UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
1 CHIEF COMPLAINT: My eye is swollen shut.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course
The patient is a !" y.o male that presented to the #R and was admitted on the e$enin% o& '()*(+,. The patient initially
$isited an eye clinic on '(+" to e$aluate his le&t eye medial aspect pustular lesions associated with swellin%- he went home
with .e&le/ with instructions to &ollow up i& symptoms worsened. The &ollowin% day0 the patient de$eloped worsenin%
swellin% and erythema in$ol$in% the pre1or2ital area. The patient presented to the #R with ina2ility to open le&t eye due to
swellin%0 associated with 2lurred $ision. On the early mornin% o& '()+0 the patient was ta3en to the OR &or or2ital
cellulitis. 4n the OR0 purulence and necrotic su2cutaneous tissue was disco$ered within the upper eyelid and or2it0
concernin% &or necroti5in% &asciitis. The patient currently has an open incision on le&t0 upper eyelid and is 2ein%
monitored closely. 6e descri2es his pain at the incision si%ht as dull and constant0 2ut &eels more pressure than anythin%.
6is pain is a 7!8 on a *1+* pain scale and is currently 2ein% treated with morphine &or pain.
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+'
:tudent> Brittaney Bures
PATIENT ASSESSMENT TOOL .
Assi%nment Date> April ++0 )*+,
1 PATIENT INFORMATION
A%ency> T?6(:B<
@atient 4nitials> ML A%e> !" Admission Date> '()*(+,
?ender> M Marital :tatus> Married @rimary Medical Dia%nosis with 4CD1+* code>
@rimary Lan%ua%e> #n%lish MR:A *,+.+)
Or2ital cellulitis 'A!.*+
@erior2ital cellulitis 'A'.+'
Bision distur2ance '!". C
Le$el o& #ducation> Completed hi%h school and &i$e years o& trade
school
Other Medical Dia%noses> (new on this admission
Occupation (i& retired0 what &romD> Retired electrician
<um2er(a%es children(si2lin%s> Two sons0 a%es ,' and ,!
:er$ed(Beteran> <o Code :tatus> ;ull code
Li$in% Arran%ements> Eith wi&e- sin%le story house- snow 2irds
&rom 4ndiana
Ad$anced Directi$es> Fes
4& no0 do they want to &ill them outD
:ur%ery Date> @rocedure> '()+(+, Or2itotomy
Culture( #thnicity (<ationality> #n%lish(:cottish
Reli%ion> @rotestant Type o& 4nsurance> Medicare and Mutual o& Omaha
+
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY 4nclude hospitali5ations &or any medical
illness or operation
Date Operat!" !r I##"e$$
+C"G Arthroscopy o& ri%ht 3nee
+CC" Arthroscopy o& le&t 3nee
)**G Cataract sur%ery o& le&t eye
)**" :ur%ical remo$al o& melanoma
)**" 4n%uinal lymph node dissection
)*+' Cataract sur%ery o& ri%ht eye
)*+' Myasthenia %ra$is 7crisis8
@ast medical history includes> hypertension0 hyperlipidemia0 hypothroid0 myasthenia %ra$is0
melanoma0 MR:A
2
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Comments> 4nclude date o& onset
Both o& the patient8s parents are deceased. Both parent8s had type ) dia2etes. 6is mother had two heart attac3s0 at a%es G* and G!0
2ut ultimately ended up passin% away &rom Al5heimer8s (cho3in% on her &ood. 4n addition to the dia2etes0 his &ather was also
epileptic.
1 IMMUNI%ATION HISTORY
(May state 9 &or un3nown0 e/cept &or Tetanus0 ;lu0 and @na YES NO
Routine childhood $accinations H
Routine adult $accinations &or military or &ederal ser$ice H
Adult Diphtheria (Date patient does not 3now
Adult Tetanus (Date patient does not 3now0 states 4 thin3 so
4n&luen5a (&lu (Date +*())(+' H
@neumococcal (pneumonia (Date )*+' H
6a$e you had any other $accines %i$en &or international tra$el or
occupational purposesD @lease List H
1 ALLERGIES
OR ADVERSE
REACTIONS
<AM# o&
Causati$e A%ent
Type o& Reaction (descri2e e/plicitly
Medications <o 3nown aller%ies
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' )

Other (&ood0 tape0
late/0 dye0 etc.
& PATHOPHYSIOLOGY: (include A@A re&erence and in te/t citations (Mechanics o& disease0 ris3 &actors0 how to
dia%nose0 how to treat0 pro%nosis0 and include any %enetic &actors impactin% the dia%nosis0 pro%nosis or
treatment
Myasthenia %ra$is (M? is a neuromuscular disorder0 a&&ectin% muscles and the ner$es that
control them. 4t is also an autoimmune disorder0 where the 2ody8s immune system mista3enly attac3s it8s own
healthy tissues. Ehen the immune system mista3enly considers healthy tissue as harm&ul0 the 2ody produces
anti2odies a%ainst it. :peci&ically0 &or people that ha$e myasthenia %ra$is0 these anti2odies 2loc3 the muscle
cells &rom recei$in% messa%es &rom the ner$e cell (Myasthenia %ra$is0 )*+'.
