UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Nicholas Travis

Assignment Date: 9/6/16
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: TGH
1 PATIENT INFORMATION
Patient Initials: MGT Age: 73 Admission Date: 08/29/16
Gender: Male Marital Status: Married Primary Medical Diagnosis Recurrent Left Plural
Effusion
Primary Language: English
Level of Education: Bachelors Degree Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired Teacher Thrombosis
Number/ages children/siblings: 2 children- 47 y/o son and 52 y/o
daughter
2 siblings- 64 y/o brother and 72 y/o sister
Served/Veteran: No Code Status: Full Code
If yes: Ever deployed? Yes or No
Living Arrangements: Lives at home with wife Advanced Directives: None
If no, do they want to fill them out? No
Surgery Date: 8/29/16 Procedure: N/A
Culture/ Ethnicity /Nationality: Irish/Italian
Religion: Methodist Type of Insurance: Medicare

1 CHIEF COMPLAINT:
I have a problem with getting fluid in my lungs. This has happened to me 4 times before, so when I started to get short of
breath I knew I had to come in.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
O- 09/05/16
L- Left arm
D- intermittent
C- sharp/stabbing
A- Touch/movement
R- N/A
T- none
S- 3/10
The patient was admitted on 8/29 for a recurrent pleural effusion not controlled by thoracentesis. The pt had a
decortication on 8/29 in an attempt to prevent future effusions. Patient was recovering well with no pain until 9/5 when he
began to have a sharp pain in his left arm. Ultrasound reveals a thrombus in the left cephalic vein/

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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
2003 A- Fib
2014 CAD with 3 stents
2010 Stage 3 chronic renal insufficiency
2005 Type 2 Diabetes Mellitus
5/14 Right sided diaghpragmic paralysis
1993 HTN
03/14 Idiopathic pulmonary fibrosis
5/19/14 VRE
5/6/14 Bilateral lung transplant
GERD

2
Age (in years)

Environmenta

Heart Trouble
Bleeds Easily

(angina, MI, DVT etc.)

Hypertension
FAMILY Cause
Alcoholism

l Allergies

Glaucoma

of

Problems

Problems
MEDICAL

Stomach
Diabetes
Arthritis

Seizures
Anemia

Death
Asthma

Kidney
Mental
Cancer

Tumor
Health

Stroke
Ulcers
HISTORY (if
Gout

applicable
)
Father 68 Unknown X X
Mother 79 COPD
Brother 64 X
Breast
Sister 72 X
cancer
relationship

relationship

relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO

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 Routine childhood vaccinations X
Routine adult vaccinations for military or federal service X
Adult Diphtheria (Date) Unknown Date X
Adult Tetanus (Date) Is within 10 years? 04/20/14 X
Influenza (flu) (Date) Is within 1 years? X
Pneumococcal (pneumonia) (Date) Is within 5 years? 07/01/15 X
Have you had any other vaccines given for international travel or
occupational purposes? Please List Patient cannot recall. X
If yes: give date, can state U for the patient not knowing date received

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Demerol Nausea
Levaquin Tendinitis
Medications

None known
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)
A pleural effusion is an accumulation of fluid between the parietal and visceral pleura in the chest cavity.
Pleural effusions can be classified as either exudative or transudative. Exudate is a fluid that oozed from an
area of injury or inflammation. It is characteristically high in cellular debris and protein. Transudate, on the
other hand, is secreted secondary to changes in capillary pressures (Osborn, Wraa & Watson, 2014, p. 779-780).

There are over 50 possible causes of pleural effusions. Frequent causes of exudative pleural effusions include
tuberculosis, trauma, asbestos exposure, pulmonary embolism, infection, and vascular diseases. Conversely,
transudative pleural effusions can be caused by hypothyroidism, pulmonary embolism, cirrhosis, renal
disorders, or most commonly; congestive heart failure (Osborn, Wraa & Watson, 2014, p. 779-780).

