UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Marline Faustin

Assignment Date: 02/11/16
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: TGH
1 PATIENT INFORMATION
Patient Initials: Y.S Age:65 Admission Date: 02/02/2016
Gender: Female Marital Status: Married Primary Medical Diagnosis: Encephalopathy
(348.30) (G93.40)
Primary Language: English
Level of Education: High School Diploma Other Medical Diagnoses: (new on this admission)
Patient states I dont know I have a lot of
problems
Occupation (if retired, what from?):Retired Manager Retired Manager from T-mobile
Number/ages children/siblings: One Son 41 y.o; One Brother 70
y.o
Served/Veteran: No Code Status: DNR
If yes: Ever deployed? : N/A
Living Arrangements: Patient indicates that she lives in a 3x2 one Advanced Directives: Yes
story house with husband and two dogs. If no, do they want to fill them out?
Surgery Date: N/A Procedure: N/A
Culture/ Ethnicity /Nationality: Caucasian /American
Religion: Non-denominational Christian Type of Insurance: Humana

1 CHIEF COMPLAINT:
I have terrible pain in my side and my neck , I just feel pain allover

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) This 65 y.o female presented into the emergency room on 2/2/16 with altered mental status accompanied by her
husband who was the story teller. Per husband patient was normal prior to day of admission. Husband woke up early the
morning of admission to walk their dogs and found the patient confused with unsteady gait. Per patient she states I really
dont know when the pain started I think about a month ago patient didnt recall her confusion on admission. Patient
stated that the location of her pain was all over her body and that it was a constant pain that felt like something was
stabbing her. Movement, walking and eating made the pain more aggravating. Per patient pain medication made it more
tolerable. Upon presentation to TGH patient underwent CTH w/o contrast showing no acute findings. Labs
for UDS were negative but with UA suggestive of UTI. Patient also underwent MRI of lumbar spine that showed scoliosis
with normal cervical MRI. Patient was also seen by psychiatry and was started on Cymbalta for anxiety.
Patient was diagnosed with encephalopathy upon admission related to suggestive UTI and was treated with Macrobid.
Now patient is AAOX3 with no signs of UTI and with possible discharge.

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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
2004 Vulva dysplasia: Tx. Vulvectomy
2008 Hypothyroidism: Tx. Synthroid 100mcg daily
08/23/2014 LE weakness Tx. Hospitalization /Cerebral aneurysm s/p coiling
2015 Scoliosis: Tx baclofen 10mg

(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 (age of
48 Accident
death)
Mother N/A Sickness
Brother 70
Sister N/A
relationship

relationship

relationship

Comments: Include age of onset

Mother: age of onset is unknown per patient
Father: age of onset for diabetes per patient was 30.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations U
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U
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
Codeine makes me really itchy

Medications

N/A
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)
Encephalopathy is a broad term used to describe brain damage, malfunctioning or disease. The common symptom of this
disorder is an altered mental status. The causes of this brain abnormality are numerous and varied. Several examples of
the causes of encephalopathy are; infections, anoxia, metabolic problems, toxins, drugs, trauma and physiological
changes. Encephalopathy is always a result of an underlying complication that can either be from kidney failure,
cirrhosis, anoxia or alcoholism. When the underlying cause is treated early this can eradicate or reduce the symptoms
depending on what type of encephalopathy it is. With infectious encephalopathy bacteria, viruses, parasites enter the
blood stream and cross the blood brain barrier. With anoxic encephalopathy it is usually due to trauma where enough
oxygen cannot get to the brain. Metabolic encephalopathy is usually due to an imbalance of electrolytes or essential
minerals that causes damage to the brain. The prognosis for a patient with encephalopathy is always dependent on the
underlying cause. When treatment is delayed of the underlying causes severe brain damage can occur , coma and even
death. The most important component in prevention of encephalopathy is limiting or stopping the chance of any of the
multitudes of underlying causes.

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

Route PO Frequency B.I.D

Pharmaceutical class Antispacity Agent Home X Hospital or Both
Indication Treatment of reversible spasticity due to multiple sclerosis or spinal cord lesions.
Adverse/ Side effects Drowsiness, fatigue, weakness, seizures, nausea
Nursing considerations/ Patient Teaching: Take exactly as directed; do not double dose if a dose is missed; report any adverse effects.