Myasthenia %ra$is results in wea3ness o& $oluntary muscles. Autonomic muscles0 or in$oluntary
muscles0 are usually not a&&ected. Muscle wea3ness associated with myasthenia %ra$is worsens with acti$ity
and can lead to symptoms includin% di&&iculty 2reathin% (due to wea3ness o& diaphra%m and chest wall
muscles0 di&&iculty chewin% or swallowin%0 di&&iculty tal3in%0 ina2ility to hold head up due to wea3ened nec3
muscles0 wea3ness o& &acial muscles0 di&&iculty tal3in% or $oice chan%es0 &ati%ue0 dou2le $ision0 and eyelid
droopin% (Myasthenia %ra$is0 )*+'.
The cause o& myasthenia %ra$is is un3nown and can a&&ect people at any a%e- howe$er0 it is most
commonly seen in youn%er women and older men. Ehen determinin% i& a patient has myasthenia %ra$is0 a
physical e/am (includin% an e/tensi$e neurolo%ical e/am is per&ormed &irst in order to chec3 &or muscle
wea3ness0 and to ma3e sure re&le/es and sensation are normal. Other tests include chec3in% &or acetylcholine
receptor anti2odies0 a CT or MR4 o& the chest0 ner$e conduction studies0 an #M?0 pulmonary &unction tests0 and
an edrophonium test (Myasthenia %ra$is0 )*+'.
Because myasthenia %ra$is is an autoimmune disorder0 there is no cure- howe$er0 lon%1term remission is
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' '
possi2le with treatment and li&estyle chan%es. Li&estyle chan%es include restrictin% daily acti$ities0 restin%
throu%hout the day0 usin% an eye patch (i& e/periencin% dou2le $ision0 and a$oidin% stress and heat e/posure.
Medication may 2e prescri2ed0 includin% neosti%mine or pyridosti%mine0 to impro$e the communication
2etween the ner$es and muscles. @rednisone mi%ht also 2e prescri2ed in order to suppress the immune system
response. @hysical therapy is also encoura%ed to 2uild muscle stren%th (Myasthenia %ra$is0 )*+'.
Complications could cause li&e1threatenin% 2reathin% pro2lems0 called a myasthenia crisis0 and 2reathin%
assistance with a $entilator may 2e reIuired. A procedure called plasmapheresis can 2e used to help end the
crisis. This procedure in$ol$es remo$in% the plasma &rom the 2lood0 which contains the anti2odies0 and
replacin% it with donated plasma &ree o& anti2odies. Another procedure0 called immuno%lo2ulin in&usion0 can
also 2e done0 in which lar%e amounts o& help&ul anti2odies are %i$en directly into the 2loodstream (Myasthenia
%ra$is0 )*+'.
Myastenia %ra$is ()*+'. 4n A.D.A.M. Medical Encyclopedia. Retrie$ed &rom
http>((www.nc2i.nlm.nih.%o$(pu2medhealth(@M6***+A'+(
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' ,
& MEDICATIONS: J4nclude 2oth prescription and OTC- home (reconciliation0 routine0 and @R< medication. ?i$e trade and
%eneric name.K
Na'e a(eta'"!p)e" *TYLENOL+ C!"(e"trat!" *',/'#+ 2 ta-#et$ *2 . 32& ', ta-#et+ D!$a,e A'!/"t *',+ 0&1 ',
R!/te Ora# Da#2
P)ar'a(e/t(a# (#a$$ a"a#,e$($ a"3 a"tp2ret($
H!'e H!$pta# !r 4!t)
I"3(at!" U$e3 5!r t)e re#e5 !5 5e6er a$ 7e## a$ a()e$ a"3 pa"$ a$$!(ate3 7t) 'a"2 (!"3t!"$.
S3e e55e(t$/N/r$", (!"$3erat!"$ Ehen used at appropriate dosa%e0 side e&&ects are minimal. :e$ere side e&&ects include li$er disease( Monitor &or symptoms o& li$er
dama%e0 includin%> dar3 urine0 persistent nausea($omitin%. Do not e/ceed , %rams o& acetaminophen &rom all sources in ), hours &or patients who wei%h ,* 3% or more.