Post lung transplant pleural effusions are common as well. There are several factors that can lead to this
complication. Post transplant effusions can occur secondary to graft rejection, immunosuppressants, and
pleural damage sustained during the procedure (Leard, 2016).

Normally, there is 10-20 ml of serous fluid between the visceral and parietal pleura. This fluid acts as a
lubricant, which aids in inspiration and expiration. In a patient with pleural effusion, there is excess fluid in this
pleural space. The excess fluid can compress the lungs or diaphragm. In extreme cases, the fluid can even
compress the heart, resulting in cardiac tamponade (Osborn, Wraa & Watson, 2014, p. 780).

The signs and symptoms of pleural effusion vary greatly with the underlying etiology. Some patients may be
asymptomatic while others will complain of difficulty breathing, pleuritic chest pain, persistent cough, or
referred pain to the neck, shoulder, or abdomen. Common assessment findings include dullness upon
percussion, lack of tactile fremitus, pleural friction rub, and diminished breath sounds on the affected side
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(Osborn, Wraa & Watson, 2014, p. 780).

Useful diagnostic tests include X-Ray, CT, and ultrasound imaging. These imaging tests are used to determine
the amount and location(s) of fluid accumulation. The most commonly ordered chest X-Rays ordered are
upright lateral and upright anterior-posterior radiographs. Pleural effusions are much easier to identify on
upright images than supine images due to the pooling of fluid. After the fluid is located, thoracentesis may be
preformed to obtain further analysis of the fluid (Osborn, Wraa & Watson, 2014, p. 780).

Treatment recommendations vary greatly from patient to patient. The priority for most patients is treatment of
the underlying cause, which will often lead to the pleural effusion resolving on its own. For more severe cases, a
thoracentesis is often preformed. This involves draining the fluid through a needle or catheter that is inserted in
the chest wall. For persistent effusions, repeat thoracentesis may not be enough. These patients may require
shunts, pleurodesis, pleural catheters, or even a pleurectomy (Osborn, Wraa & Watson, 2014, p. 780).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation),
routine, and PRN medication . Give trade and generic name.]
Name Sirolimus/Rapamune Concentration 2mg per tab Dosage Amount 2 mg

Route PO Frequency qd
Pharmaceutical class Immunosuppressants Both
Indication Rejection prophylaxis
Adverse/ Side effects Opportunistic infections. PML, venous thromboembolism, angioedema, ascites, pleural effusion.
Nursing considerations/ Patient Teaching- Side effects exhibited in the pt are pleular effusion, thromboembolism. Watch out for infections

Name Norvasc/Amlodipine Concentration 5mg per tab Dosage Amount 5mg

Route PO Frequency qd
Pharmaceutical class Calcium channel blocker Both
Indication Antidysthrythmic
Adverse/ Side effects Angina, hypotension, fatigue, bausea, dizziness, palptations
Nursing considerations/ Patient Teaching Report dizziness, stand up slow,

Name Zithromax/Azithromycin Concentration 250mg tab Dosage Amount 250 mg

Route PO Frequency qd
Pharmaceutical class macrolides Hospital
Indication Bacterial infection
Adverse/ Side effects- angioedema, hepatatoxic, torsades, diarrhea, nausea, abd pain
Nursing considerations/ Patient Teaching- Medication must be takens as prescribed if continued after discharge`

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Name Lasix/Furosemide Concentration 40 mg tab Dosage Amount 40 mg

Route PO Frequency qd
Pharmaceutical class Loop Diuretic Both
Indication- renal insuf.
Adverse/ Side effects- Hypokalemia, metabolic alkalosis, anemia, anaphylaxis
Nursing considerations/ Patient Teaching- look for dizziness when standing

