UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Heidi Bosmans

MSI & MSII PATIENT ASSESSMENT TOOL .

Agency: SMH

1 PATIENT INFORMATION
Patient Initials:
Gender:

SD

Female

Assignment Date: 4/10/15

Age: 46

Admission Date: 4/4/15

Marital Status: single

Primary Medical Diagnosis: infected Diabetic foot

ulcer

Primary Language: English

Level of Education: Masters degree

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): retired from medical billing

Number/ages children/siblings: none

Served/Veteran: no
If yes: Ever deployed? Yes or No

Code Status: Full code

Living Arrangements: lives in one story home shared with her

parents

Advanced Directives: No
If no, do they want to fill them out? no
Surgery Date:
Procedure:

Culture/ Ethnicity /Nationality: Caucasian

Religion: none

Type of Insurance: Blue Cross

1 CHIEF COMPLAINT: Patient states, I have an infected foot wound.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) Patient came to SMH emergency room on 4/4/15 after being referred by her podiatrist for a non-healing ulcer
to her left heel for the past six months. Her podiatrist did a culture on 4/3/15 which showed her ulcer was infected with
Streptococcus agalaticae. Podiatrist wanted her to come to the hospital for surgical debridement of her wound.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date

Operation or Illness

Father

72

Mother

72

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable
)

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Alcoholism

Vitrectomy
Kidney/pancreas transplant
Myocardial Infarction, stent placement
Left leg stent placement
Charcot foot
Left great toe amputation

Age (in years)

1991
2000
2007
2010
2008
2008

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
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus within ten years
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) 2014
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

University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
PCN
Keflex
Lortab
Dilaudid
sulfas
Reglan
Zofran
Lovenox

Medications

Other (food, tape,

latex, dye, etc.)

Type of Reaction (describe explicitly)

itching
itching
N/V
n/v
nausea
diarrhea
hallucinations
Rapid heart rate

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)
Diabetic foot ulcer are cause by a combination of factors. Peripheral sensory neuropathy is extremely common
in patients with diabetes. Chronically high blood sugars damage nerves, resulting in the nerves not being able to
properly conduct messages to and from the brain. Symptoms of neuropathy are numbness, tingling, pins and
needles etc. Injuries can go unnoticed to due numbness from neuropathy. A small injury that is not noticed
early and treated can quickly become an ulcer. Treatment includes debridement which is the removal of necrotic
tissue, offloading which is to stop bearing any weight on the affected foot, and infection control. If someone has
an infected foot wound, they should be hospitalized and treat with IV antibiotics. Depending on the
extensiveness of the wound, amputation may be necessary (Kruse and Edelman, 2006).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: Aspirin (Ecotrin)

Concentration

Dosage Amount: 325 mg

Route: PO

Frequency: daily

Pharmaceutical class: salicylates

Home

Hospital

or

Both

Indication: Hx of MI, stents

Adverse/ Side effects: GI Bleeding, anaphylaxis, laryngeal edema
Nursing considerations/ Patient Teaching: avoid taking with NSAIDs because of increased risk for GI bleeding, report tarry black stools and coffee ground
emesis, and any other unusual bleeding
Name: Plavix (clopidogrel)

Concentration

Dosage Amount 75 mg

Route PO

Frequency: daily

Pharmaceutical class: platelet aggregation inhibitors

Home

Hospital

or

Both

Indication: Hx of MI, stents

Adverse/ Side effects: GI bleeding, drug rash with eosinophilia and systemic symptoms, bleeding, neutropenia, TTP
Nursing considerations/ Patient Teaching: monitor bleeding time, advise patient to notify HCP promptly if fever, chills, sore throat, rash, or unusual bleeding
occur
Name: Imdura (Isosorbide)

Concentration

Dosage Amount: 30 mg

Route PO

Frequency daily

Pharmaceutical class: nitrates

Home

Hospital

or

Both

Indication: Prophylactic management of angina pectoris

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects:dizziness, hypotension, headache, tachycardia

Nursing considerations/ Patient Teaching: may cause dizziness, instruct patient not drive until response to medication is known, move slowly to prevent
orthostatic hypotension, headache is common.
Name Paxil (Paroxentine hydrochloride)