Name Tegretol XR (carbamazepine) Concentration N/A Dosage Amount 100mg

Route PO Frequency B.I.D

Pharmaceutical class Mood stablizers Home X Hospital or Both
Indication Treatment of tonic-clonic, mixed, and complex-partial seizures; Neurogenic pain
Adverse/ Side effects: Suicidal thoughts, ataxia, drowsiness, Steven Johnsons Syndrome, toxic epidermal necrolysis, aplastic anemia, thrombocytopenia
Nursing considerations/ Patient Teaching: Avoid drinking grapefruit juice with this medication; monitor signs of adverse effects

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Name Cymbalta DR (duloxetine) Concentration N/A Dosage Amount 60 mg

Route PO Frequency Daily

Pharmaceutical class SSNRIs; antidepressant Home Hospital or Both X
Indication General anxiety disorder; major depression
Adverse/ Side effects Neuroleptic malignant syndrome, seizures, suicidal thoughts; drowsiness; insomnia; constipation; dysuria; sweating
Nursing considerations/ Patient Teaching Avoid driving or heavy machinery; do not take with alcohol; monitor for signs of adverse effects

Name Lovenox (enoxaparin) Concentration N/A Dosage Amount 40mg

Route SQ Frequency Daily

Pharmaceutical class Low molecular weight heparin /antithrombic Home Hospital X or Both
Indication Prevents VTE; Treatment for acute ST segment elevation
Adverse/ Side effects Bleeding; anemia : thrombocytopenia
Nursing considerations/ Patient Teaching Report any signs of bleeding; Do not take aspirin while on this drug

Name Dilaudid (hydromorphone) Concentration N/A Dosage Amount 4-6 mg

Route PO Frequency PRN Q3hrs

Pharmaceutical class Opioid agonist Home Hospital X or Both
Indication Moderate to severe pain
Adverse/ Side effects constipation; hypotension; respiratory depression; confusion; sedation
Nursing considerations/ Patient Teaching Change position slowly to minimize orthostatic hypotension; Advise patient on the abuse pontential of this drug; monitor
RR.

Name Macrobid (nitrofurantoin) Concentration N/A Dosage Amount 100mg

Route PO Frequency Q12hrs

Pharmaceutical class Anti-infectives Home Hospital X or Both
Indication Prevention and treatment for urinary tract infections
Adverse/ Side effects Hepatotoxicity; C.diff; anorexia; pulmonary fibrosis; nausea; vomiting;
Nursing considerations/ Patient Teaching: Take medication as prescribed; Watch for adverse effects; Monitor bowel functions

Name Zofran HCl (ondansetron) Concentration 4mg/2ml Dosage Amount 4mg

Route IV Frequency Q6hrs PRN

Pharmaceutical class: antiemetic Home Hospital X or Both
Indication Prevention of nausea and vomiting
Adverse/ Side effects: Serotonin syndrome; HA; dizziness; Steven-Johnson Syndrome
Nursing considerations/ Patient Teaching : Monitor ECG; Take as directed; notify HCP/Nurse of any side effects or adverse effects.

Name Synthroid,Levothroid (levothyroxine) Concentration N/A Dosage Amount 100 mcg

Route PO Frequency Daily

Pharmaceutical class Thyroid preparations Home Hospital or Both X
Indication Hypothyroidism
Adverse/ Side effects: HA, arrhythmias; irritability; sweating
Nursing considerations/ Patient Teaching: Monitor adverse effects; inform patient to take medication at the same time every day 1 hour before meals or 2 hours after

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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? Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Consider co-morbidities and cultural considerations):
24 HR average home diet:

Breakfast:2 Scramble eggs; 1 cup of coffee; 1 slice of According to My Plate this patients 24 hr meal plan for
wheat toast ; banana this particular day she chose was over the recommended
caloric intake. The recommended was 2000 calories and
My Plate calculated she had 2139 calories. Given that she
doesnt have any medical Hx of HTN or diabetes she can
follow a regular diet; but My Plate suggested that she
increases her intakes of vegetables, whole grains and dairy
while she limits her intake of proteins and fruits. The
recommended portion sizes for this Caucasian female is 6
oz of whole grains, 2.5 cups of vegetables 3 cups of fruit
and 5 oz of protein. As you can see on the graph it shows
where she is missing portions and where she is over.

Lunch: grilled chicken salad; fresh mix fruit; diet coke

Dinner: Chicken stir-fry; garlic bread ; ice-cream and

cranberry juice/water

Snacks: Almonds and Cheddar cheese; 8 oz. diet coke

Liquids (include alcohol): 8 oz.Diet coke; coffee; cranberry

juice; water

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? My husband does

How do you generally cope with stress? or What do you do when you are upset? Well, I usually talk about it and resolve
whatever thats stressing me out

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Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I suffer from depression and anxiety every once in a while but I take medications for itI dont want to really get into
detail sorry

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? ___No_____

Have you ever been talked down to?_____No__________ Have you ever been hit punched or slapped? No
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
___________________No_______________________ If yes, have you sought help for this? N/A
Are you currently in a safe relationship? Yes Im married with a wonderful husband

