using a diagnostic test is not
necessary, but often times it can be useful. Antiviral therapy can be started even if diagnostic test has not been
done, but symptoms must be present. Nasopharyngeal or nasal swabs can be collected for a rapid influenza
diagnostic test (RIDT), viral culture, immunofluorescence, or a rapid molecular assay. The RIDT is frequently
used because the results are received in 15 minutes, but it commonly reads false negatives, which can lead to
misdiagnosis and incorrect pharmacological treatment. (Centers for Disease Control and Prevention , 2016)

 5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name Concentration Dosage Amount
Oseltamivir (Tamiflu) 30 mg capsule
Route Frequency
PO BID
Pharmaceutical class
Home Hospital or Both
Neuraminidase inhibitors

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Indication
Treatment of uncomplicated acute illness due to influenza
Adverse/ Side effects
Seizures, nausea, vomiting, abnormal behavior, agitation, insomnia, delirium, vertigo, bronchitis
Nursing considerations/ Patient Teaching
Treatment with oseltamivir should be started as soon as flu symptoms appear (within 2 days of exposure).
Name Concentration Dosage Amount
mometasone/formoterol (Dulera) 200/5mcg
Route Frequency
Inhaler Inhale 2 puffs BID
Pharmaceutical class
Home Hospital or Both
Corticosteroids/adrenergics
Indication
Prophylactic asthma therapy and it may decrease the need for systemic corticosteroids in patients with
asthma/prevent bronchospasm
Adverse/ Side effects
Headache, dysphonia, cough, wheezing, anaphylaxis, laryngeal edema, bronchospasm/ asthma related death,
paradoxical bronchospasm, dry mouth
Nursing considerations/ Patient Teaching
Rinse mouth after each use
Name Concentration Dosage Amount
Albuterol- Ipratropium (DuoNeb) Albuterol sulfate 2.5mg + 3mL
Ipratropium bromide 0.5mg
Route Frequency
Nebulizer Give 3mL Q4H
Pharmaceutical class
Home Hospital or Both
Adrenergics/ anticholinergics
Indication
Used as a bronchodilator to treat asthma/adjuctive management of bronchospasm caused by asthma
Adverse/ Side effects
Nervousness, restlessness, chest pain, palpitations, paradoxical bronchospasm/dizziness, cough, allergic reactions
Nursing considerations/ Patient Teaching
Instruct patient on nebulizer
Name Concentration Dosage Amount
Methylprednisolone (Solu-Medrol) 40 mg
Route Frequency
IV Q8H
Pharmaceutical class
Home Hospital or Both
Corticosteroids
Indication
Used systemically and locally in a wide variety of chronic diseases: inflammatory, allergic, hematologic,
neoplastic, autoimmune disorders, and immunosuppressant.
Adverse/ Side effects
Depression, euphoria, hypertension, peptic ulceration, anorexia, nausea, acne, skin breakdown, adrenal
suppression, hypokalemia, thromboembolism, cushingoid appearance, increased risk of infection, muscle wasting
Nursing considerations/ Patient Teaching
Infuse over 2 minutes and store at room temperature. Go over list of side effects with patient and educate patient
on not stopping the medication abruptly because this can result in adrenal insufficiency. Educate patient on
immunosuppression and avoiding people with known contagious illnesses.

Name Concentration Dosage Amount

Aspirin (acetylsalicyclic acid) 81 mg per 1 tablet (chewable)
Route Frequency
PO 1 x day
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Pharmaceutical class
Home Hospital or Both
Salicylates
Indication
Prophylaxis of transient ischemic attacks and MI
Adverse/ Side effects
GI bleeding, dyspepsia, epigastric distress, nausea, abdominal pain, anemia, rash, tinnitus
Nursing considerations/ Patient Teaching
Instruct patient to report bleeding gums, tarry stools, fever. Caution patient to avoid concurrent use of alcohol to
minimize possible gastric irritation. Aspirin must be withheld 1 week prior to surgery.