Concentration

Dosage Amount: 40 mg

Route: PO

Frequency: daily

Pharmaceutical class: SSRI

Home

Hospital

or

Both

Indication: panic disorder

Adverse/ Side effects: neuroleptic malignant syndrome, suicidal thoughts, anxiety, dizziness, drowsiness, headache, stevens-johnson syndrome, serotonin
syndrome
Nursing considerations/ Patient Teaching: may cause dizziness or drowsiness, avoid driving until response to drug is known, monitor/report suicidal thoughts
Name: Coreg (carvedilol)

Concentration

Dosage Amount: 10 mg

Route: PO

Frequency daily

Pharmaceutical class: beta blocker

Home

Hospital

or

Both

Indication: HTN
Adverse/ Side effects: bradycardia, HF, pulmonary edema, stevens-johnson, anaphylaxis, angioedema
Nursing considerations/ Patient Teaching: Check pulse and BP before giving, may cause dizziness, closely monitor blood glucose as the medication may mask
signs of hypoglycemia
Name: Nexium (esomeprazole)

Concentration

Dosage Amount: 40 mg

Route: PO

Frequency BID

Pharmaceutical class: proton pump inhibitor

Home

Hospital

or

Both

Indication: GERD
Adverse/ Side effects: pseudomembranous colitis, abd pain, constipation
Nursing considerations/ Patient Teaching: report symptoms of GI bleed, avoid alcohol
Name Lyrica (pregabalin)

Concentration

Dosage Amount 50 mg

Route: PO

Frequency: TID

Pharmaceutical class:non opiod analgesic

Home

Hospital

or

Both

Indication: diabetic peripheral neuropathy

Adverse/ Side effects: suicidal thoughts, dizziness, dry mouth
Nursing considerations/ Patient Teaching: do not discontinue abruptly, may cause dizziness, avoid alcohol
Name: Prograf (tacrolimus)

Concentration

Dosage Amount 2.5 mg

Route PO

Frequency daily

Pharmaceutical class: immunosupressants

Home

Hospital

or

Both

Indication: kidney transplant

Adverse/ Side effects: seizures, GI bleed, headache, abd pain
Nursing considerations/ Patient Teaching: teach patients to wear sunscreens and protective clothing, avoid eating grapefruits, need for lifelong therapy
Name: Vancomycin

Concentration: 1 gm / 90 mins

Route: IVPB

Dosage Amount: 1 gm

Frequency: once daily

Pharmaceutical class: antibiotic

Home

Hospital

or

Both

Indication: infected foot ulcer

Adverse/ Side effects: red man syndrome, anaphylaxis, nephrotoxicity, n/v
Nursing considerations/ Patient Teaching: report signs of hypersensitivity, tinnitus, vertigo, and hearing loss

University of South Florida College of Nursing Revision September 2014

Name: Sliding scale insulin aspart (novolog)

Concentration:

Route: SC injection

Dosage Amount: sliding scale

Frequency: before meal

Pharmaceutical class: pancreatics

Home

Hospital

or

Both

Indication: type 1 diabetes

Adverse/ Side effects: hypoglycemia, lipodystrophy, anaphylaxis
Nursing considerations/ Patient Teaching: rotate injection sites, emphasize importance of following nutritional guidelines and exercise, monitor for signs of
hypo/hyperglycemia and what to do if they occur
Name: Prednisone

Concentration:

Route: PO

Dosage Amount: 5 mg
Frequency: daily

Pharmaceutical class: immune modifers

Home

Hospital

or

Both

Indication: kidney/pancreas transplant

Adverse/ Side effects: peptic ulceration, thromboembolism, cushing syndrome, increased risk for infection
Nursing considerations/ Patient Teaching: do not stop medication abruptly. This medication causes immunosuppression and may mask symptoms of infection.
Patient should avoid people with known infections and report possible infections immeadiately

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Consistent carbs
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
This patients home diet consists almost completely of
carbohydrates, with little to no protein, fruits, and
vegetables.
Breakfast: 2 eggo waffles
Because she has diabetes, this patient should cut down
significantly on her carbs, and increase her intake of fruits,
vegetables. In addition, because she has a wound, it is
important for her to increase her intake of vitamin C and
protein.
For example, for breakfast she could eat one waffle and top
it with strawberries, and with some low fat yogurt on the
side.
Lunch: lunchmeat or cheese sandwich
For lunch, she could have a large salad with a variety of
vegetables, with pretzels and hummus on the side
For dinner, she could grilled chicken, brown rice, a whole
wheat roll, and a side of spinach
Dinner: fried chicken and rice
For snack, she could have unsalted pretzels, apple or orange
slices, or grapes
Snacks: pretzels
Liquids (include alcohol): water, ice tea
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? mother
How do you generally cope with stress? or What do you do when you are upset?
Patient states, Xanax