Name Prednisone//Deltasone Concentration 2.5 mg per tab Dosage Amount 5 mg

Route PO Frequency qd
Pharmaceutical class- corticosteroid Both
Indication- anti-inflammatory effects.
Adverse/ Side effects- anaphylaxis, adrenal insuf. Indection, HTN, CHF, fluid retention, hypokalemia, edema, nausea
Nursing considerations/ Patient Teaching- Monitor edema regularly and report and changes to the doctor

Name Prograf/Tacrolimus Concentration 10 mg per tab Dosage Amount 10 mg

Route PO Frequency q12h

Pharmaceutical class- Immunosuppressants Both
Indication Rejection prophylaxis
Adverse/ Side effects- infection, malignancy, lymphoma, tremor, diarrhea, headache, HTN, nausea/vomiting
Nursing considerations/ Patient Teaching- Look for s/s of infections and contact provider at first sign of infection

Name Lantus Concentration 100 units/ ml Dosage Amount 10 units

Route - SQ Frequency qd
Pharmaceutical class Insulin Both
Indication- Hyperglycemia
Adverse/ Side effects- hypoglycemia, hypokalemia, rash, weight gain, headache, edema
Nursing considerations/ Patient Teaching- make sure you have meals planned throughout the day while taking insulin.

Name Novolog Concentration 100 units/ml Dosage Amount sliding scale

Route- SC Frequency- before meals

Pharmaceutical class- Insulin Both
Indication- Hyperglcemia, DM management
Adverse/ Side effects- hypoglycemia, hypokalemia, anaphylaxis, injection site pain, rash, weight gain, headache
Nursing considerations/ Patient Teaching- Have food ready prior to injecting novolog

Name Norco/Acet-hydrocodone Concentration 5/325 per tab Dosage Amount 5mg/325mg

Route PO Frequency PRN q 8 hrs

Pharmaceutical class Opioid Hospital
Indication- Pain management
Adverse/ Side effects- resp. depression, hepatotoxic, adrenal insufficiency, lightheaded, dizzy, nausea/vomiting, constipation
Nursing considerations/ Patient Teaching- Patient needs to let staff know if he wants his pain medications b/c its a PRN order

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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? Regular Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Unrestricted Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: 2 Eggs, 3 slices of bacon, OJ, and 1 piece of The patients home diet has some areas of concern and
toast is certainly not ideal. The positives of the patients diet
are that he is getting adequate protein and vegetable
intake. Having adequate protein intake will help the
patient heal and recover from his illness and the
procedures. The vegetables will help as well,
providing essential nutrients to the patient.

There are, however, several areas of concern within

his diet. The first area of concern is his sugar intake.
The positive is that his sugar consumption is almost
exclusively from fruits. However, with his diabetes,
the patient must be educated on how fruits can affect
his blood sugar. As long as the patient understands
this, fruit can play an important role in a diabetic diet.

The next area of concern is the patients sodium

intake. The patient had over 3,000 mg of sodium in his
24 hr diet. This level of sodium is far too high,
especially when considering the patients medical
history and medications. Increased sodium intake will
lead to fluid retention. The patient has a history of
renal insufficiency, which means that there is already
decreased dieresis in the body. In addition, the
patients corticosteroids and the immunosuppressants
have edema listed as a possible side effect.

Lunch: Turkey sandwich, French fries, and unsweet tea

Dinner: Meatloaf, peas, mashed potatoes,

Snacks: Beef jerky, bananas, nuts

Liquids (include alcohol): Tea, water, occasional soda

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 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? I would say the biggest help is my wife, she always takes very good care of me.

How do you generally cope with stress? or What do you do when you are upset?
I like to relax with friends and family. When Im around my family it always makes me feel better. Laughing and having
a good time seems to help a lot with my stress.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Its very frustrating to be going through this process over and over again. Im starting to wonder if they will ever
get it under control. But at the same time, I would have been dead already if it wasnt for the transplant, so I guess
I just have to deal with it.