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: 65 y.o Integrity vs. Despair
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
According to Eriksons developmental stage my patient falls within the eighth stage of development which is Ego integrity vs.
despair. In this stage of development these older adults are retired and reflect back on their life and contemplate whether if it was a
productive and successful life or unproductive and unsuccessful life. When they feel that theyve reached success in this stage it
leads to the virtue of wisdom. If theyve reflect back and found their life as not a success it leads to depression and despair. As for
my patient I feel that she falls within disparity instead of Ego integrity. I say this because of the numerous of antidepressants she
stated she has been on. She appeared to be anxious and refused to talk about the cause of her depression.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
Patient mentioned that her diseases have limited her ability to take care of her two dogs and that she is barely able to
take them on walks. She mentioned that bother her because her dogs are her babies.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?: I dont know thats why Im here

What does your illness mean to you? It means that Im sick. I dont blame it on God he has a reason for everything he
does.

+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? ______Men_______________________________
Are you aware of ever having a sexually transmitted infection? _________No______________________________
Have you or a partner ever had an abnormal pap smear?_____Yes______________________________
Have you or your partner received the Gardasil (HPV) vaccination? ____________No___________________

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Are you currently sexually active? No_____ If yes, are you in a monogamous relationship? ____N/A___________
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? ________No

How long have you been with your current partner?__________________21 years___________________

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

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

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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?
____ A lot I pray all the time_______________________________________________
________________________________________________________________________________________
Do your religious beliefs influence your current condition?
___________No why would it____________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? YesX No
If so, what? How much?(specify daily amount) For how many years? X years
1 pack every 3 days (0.25 packs per
Cigarettes (age 45 thru 65 )
day)
If applicable, when did the
Pack Years: 6 years N/A
patient quit?
N/A 5 months ago
Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? No If yes, what did they use to try to quit? determination
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No X
What? N/A How much? (give specific volume) For how many years?N/A
Volume: N/A (age thru )
Frequency:
N/A
Socially= 1X week or month??
If applicable, when did the patient quit? How many drinks 2 or 9? Be specific N/A
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No X
If so, what? N/A
How much? N/A For how many years? N/A
(age thru )

Is the patient currently using these drugs?

If not, when did he/she quit? N/a
Yes No N/A
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks No
5. For Veterans: Have you had any kind of service related exposure? N/A

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 10 REVIEW OF SYSTEMS
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: Diverticulitis Life threatening allergic reaction
Bathing routine: Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other: Scoliosis
Be sure to answer the highlighted area Last colonoscopy? Dont recall
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: A-
Post-nasal drip Normal frequency of urination: 6 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2 x/day Diabetes Type:
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? 11 Encephalitis
last CXR? menopause 51 age? Meningitis
Other: Date of last Mammogram &Result: Other: Encephalopathy
Date of DEXA Bone Density & Result:
Cardiovascular N/A 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
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 02/02/16 Arthritis Chicken Pox
Other: Other: Other:

General Constitution
Recent weight loss or gain
How many lbs? 20 lbs
Time frame? One month
Intentional? No
How do you view your overall health? Sick
University of South Florida College of Nursing Revision September 2014 9
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 patient seems very anxious and is reluctant to carry on.

University of South Florida College of Nursing Revision September 2014 10

10 PHYSICAL EXAMINATION:

General Survey: Appears Height 55 Weight 130 BMI22.3 Pain: (include rating and
well developed and well- Pulse 95 Blood Pressure: (include location) location)
nourished. Respirations 20 149/83 Left arm 7 (0-10 scale) All over
Temperature: (route SpO2 97% Is the patient on Room Air or O2 :
taken?) 99.4 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, agitated, 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?

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: Patient is only missing dentures facial symmetry is WDL

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 X Amount: scant small X moderate large
Color: whiteX pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL CL LUL CL
RML inspiratory wheezing LLL inspiratory wheezing
RLL inspiratory wheezing

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
University of South Florida College of Nursing Revision September 2014 11
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze) : Normal Sinus Rhythm

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: Carotid: Brachial: Radial: Femoral: Popliteal: DP: PT:
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

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 02 / 09 / 2016 ) Formed Semi-formed Unformed Soft X Hard Liquid
Watery
Color: Light brown Medium Brown X 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: (upon admission it was cloudy during assessment it was clear)
Previous 24 hour output: mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance X
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___ 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 : Scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

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

University of South Florida College of Nursing Revision September 2014 12

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):
Urinalysis: Upon admissions a urinalysis was done and patients urine appeared cloudy slightly foul smell;
positive for nitrites which is indicative of infection.
Urine Culture: positive for E.choli upon admission. Then after antibiotic treatment urine culture was negative of
E. coli.
ECG (12 lead): Patient reported chest pain upon admission Ecg showed no abnormalities of T wave results
showed normal sinus rhythms. Patient was removed off telemetry monitor as of 02/10/2016.
UDS: Negative toxicology
CXR: Tiny bilateral pleural effusions; cardiomediastinal silhouette was normal in vasculature
CTH: No evidence of acute intracranial pathology.
Brain MRI: No evidence of cerebral hemorrhage; No restricted diffusion to suggest ischemia.