Na'e a$pr" EC C!"(e"trat!" 1 ta-#et *1 . 32& ', ta-#et+ D!$a,e 32& ',
R!/te Ora# Fre8/e"(2 Da#2
P)ar'a(e/t(a# (#a$$ $a#(2#ate$
H!'e H!$pta# !r 4!t)
I"3(at!" I"5#a''at!r2 3$!r3er$9 '#3 t! '!3erate pa"9 5e6er9 pr!p)2#a.$ !5 tra"$e"t $()e'( atta(:$ a"3 MI.
S3e e55e(t$/N/r$", (!"$3erat!"$ ?4 BL##D4<?0 dyspepsia0 epigastric distress0 nausea0 a2dominal pain0 anore/ia0 hepatoto/icity0 $omitin%0 anemia0 tinnitus( 9se
cautiously o& patient has a history o& ?4 2leedin%0 chronic alcohol use0 or se$ere hepatic or renal disease.
Na'e a;aTHIOpr"e *IMURAN+ C!"(e"trat!" 1 ta-#et *1 . &1 ', ta-#et+ D!$a,e &1 ',
R!/te Ora# Fre8/e"(2 Da#2
P)ar'a(e/t(a# (#a$$ p/r"e a"ta,!"$t$
H!'e H!$pta# !r 4!t)
I"3(at!" I" MG9 I'/ra" 7!r:$ -2 3e(rea$", t)e "/'-er !5 a"t-!3e$ " t)e -#!!3. T)e$e $pe(5( a"t-!3e$ 3e$tr!2 t)e re(ept!r $te$ !" t)e '/$(#e$. <)e"
t)ere are 5e7er a"t-!3e$ t! 3e$tr!2 t)e re(ept!r $te$9 t)e '/$(#e$ ,et $tr!",er.
Side effects/Nursing considerations Anorexia, hepatotoxicity, nausea, vomiting, diarrhea, mucositis, pancreatitis, anemia, leukopenia, pancytopenia, thrombocytopeni,
joint pain, rash, risk for cancer/ Contraindicated in hypersensitivity and concurrent use of mycophenolate.
Na'e -a(tra("=p!#2'2." - *POLYSPORIN+
!p)t)a#'( !"t'e"t
C!"(e"trat!" D!$a,e A'!/"t 1 t/-e
R!/te T!p(a# Fre8/e"(2 > t'e$ 3a#2
P)ar'a(e/t(a# (#a$$ t!p(a# a"t-!t($
H!'e H!$pta# !r 4!t)
I"3(at!" /$e3 t! treat '"!r 7!/"3$ a"3 t! )e#p pre6e"t !r treat '#3 $:" "5e(t!"$.
S3e e55e(t$/N/r$", (!"$3erat!"$ Burnin%0 redness0 or irritation o& the s3in( <ot &or inLection into the eye( @rolon%ed use o& may result in o$er%rowth o& non1
suscepti2le or%anisms0 includin% &un%i.
Na'e 3!(/$ate $!3/' *COLACE+ C!"(e"trat!" 1 (ap$/#e *1 . 111 ',+ D!$a,e A'!/"t 111 ',
R!/te Ora# Fre8/e"(2 2 t'e$ 3a#2
P)ar'a(e/t(a# (#a$$ $t'/#a"t #a.at6e$/$t!!# $!5te"er$
H!'e H!$pta# !r 4!t)
I"3(at!" Treat'e"t !5 (!"$tpat!" a$$!(ate3 7t) 3r29 )ar3 $t!!#$ a"3 3e(rea$e3 "te$t"a# '!t#t2/ Pre6e"t!" !5 !p!3="3/(e3 (!"$tpat!".
Side effects/Nursing considerations electrolyte imbalances, dehydration, abdominal cramps, nausea, vomiting, diarrhea, rashes, urine discoloration/ Excessive or
prolonged use may lead to dependence, fluid and electrolyte imbalance, and vitamin and mineral deficiencies.
Na'e 3p)e")23rAMINE *4ENADRYL+ C!"(e"trat!" 1 'L? &1 ', !5 &1 ',/'L D!$a,e &1 ',
R!/te I"tra6e"!/$ Fre8/e"(2 Da#2
P)ar'a(e/t(a# (#a$$ a"t)$ta'"e$
H!'e H!$pta# !r 4!t)
I"3(at!" Re#e5 !5 a##er,( $2'pt!'$ (a/$e3 -2 )$ta'"e re#ea$e.
Side effects/Nursing considerations drowsiness, dizziness, headache, blurred vision, tinnitus, hypotension, palpitations, anorexia, dry mouth, constipation, nausea,
urinary retention, photosensitivity, chest tightness, thickened bronchial secretions, wheezing/ Given as pre- treatment prior to IVIG.
Na'e e"a#apr#at *VASOTEC+ C!"(e"trat!" 1 'L? 1.2& ', !5 1.2& ',/ 'L D!$a,e A'!/"t 1.2& ',
R!/te "tra6e"!/$ Fre8/e"(2 E6er2 0 )!/r$ PRN
P)ar'a(e/t(a# (#a$$ a(e ")-t!r$
H!'e H!$pta# !r 4!t)
I"3(at!" A#!"e !r 7t) !t)er a,e"t$ " t)e 'a"a,e'e"t !5 )2perte"$!".