+2 DOMESTIC VIOLENCE ASSESSMENT

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

Have you ever felt unsafe in a close relationship? ____________No___________________________________________

Have you ever been talked down to?_____Yes_____ Have you ever been hit punched or slapped? ____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

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 X 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

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patients age group: Ego integrity vs despair

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
I classify the patient as ego integrity. During integrity vs despair patients are reflecting on their lives and
accomplishments. This patient seemed to be very proud of his life so far and all of the experiences that he has had. He
seemed to be particularly proud of his family. When he spoke about them you could see the pride that he had for the
children that he and his wife raised.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of
life:
Little to none. The patients health issues had not impacted how the patient views his accomplishments or his life up to
this point. The patient feels as though these issues are simply something he has to deal with.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I have had this issue over and over, its just the way that my body has reacted to the transplants I guess.

What does your illness mean to you?

Not sure I understand the question. But it doesnt really mean anything special to me, just something I have to deal
with.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record

Have you ever been sexually active?_______________Yes____________________________________

Do you prefer women, men or both genders? ___________Women_________________________________________
Are you aware of ever having a sexually transmitted infection? _______No___________________________
Have you or a partner ever had an abnormal pap smear?__________Not that I know of_ ____________________
Have you or your partner received the Gardasil (HPV) vaccination? ________Not sure_________________

Are you currently sexually active? ________Yes___________________ If yes, are you in a monogamous relationship?
_______Yes______ When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease
or an unintended pregnancy? __________N/A________________________

How long have you been with your current partner?_________Over 50 years_________________________________

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

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 am Methodist and although I do not practice I believe with all my heart.
__________________________________________________________________________________________
__________________________________________________________________________________________
_________
Do your religious beliefs influence your current condition?
____________Yes, my wife and I pray often for healing and wellness. I feel the praying helps me to remain
positive throughout difficult times.
__________________________________________________________________________________________
__________________________________________________________________________________________
____________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No X
If so, what? How much?(specify daily amount) For how many years? 0 years
N/A N/A (age thru )

If applicable, when did the

Pack Years: N.A
patient quit?
N/A
Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much?- NO If yes, what did they use to try to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes X No
What?Beer How much? 2-3 For how many years?
Volume: 12 oz (age 21 thru 69 )
Frequency: Weekends
If applicable, when did the patient quit?
4/2012

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?
Yes No
N/A N/A

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Currently- No
Past- Not that I know of.

5. For Veterans: Have you had any kind of service related exposure?
N/A

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 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Constipation Irritable
Integumentary Night sweats
Bowel
GERD
Changes in appearance of skin Fever
Cholecystitis
Indigestion Gastritis /
Problems with nails HIV or AIDS
Ulcers
Hemorrhoids Blood in
Dandruff Lupus
the stool
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Life threatening allergic
X Use of sunscreen SPF: 15 Diverticulitis
reaction
Bathing routine: Nightly Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area X Last colonoscopy? Age 65
HEENT Other: Hematologic/Oncologic
X Difficulty seeing -- Glasses Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing X dysuria At times Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known:
Normal frequency of urination:
Post-nasal drip Other:
x/day
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
X Routine brushing of teeth 2 x/day X Diabetes Type: 2
X Routine dentist visits 1
Hypothyroid /Hyperthyroid
x/year
X Vision screening yearly Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
X Cough - dry and improving 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
Ticks or Tremors
irregular
Environmental allergies menarche age? Encephalitis
last CXR? menopause age? Meningitis
Other: Bilateral lung transplan Date of last Mammogram &Result: Other:

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Plural Effusion Date of DEXA Bone Density &
Cardiovascular Result: MEN ONLY Mental Illness
Infection of male
X Hypertension Depression
genitalia/prostate?
Hyperlipidemia X Frequency of prostate exam? Schizophrenia
Date of last prostate exam? Cant
Chest pain / Angina Anxiety
recall, but recent
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
X Injuries or Fractures Left
Murmur Childhood Diseases
arm pain
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
X Arrhythmias Osteomyelitis Scarlet Fever
X Last EKG screening, when? -
Arthritis Chicken Pox
8/31/16
Other: 2 degree type 1 and 1st
Other: Other:
degree
Blocks on and off
General Constitution
Recent weight loss or gain
How many lbs? N/A
Time frame? N/A
Intentional? N/A
How do you view your overall health? Its declining with age, thats for sure.