Name Concentration Dosage Amount

albuterol (Proventil HFA) 90 mcg
Route Frequency
Inhalation 2 puffs 4 x day
Pharmaceutical class
Home Hospital or Both
Adrenergics
Indication
Used as a quick-relief agent for acute bronchospasm and for prevention of exercise-induced bronchospasm
Adverse/ Side effects
Nervousness, restlessness, tremor, paradoxical bronchospasm with overuse of inhaler, chest pain, palpitations,
hyperglycemia, hypokalemia
Nursing considerations/ Patient Teaching
Caution patient not to exceed recommended dose to prevent paradoxical bronchospasm. Instruct patient to prime
unit with 4 sprays before using and to discard canister after 200 sprays.

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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? Standard diet. Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Low-fat and no processed Consider co-morbidities and cultural considerations):
foods. The patient’s home diet met three of the five “My Plate”
24 HR average home diet: nutritional requirements, but the patient did not satisfy the
Breakfast: Prunes, cereal, low-fat milk refined grain and dairy components. The patient consumes
plenty of vegetables and fruits, but must add more whole
Lunch: Salad, soup, grapefruit, prunes grains and dairy products.
I would recommend the patient to add in whole grain foods
Dinner: Vegetables with fish or chicken and dairy products to his lunch and dinner. The patient
could potentially add 1 cup of brown rice or 1 cup of
Snacks: Nuts or fruit (tangerine) quinoa to his lunch salad. These foods have a low-glycemic
index and contain fiber. The patient can also add 1 slice of
Liquids (include alcohol): water, peppermint tea low-fat cheese and 1 glass of low-fat milk to his afternoon
snack. The patient could also add yogurt to his diet if
cheese and milk is undesirable. I was concerned that the
patient would not fulfill the “My Plate” protein
requirement, but the patient did satisfy this goal.

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? The patient elaborated on how he is rarely ever ill and that he usually takes care of
himself. When the patient is ill, it is usually with a mild cold.

How do you generally cope with stress? or What do you do when you are upset?
The patient uses exercise as a coping tool. The patient states that he usually does not experience stress. The patient says
that he can be a temperamental person, but that he always regrets his anger after an outburst.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The patient verbalizes that he has had no recent difficulties in regards to emotions and relationships.

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+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? Patient says “no.”

Have you ever been talked down to? The patient was talked down to as a child. Have you ever been hit punched or
slapped? The patient was hit as a child.

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Patient states “yes.” If yes, have you sought help for this? The patient sought therapy.

Are you currently in a safe relationship? The patient states “yes.” The patient has been married for 62 years.

 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: Ego integrity vs. despair is the stage where the person reflects over one’s life and accepts its meaning. The
successful completion of this stage is looking back at ones’ life and feeling a sense of integrity and fulfillment. The individual also
exhibits a willingness to face and accept death. Unsuccessful completion of this stage is despair. The person experiences
dissatisfaction with life and does not want to face death. (Halter, 2014; Davis's Drug Guide, 2000-2017)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
I believe my patient is in the integrity stage because he seemed very content and at peace with himself and the life he has
lived. He seemed content and fulfilled with his past profession, and although he is retired, he still lives an active lifestyle
at the age of 84. He smiled and laughed often and even made jokes.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The patient was diagnosed with influenza A and he seemed to be taken aback at the fact that he did indeed have the flu. It
seemed as though he thought this illness came out of the blue. Given this, the patient was very light-hearted an in a very
joyful mood. He did not seem to be negatively affected by this hospitalization.
+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
The patient says that the cause of his illness was incubating the flu.

What does your illness mean to you?

The patient wants to go home and he does not think that he needed this hospitalization.

+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? The patient has and still is currently sexually active.
Do you prefer women, men or both genders? The patient prefers women.
Are you aware of ever having a sexually transmitted infection? The patient is not aware of any sexually transmitted
infection and he believes he has never had one.
Have you or a partner ever had an abnormal pap smear? Patient thinks that perhaps his wife has had an abnormal pap
smear.

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Have you or your partner received the Gardasil (HPV) vaccination? Patient and wife have not received Gardasil.

Are you currently sexually active? The patient is sexually active. If yes, are you in a monogamous relationship? Patient is
in a monogamous relationship. When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? The patient takes no measures.