Lab Dates Trend Analysis

Glucose 80 Patients glucose values
02/08 104 are on an upward trend
02/09 100 but are normal because
02/10 patient is not diabetic.

Sodium 02/08 137 Patients Na+ levels are

02/09 140 within defined limits her
02/10 139 disease process or
polypharmacy is not
affecting it.
Potassium 02/08 3.9 Patients K+ are WDL
02/09 4.1 there is no significant
02/10 4.1 trend to determine
problem

BUN 02/08 9 Patients BUN is in WDL

02/09 9 no significant trend that
02/10 7 needs to be assessed.

Creatinine 02/08 0.7 Patients Cr is WDL upon

02/09 0.8 admission and throughout
02/10 0.9 hospitalization.

WBC 02/08 5.65 The trend on the patients

02/09 5.21 WBC seems to be normal
02/10 4.49 up until the last day. I
would say the reason for
this minute drop would
be due to her antibiotics
that shes been on that
was fighting her UTI.
Although I find it strange
that her WBC werent
University of South Florida College of Nursing Revision September 2014 13
 remarkably high upon
admission since the
suggestive diagnosis was
a UTI.
RBC 02/08 3.35 The low RBC trend here
02/09 3.49 that is fluctuating is
02/10 3.40 related to the low
hemoglobin count that is
caused by her
hypothyroidism. You can
see that the numbers
move in the same
directions.
HMG 02/08 9.7 According to these trends
02/09 10.3 my patients hemoglobin
02/10 9.8 is low. I would say there
is a few factors that may
cause this fluctuation in
her HMG the main one is
that she has
hypothyroidism. Studies
show low Hmg levels is
associated with
hypothyroidism.
PLT 02/08 262 According to these trends
02/09 267 my patient seems to have
02/10 296 a regular platelet count
with no significant
changes.

+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.)
Patient was on fall risk precautions; regular diet was ordered; vitals were WDL; psychiatric consult was ordered
due to patients altered mental status upon admission and Hx of antidepressants; As listed above patient
underwent CTH, Brain MRI, UA,UDS,CXR, Urine culture exam prior to diagnosis.

University of South Florida College of Nursing Revision September 2014 14

 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Acute confusion r/t over 60 years of age as evidence by fluctuation in cognition upon admission.
Sn: My diagnosis was encephalopathy but I couldnt find a nada diagnosis for it because on the patient chart it said the
encephalopathy was unspecified. So I chose this one because altered mental status/confusion commonly occurs in older
adults when they have UTIs.
2.

3.

4.

5.

University of South Florida College of Nursing Revision September 2014 15

 15 CARE PLAN
Nursing Diagnosis: Acute confusion r/t over 60 years of age as evidence by fluctuation in cognition upon admission.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References (Ackleys) is Provided
Client will demonstrate restoration Assess the clients By assessing the patients cognition Patient is now alert and oriented to
of cognitive status to baseline once behavior and cognition and behavior throughout the day time, place and person. This can be
treatment is finished. systematically and continually and night puts a lower risk of evaluated by utilizing the
throughout the day and night as injury to these older patients as Confusion Assessment Tool.
appropriate. well as helping the nurse monitor
the progression of the patients
health.
Client will maintain Functional 1.)Treating the underlying cause By treating the underlying cause of By asking the patient to use
capacity before and after discharge of confusion in collaboration with confusion patients capacity to returned demonstration or by
the health care team function will be restored. observing the patient complete
2.) Maintaining normal electrolyte ADLs is a way this goal or
balance, making sure adequate outcome can be evaluated.
nutrition is being met, normal
oxygenation and normal body
temperature

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 *

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 References

Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed.). Maryland

Heights., Minnesota: Elsevier.

Encephalopathy Symptoms, Causes, Treatment - What is the prognosis (outlook) for encephalopathy? - MedicineNet.
(n.d.). Retrieved February 22, 2016, from
http://www.medicinenet.com/encephalopathy/page7.htm#what_is_the_prognosis_outlook_for_encephalopathy

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