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, everyone here has been great at explaining what is going on. I also kinda know what to expect having been through
this multiple times before.

University of South Florida College of Nursing Revision September 2014 11

10 PHYSICAL EXAMINATION:

General Survey: Height 6 1 Weight 260 lbs BMI Pain: (include rating and
Pulse 88 Blood Pressure: (include location) location)
Respirations 20 R arm- 127/63 2/10- Right arm
Temperature: (route SpO2 98% Is the patient on Room Air or OR
taken?) RA
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
X 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]

X awake, calm, relaxed, interacts well with others, judgment intact

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

X clear, crisp diction

Mood and Affect:X pleasant X cooperative X cheerful X talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
X Skin is warm, dry, and intact X Skin turgor elastic X No rashes, lesions, or deformities
X Nails without clubbing X Capillary refill < 3 seconds X 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:X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ X Trachea midline
X Thyroid not enlarged X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge
X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
X PERRLA pupil size / mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmus
X Ears symmetric without lesions or discharge Whisper test heard: Not preformed
X Nose without lesions or discharge X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Intact
Comments:

Pulmonary/Thorax:X Respirations regular and unlabored X Transverse to AP ratio 2:1 X Chest expansion symmetric
X Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large None- dry cough
Color: white pale yellow yellow dark yellow green gray light tan brown red N/A
Lung sounds: Diminished in bases
RUL Clear LUL Clear
RML Clear LLL Diminished
RLL Diminished

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

Cardiovascular: X No lifts, heaves, or thrills
Heart sounds: X S1 S2 audible X Regular Irregular X No murmurs, clicks, or adventitious heart sounds X No JVD

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

Currently in sinus rhythm

X Calf pain bilaterally negative X Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: Not assessed DP: 3
PT: Not assessed
X No temporal or carotid bruits Edema: 2 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: Legs/arms pitting
X Extremities warm with capillary refill less than 3 seconds

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

X Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 09 / 05 / 2016 ) Formed and Soft
Color: Medium Brown
Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor X Not assessed, patient alert, oriented, denies problems
Other Describe: N/A

GU Urine output: X Clear Cloudy Color: Previous 24 hour output: 825 mLs
Foley Catheter Urinal or Bedpan X Bathroom Privileges with assistance
CVA punch without rebound tenderness Not preformed

Musculoskeletal: X Full ROM intact in all extremities without crepitus

X Strength bilaterally equal at __5___ RUE __5___ LUE __5__ RLE & __5__ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
X vertebral column without kyphosis or scoliosis
X Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological:X Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
X CN 2-12 grossly intact X Sensation intact to touch, pain, and vibration Rombergs Negative -Not
Preformed
Stereognosis, graphesthesia, and proprioception intact X 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
No available equipment to perform DTR

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
University of South Florida College of Nursing Revision September 2014 13
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

Tacrolimus- 11.3 09/0516 Steady Immunosuppressant
levels are WNL
Glucose- 214 09/06/16 Increased from Blood sugar is elevated
yesterday prior to insulin
administration
BUN- 62 09/05/16 Steady Expected with patients
renal history
Creatinine- 2.4 09/05/16 Steady Expected with patients
renal history

Ultrasound of left arm- Thrombus in the left cephalic vein

CT scan of chest- Trace pleural effusion and bilateral atelectasis

+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.)

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

1. Ineffective breathing pattern r/t decreased lung expansion aeb dyspnea with activity, diminished lung sounds. and
bilateral atelectasis on CT scan.