How long have you been with your current partner? The patient has been with his partner for 62 years.
Have any medical or surgical conditions changed your ability to have sexual activity? Past prostate cancer has made it
difficult for the patient to ejaculate.

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
Patient has no concerns.

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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?
The patient identifies with Judaism but does not believe in a divinity. The patient does not understand how a higher power could have
allowed the Holocaust to occur.
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
N/A.

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
For how many years? Roughly
If so, what? How much?(specify daily amount)
20 years
The client began smoking 1 pack a
Cigarettes (age 20 thru 40 )
day in college.
The patient first smoked a
cigarette at 9 years of age.
If applicable, when did the
Pack Years:
patient quit? 40 years ago.

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?
The patient’s wife smoked cigarettes in the past but successfully quit. She smoked a quarter of a pack a day.
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
How much? 1-2 glasses of wine
What? For how many years?
1 glass of vodka
Wine and vodka. Volume: (age 40 thru 84 )
The patient started drinking
Frequency: Every day.
regularly 40 years ago.
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?
Yes. Marijuana. How much? For how many years?
Amount is unknown. (age thru ) -Unknown
The patient smoked recreationally at
times in the 70’s.
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
The patient was exposed to hazards while he lived in China because the bombing done by Japan. The patient also worked
in a psychiatric hospital for 1 year.

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 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
Pancreatitis
Hives or rashes Sarcoidosis
Contracted dysentery in China
Skin infections Colitis Tumor
Use of sunscreen SPF: Diverticulitis Life threatening allergic reaction
Bathing routine: Appendicitis Enlarged lymph nodes
Other: Patient does not use sunscreen
Abdominal Abscess Other:
because he only swims after 3pm.
Last colonoscopy?
HEENT Other: Hematologic/Oncologic
Difficulty seeing- wears glasses Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily- varicose veins
Difficulty hearing –wears hearing aids dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: O+
Normal frequency of urination: 8-9
Post-nasal drip Other:
x/day
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 Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry & 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? Yesterday. menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia (borderline) Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? 1x year 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
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 Last EKG screening, when? Arthritis- in left toe 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? The patient believes he is in good health and is content with his 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? No.

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±10 PHYSICAL EXAMINATION:

General Survey: Alert Height 59 inches Weight 175 lbs. BMI 37.62 Pain: (include rating and
and oriented. Patient is Pulse 92 bpm Blood Pressure: (include location) location)
awake and talkative. Respirations 19 No pain.
Temperature: (route SpO2 Is the patient on Room Air or O2
taken?) 94% 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

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]

clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: Location: Date inserted:
Fluids infusing? no yes - what? IV Solumedrol

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:
Comments:

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL LUL- wheezing
RML-crackles LLL- wheezing
RLL

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

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

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

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

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date / / ) 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: Straw 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 _______ RUE _______ LUE _______ RLE & _______ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

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

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±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis

Influenza A 2/6/17 Positive.

The patient tested
positive for influenza A,
and now antiviral
treatment can commence.
Influenza B Negative.
SGR-chest 2/6/17 Mild streaky atelectasis
posterioranterior and or fibrosis noted in the
lateral X-ray lung bases. Otherwise,
lungs are clear.
The chest X-ray was done
on this patient to examine
other possible causes of
his current SOB and
wheezing, given his
history of asthma.
Glucose 2/6/17 91
The patient is on steroids,
which can cause
hyperglycemia, therefore
his serum glucose should
be monitored. The normal
glucose range is 70-110
and 91 falls within this
range.
Potassium 2/6/17 4.6
Albuterol and
methylprednisolone can
cause hypokalemia,
therefore potassium
levels should be
monitored. The patient’s
potassium falls within the
normal potassium range
of 3.5-5.3

+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.)
The patient had a scheduled echocardiogram for 2/7/17 to determine if the patient has chronic pulmonary heart
University of South Florida College of Nursing – Revision September 2014 14
disease. The patient has had asthma for about 30-40 years and also underwent aortic valve replacement in 2011.
The echocardiogram will help determine the patient’s current heart status. Given the patient’s diagnosis of
influenza A and his history of asthma, O2 saturation levels should be monitored to ensure the patient is perfusing
adequately. The patient should be encouraged to use his incentive spirometer to aid in optimal inflation of the
lungs and in the prevention of pneumonia.