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Mothers illness/advancing age

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are

University of South Florida College of Nursing Revision September 2014

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?_____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? ______________________
Are you currently in a safe relationship? No currently in a relationship

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
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: Stagnation refers to the failure to find a way to contribute. These individuals may feel disconnected or
uninvolved with their community and with society as a whole. (Cherry, n.d.)
Generativity is the concern in establishing and guiding the next generation. (David & Clifton 1995)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

I believe my patients in stagnation because she has not had children and she is not working any more. She has in a sense
left her mark of the world.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

Her multiple health problems have resulted in her not having children and not working.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states, They say its genetics or environmental causes that cause diabetes.
What does your illness mean to you?
Patient states, a lot of doctors visits.

+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_______________________________________

University of South Florida College of Nursing Revision September 2014

Have you or a partner ever had an abnormal pap smear?

_____________________no________________________________ Have you or your partner received the Gardasil
(HPV) vaccination? _____________________no______________________
Are you currently sexually active? ___________no________________ If yes, are you in a monogamous relationship?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _______none___________________________
How long have you been with your current partner?____________not in a
relationship____________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity?
___________no________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
no

University of South Florida College of Nursing Revision September 2014

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
________none______________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
____no__________________________________________________________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much?

Has the patient ever tried to quit?

If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? Patient states she drank alcohol
once or twice at a young age and has avoided
How much?
it since
Volume:
Frequency:
If applicable, when did the patient quit?

Yes

No
For how many years?
(age

thru

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

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?

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:
Other: skin cancer

Be sure to answer the highlighted area

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
x/day
Routine dentist visits
x/year
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other: gastroparesis

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer (skin)
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
2

Diabetes

Type: 1

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? 2004
menstrual cycle
regular
irregular
menarche
age? 15
menopause
age? 35
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision September 2014

10

Last EKG screening, when? Few days

ago
Other: rapid heart rate

Arthritis
Other:

Chicken Pox
Other:

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health?

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Paresthesia/numbness in hands and feet

Any other questions or comments that your patient would like you to know?

University of South Florida College of Nursing Revision September 2014

11

10 PHYSICAL EXAMINATION:
General Survey: patient
is a pleasant, obese 46
year old woman
Temperature: (route
taken?) 98.0 oral

Height 5ft
Pulse 98
Respirations 16
SpO2

95%

Weight 171
BMI 33.4
Blood Pressure: (include location)
147/75 L arm
Is the patient on Room Air or O2

Pain: (include rating and

location)
7/10
Left foot

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
wound to left heel
was not WNL (within normal limits)
Central access device Type:
24 g
Location:
LFA
Date inserted:
4-8-15
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 4 / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: normal
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large none
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL
CL
LUL CL
RML
CL
LLL CL
RLL
CL

Chest expansion symmetric

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

University of South Florida College of Nursing Revision September 2014

12

Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular

No murmurs, clicks, or adventitious heart sounds

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3
Brachial:
3 Radial: 3
Femoral: 3
Popliteal:
DP: not felt,
heard on doppler
PT: not felt, heard on doppler
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:
BLE
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 4 / 8 / 15
)
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
Other Describe:

Not assessed, patient alert, oriented, denies problems

GU
Urine output:
Clear
Cloudy
Color:
yellow
Previous 24 hour output:
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at _____4__ RUE ___4____ LUE ____4___ RLE

2000

& ___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

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 (not
tested)
Stereognosis, graphesthesia, and proprioception intact (not tested)
Gait smooth, regular with symmetric length of
the stride (gait asymmetric due to ulcer on bottom of left foot)
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:
Biceps:
(not assessed)

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

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.

University of South Florida College of Nursing Revision September 2014

13

Lab
K
3.8
5.0
4.3
4.4
4.1
4.0

Dates
4/4
4/5
4/6
4/8
4/9
4/10

WBC
15.8
14.3
10.9
10.4
10.4

4/4
4/5
4/8
4/9
4/10

Hct
35.5
34.5
39.5
35.8
35.8

4/4
4/5
4/8
4/9
4/10

Hgb
11.6
11.4
12.8
11.7
11.6

4/4
4/5
4/8
4/9
4/10

Trend
Potassium fluctuates
slightly throughout
hospital stay but remains
WNL.