2. Excess fluid volume r/t renal insuffency aeb recurrent pleural effusions and history of stage 3 renal insuffency.

3. Acute pain r/t vascular inflammation aeb patients complaints of left arm pain, arm swelling, warmth, and redness

4. Risk for infection r/t immunosuppressant use

5.

University of South Florida College of Nursing Revision September 2014 14

 15 CARE PLAN
Nursing Diagnosis: 1. Ineffective breathing pattern r/t decreased lung expansion aeb dyspnea with activity, diminished lung sounds. and bilateral atelectasis on
CT scan.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
1. Patient will improve lung a. Elevate the head of the bed Seated position promotes lung Met- Patient ambulated to bedside
expansion expansion (Ackley & Ladwig, chair and sat in an upright position
2011, p. 195). throughout the shift.
b. Encourage the use of deep Deep breathing exercises can help Not met. Pt refused taking part in
breathing exercises to increase ling expansion (Ackley deep breathing exercises multiple
& Ladwig, 2011, p. 195). times throughout the shift.
c. Encourage the use of incentive IS can also help to increase lung Not met- Initial IS- 1500 mL
spirometer expansion (Ackley & Ladwig, Final- 1350 mL
2011, p. 195).
2. Encourage adequate rest and a. Limit interruptions at night Adequate sleep is necessary to Met- Pt states that he slept very
sleep promote healing and limit fatigue well last night
(Ackley & Ladwig, 2011, p. 195).
b. Allow patient to rest after PT Rest will help the pt to heal Met- Pt had several hours of
(Ackley & Ladwig, 2011, p. 195). uninterrupted rest following PT
3. Patient can recognize signs of a a. Educate patient on signs and By knowing the s/s the patient will
recurrent pleural effusion symptoms of pleural effusion be able to seek medical attention
quickly (Ackley & Ladwig, 2011,
p. 195).

Include a minimum of one

Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
University of South Florida College of Nursing Revision September 2014 15
Consider the following needs:
SS Consult
Dietary Consult
X PT/ OT
Pastoral Care
Durable Medical Needs
X F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

Nursing Diagnosis: 2. Acute pain r/t vascular inflammation aeb patients complaints of left arm pain, arm swelling, warmth, and redness

Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
1. Keep patients pain below a 4/10 a. Provide pain medication as Proper administration of pain Met- pain medications were
throughout the shift appropriate per the MAR. medications can help to treat pain administered PRN
medications (Ackley & Ladwig,
2011, p. 604).
b. Provide distraction techniques. Distractions can help keep the Met- the pts wife stayed with him
patients mind off of the pain all shift, patient had use of
(Ackley & Ladwig, 2011, p. 605). television and Smartphone
2. Prevent dislodgment of left arm a. Monitor swelling, pain, pulse, Any acute changes may signify Met- physical assessments of
thrombus. and redness in patients left arm. dislodgment or decrease in blood patients arm preformed throughout
flow (Ackley & Ladwig, 2011, p. shift
641).
3. Prevent formation of new a. Use of SCDs throughout shift SCDs can help to prevent Not Met- pt states that he does not
thrombus thrombus formation (Ackley & want to wear the SCDs today
Ladwig, 2011, p. 642).
University of South Florida College of Nursing Revision September 2014 16
 b. Promote ambulation Ambulation can help to prevent Met- Pt ambulated the halls with
(Ackley & Ladwig, 2011, p. PT and his wife multiple times
643).thrombus formation throughout the shift.

Include a minimum of one

Long term goal per care plan

University of South Florida College of Nursing Revision September 2014 17

 References

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

Leard, L. (2016, May 26). Pleural complications in lung transplantation.

Retrieved from http://www.uptodate.com/contents/pleural-complications-in-lung-transplantation

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

Preparation for practice (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall.

SuperTracker: My Foods. My Fitness. My Health. (n.d.).

https://supertracker.usda.gov

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University of South Florida College of Nursing Revision September 2014 19