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

1. Readiness for enhanced health management related to influenza A as evidence by desire to enhance
management of present illness.

2. Activity intolerance related to fatigue as evidence by shortness of breath.

3. Ineffective breathing pattern related to asthma as evidence by dyspnea.

4.

5.

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± 15 CARE PLAN
Nursing Diagnosis: Readiness for enhanced health management related to influenza A as evidence by desire to enhance management of present
illness.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
* Compliance to antiviral treatment 1). Provide knowledge as needed 1). Knowledge on the antiviral 1). Patient will demonstrate
regimen through adequate related to the pathophysiology of medication and prevention of commitment to antiviral therapy
education. the illness, prescribed activities, influenza through immunization for the prescribed number of days.
and prescribed medications. and will contribute to the client’s
taking action for health promotion
and protection.

2). Review the patient’s strengths
in the management in of the
therapeutic regimen.
2). Knowledge, self-efficacy, self- 2). Patient reflects and verbalizes a
esteem, and emphasizing benefits minimum of two of his strengths.
of medication compliance will
increase the patient’s desire to
follow the full course of
medication.

3). Help the client maintain 3). Ongoing social support has3). Wife verbalizes that she will
existing support and seek shown to be a factor contributing to
assist her husband with the
additional supporters as needed. the ongoing maintenance of adherence of his medication. Wife
positive health behaviors. verbalizes frequency and length of
drug therapy.
±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 patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
□Palliative Care
University of South Florida College of Nursing – Revision September 2014 16
± 15 CARE PLAN
Nursing Diagnosis: Ineffective breathing pattern related to asthma as evidence by dyspnea.
Patient Goals/Outcomes Nursing Interventions to Rationale for Interventions Evaluation of Goal on Day Care
Achieve Goal Provide References is Provided
Patient’s shortness of breath and 1). Monitor respiratory rate, depth, 1). Monitoring the patient’s 1). Respiratory rate was kept 12-
wheezing diminishes, and O2 and ease of respiration. breathing is of utmost importance 20 breaths/minute.
saturation and respiratory rate is given his condition, age, and past
kept within normal ranges. medical history.

2). Encourage use of incentive
spirometer.
2). Using the incentive spirometer 2). The patient successfully uses
decreases the patient’s risks for the incentive spirometer ten times
pneumonia and other respiratory per hour.
complications. The Incentive
spirometer increases lung capacity,
aids in tissue perfusion, and
strengthens the lungs.

3). Assist the client and family 3). Awareness of precipitating 3). Patient and wife verbalize
with identifying other factors that factors helps clients avoid them precipitating factors that result in
precipitate or exacerbate episodes and decreases ineffective breathing ineffective breathing episodes.
of ineffective breathing patterns. episodes.

±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 patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
□Palliative Care

University of South Florida College of Nursing – Revision September 2014 17

 References

Ackley, B. J., Ladwig, G. B., & Flynn Makic, M. (2017). Nursing Diagnosis Handbook an Evidence-Based

Guide to Planning Care (11th ed.). St. Louis , MO: Elsevier.

Centers for Disease Control and Prevention . (2016, October 26). Influenza Signs and Symptoms and the Role of

Labratory Diagnostics .

Davis's Drug Guide. (2000-2017). Davis's Drug Guide . (Unbound Medicine Inc. )

Halter, M. J. (2014). Varcarolis' Foundations of Psychiatric Mental Health Nursing (7th ed.). St. Louis , MO:

Elsevier.

Huether, S. E., & McCance , K. L. (2017). Understanding Pathophysiology (6th ed.). St. Louis, MO: Elsevier.

United States Department of Agriculture . (n.d.). Retrieved from ChooseMyPlate.gov.

World Health Organization. (2016, November ). Avian and other zoonotic influenza. Retrieved from World

Health Organization.

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