Analysis
Potassium is normal. This
is an important lab value
to check for this patient
for several reasons. She
has a history of MI, takes
steroids, and has a kidney
transplant. Her normal
levels indicate her
kidneys are excreting K
normally. Elevated or
lowered K can cause
cardiac dysrhythmia.
Steroids may cause
hypokalemia.
Upon admission, patients Elevated WBCs indicates
WBCs were elevated.
an infection. Patients
Throughout hospital stay, infection was treated with
they decreased and
IV antibiotics, lowering
returned to a normal level the WBC count
Patients hematocrit
remained in the slightly
low/low end of normal
range for women.

Patients hemoglobin
remained in the slightly
low/low end of normal
range for women.

Hct is an important lab

value to look at for this
patient because she has a
wound, and is at risk for
bleeding due to her taking
aspirin (ecotrin) and
clopidogrel (Plavix)
which alter platelet
function. Low hct might
also indicate renal
dysfunction because red
blood cells are produced
in the kidneys. Her
hematocrit is only slightly
low which may be a result
of scant blood loss from
her wound, and is not
concerning at this time.
Reasons for looking at
this lab and analysis are
the same as hematocrit.

University of South Florida College of Nursing Revision September 2014

14

Platelets
158,000
116,000
218,000
235,000
205,000

4/4
4/5
4/8
4/9
4/10

Glucose
254
206
228
241
220
289

4/4
4/5
4/6
4/8
4/9
4/10

Vancomycin trough level

17 mcg/ml

Patients platelets
dropped the day after
admission but increased
on subsequent days

Patients glucose has

remained consistently
elevated.

This was the only value I

found on the chart.
4/6

Patient is taking
clopidogrel and aspirin
which can cause
thrombocytopenia. On 4/5
her platelets dropped
below normal limits the
next day they returned to
WNL.
Because of this patients
diabetes it is important to
monitor her glucose.
Elevated glucose can
impaired wound healing,
and increase risk for (and
worsen already existing)
infections. In addition for
pre-existing diabetes,
glucose can be increased
by the added stress of
having a wound, and
being hospitalized.

Therapeutic trough level

for vancomycin is
approx.. 10-20 mcg/ml.
Since the patient level is
17 mcg/ml, this indicated
she is receiving enough of
the drug to be it do be
effective.

+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.)
Accuchecks, consistent carbs diet, LE vascular check with Doppler, wound care (wound vac with dakin solution) 3x
weekly (mon, wed, fri), ICM consult because of need for home health nurse, wound care nurse consult for assistance
with wound vac application
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Impaired tissue integrity r/t wound, presence of infection, altered circulation aeb diabetic foot ulcer, patient stating, Ive
had this wound for 6 months., wound culture positive for streptococcus agalacticae
2. Risk for falls; risk factors: difficulty with gait because of foot ulcer, peripheral neuropathy, antihypertensive medications

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3. Pain r/t foot wound aeb patient reporting pain level 7/10
4. Activity intolerance r/t obesity, pain, injury to foot aeb patient stating, I hobble around and can only take a few steps.
5. Ineffective self health management r/t complexity of therapeutic regimen, multiple health problems aeb development of
foot ulcer, high blood glucose
6.Risk for infection (in addition to current infection) risk factors: broken skin on foot, immunosuppression, high blood
glucose, Type one diabetes

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 15 CARE PLAN
Nursing Diagnosis: Impaired tissue integrity r/t wound, presence of infection, altered circulation aeb diabetic foot ulcer, patient stating, Ive had this wound
for 6 months., wound culture positive for streptococcus agalacticae

Patient Goals/Outcomes
Report any altered sensation or
pain at site of tissue impairment

Nursing Interventions to Achieve

Goal
Assess the site of impaired tissue
integrity and determine cause

Demonstrate understanding of plan

to heal tissue and prevent re-injury

Determine the size and depth of

wound

Describe measures to protect and

heal the tissue, including wound
care

Monitor the site of tissue integrity

at least once a day for color
changes, redness, swelling,
warmth, pain, or other signs of
infection. Determine when patient
is experiencing changes in
sensation or pain.
Monitor the status of the skin
around the wound. Monitor the
patients skincare practices, noting
type of soap or other cleansing
agents used, temperature of water,
and frequency of skin cleansing.

Experience a wound that decreases

in size and has increased
granulation tissue

Identify a plan for debridement if

necrotic tissue is present and if
consistent with overall client
management goals

Rationale for Interventions

Provide References
The etiology or cause of the wound
must be determine before
appropriate interventions can be
implemented. This provides the
basis for additional testing and
evaluation to start the assessment
process (Ackley & Ladwig, 2011).
Serial wound assessments are more
reliable when performed by same
care giver, with patient in the same
position using the same techniques
(Ackley & Ladwig, 2011).
Systematic inspection can identify
impending problems early (Ackley
& Ladwig, 2011).

Evaluation of Goal on Day Care

is Provided
No change in sensation, pain was
reported to be 7/10

Individualize the plan according to

the clients skin condition, needs,
and preferences. Client should
avoid harsh cleansing agents, hot
water, extreme friction or force, or
too frequent cleansing (Ackley &
Ladwig, 2011).
Debride devitalized tissue within
the wound bed when appropriate
with individuals condition and
consistent with overall goals of
care (Ackley & Ladwig, 2011).

Granulation tissue present

University of South Florida College of Nursing Revision September 2014

Yes, patient understood plan of care

Yes

17

Instruct and assist the client and

caregivers in understanding in
understanding how to change
dressings and in the importance of
maintaining a clean environment.
Provide written instructions and
observe them in completing a
dressing change. *
Teach skin and wound assessment
and ways to monitor for signs and
symptoms of infection,
complications, and healing.*

Client should be aware of how to

care for their wound, while
effectively preventing infection.
This also involves them in their
care and reduces feelings of
powerlessness (Ackley & Ladwig,
2011).
Early assessment and intervention
help prevent serious problems from
developing (Ackley & Ladwig,
2011).

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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 15 CARE PLAN
Nursing Diagnosis: Risk for falls; risk factors: difficulty with gait because of foot ulcer, peripheral neuropathy, antihypertensive medications
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Remain free from falls
Be careful when getting a mostly
Changing positions slowly reduces Yes, patient did not fall this shift
immobile immobile client up. Be
risk of orthostatic hypotenstion
sure to lock the bed and have
(Ackley & Ladwig, 2011).
sufficient personnel to protect
client from falls. When rising from
lying position, have the client
change positions slowly.
Change environment to minimize
Use high risk armband/bracelet
These steps alert the nursing staff
Yes, room was free of clutter.
incidence of falls
and fall risk room sign to alert staff of increased risk of falls (Ackley & Bedside commode was place so
for increased vigilance and
Ladwig, 2011).
patient could reach it with one step
mobility assistance
on her unaffected foot, with
assistance
Explain methods to prevent injury
Thoroughly orient the client to
If the client is more familiar with
Yes
environment. Place call light within their environment, they are less
reach and show how to call for
likely to trip and fall (Ackley &
assistance. Place bedside commode Ladwig, 2011).
close to bed .
Place fall prone client in a room
Such placement allows more
that is near to the nurses station
frequent observations of the
patient(Ackley & Ladwig, 2011)
If patient is a fall risk in the
The rate of fall after discharge is
hospital, recognize that there is a
substantially increased in older
high incidence of falls after
adults who have been hospitalized
discharge, and use all measures to
recently(Ackley & Ladwig, 2011).
reduce incidence of falls
Teach the client how to safely
Walking more slowly in response
ambulate at home including using
to a visualspatial decision task
safety measures such as hand rails
may identify individuals at risk for
in the bathroom, and avoiding
multiple falls (Ackley & Ladwig,
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19

carry things or performing other

task while walking.*

2011).

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. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: an evidence-based guide to planning
care : [interventions and rationales for adult, geriatrics, mental health, pediatrics, maternal/child
health, multicultural, and client/family teaching and discharge planning (9th ed.). St. Louis, Miss:
Mosby.
Cherry, K. (n.d.). Generativity Versus Stagnation. Retrieved April 25, 2015, from
http://psychology.about.com/od/psychosocialtheories/a/generativity-versus-stagnation.htm
Davis, D., & Clifton, A. (1995, January 1). Erikson's Stages. Erikson's Stages. Retrieved July 5, 2014, from
http://www.haverford.edu/psych/ddavis/p109g/erikson.stages.html
Kruse, I., & Edelman, S. (2006, April 1). Evaluation and Treatment of Diabetic Foot Ulcers. Retrieved April 26,
2015, from http://clinical.diabetesjournals.org/content/24/2/91.full

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