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' G
Side effects/Nursing considerations dizziness, fatigue, headache, cough, hypotension, chest pain, abdominal pain, diarrhea, nausea, vomiting, proteinuria, impaired renal
function, hyperkalemia, dyspnea/ Use cautiously in patients with renal impairment, hypovolemia, hyponatremia, and concurrent diuretic therapy.
Na'e )23r!()#!r!t)a;3e *HYDRODIURIL+ C!"(e"trat!" 1 ta-#et * 1 . 2& ',+ D!$a,e A'!/"t 2& ',
R!/te Ora# Fre8/e"(2 Da#2
P)ar'a(e/t(a# (#a$$ t)a;3e 3/ret($
H!'e H!$pta# !r 4!t)
I"3(at!" Ma"a,e'e"t !5 '#3 t! '!3erate )2perte"$!".
Side effects/Nursing considerations CNS: dizziness, hypotension, anorexia, cramping, hepatitis, nausea, vomiting, STEVENS JOHNSON SYNDROME,
photosensitivity, hyperglycemia, hypokalemia, dehydration, hypercalcemia, hypochloremic alkalosis, hypomagnesemia, hyponatremia, hypophosphatemia, hypovolemia/
Additive hypotension with other antihypertensives, acute ingestion of alcohol, or nitrates.
Na'e ''/"e ,#!-/#" *)/'a"+ C!"(e"trat!" >&1 'L? >&9111 !5 119111 ',/111 'L D!$a,e A'!/"t >& ,ra'$
R!/te I"tra6e"!/$ Fre8/e"(2 E6er2 2> )!/r$
P)ar'a(e/t(a# (#a$$ ''/"e ,#!-/#"$
H!'e H!$pta# !r 4!t)
I"3(at!" U$e5/# t! $/ppre$$ t)e ''/"e $2$te' " pate"t$ 7t) ''/"!3e5(e"(2 3$ea$e$ a"3 $2"3r!'e$.
Side effects/Nursing considerations headache, lightheadedness, dyspnea, THROMBOEMBOLIC EVENTS, chest pain, vascular occlusion, nausea, RENAL FAILURE,
diuresis, local inflammation at IV site, phlebitis, hemolytic anemia, ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS, angioedema, chills, fever, sweating/
Administer in separate infusion line from other medications; initiate at 50 mg/hr and may be increased slowly if tolerated by the patient up to max 400 mg/kg/hr.
Na'e #e6!t)2r!."e *SYNTHROID9 LEVOTHROID+ C!"(e"trat!" 1 ta-#et *1 . @& '(, ta-#et+ D!$a,e A'!/"t @& '(,
R!/te Ora# Fre8/e"(2 Da#2
P)ar'a(e/t(a# (#a$$ t)2r!3 preparat!"$
H!'e H!$pta# !r 4!t)
I"3(at!" T)2r!3 $/pp#e'e"tat!" " )2p!t)2r!3$'.
Side effects/Nursing considerations Usually only seen when excessive doses cause iatrogenic hyperthyroidism: headache, insomnia, irritability, angina pectoris,
arrhythmias, tachycardia, abdominal cramps, diarrhea, vomiting, sweating, hyperthyroidism/ Initiate therapy in lower doses in patients with a history of cardiovascular
disease.
Na'e 'et!pr!#!# tartrate *LOPRESSOR+ C!"(e"trat!" 1.& ta-#et *1.& . 2& ', ta-#et+ D!$a,e A'!/"t 12.& ',
R!/te Ora# Fre8/e"(2 2 t'e$ 3a#2
P)ar'a(e/t(a# (#a$$ -eta -#!(:er$
H!'e H!$pta# !r 4!t)
I"3(at!" Treat'e"t !5 )2perte"$!"9 a","a pe(t!r$9 a"3 pre6e"t!" !5 MI.
Side effects/Nursing considerations fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes, blurred vision,
BRADYCARDIA, HF, PULMONARY EDEMA, hypotension, peripheral vasoconstriction, constipation, diarrhea, drug-induced hepatitis, dry mouth, flatulence, gastric
pain, heartburn, M liver enzymes, nausea, vomiting, erectile dysfunction, hyperglycemia, hypoglycemia/ contraindicated in uncompensated HF, pulmonary edema,
bradycardia; Use cautiously in renal and hepatic impairment.
Na'e '!rp)"e C!"(e"trat!" 1 'L ? 2', !5 2 ',/'L D!$a,e A'!/"t 2',
R!/te I"tra6e"!/$ Fre8/e"(2 E6er2 > )!/r$ PRN
P)ar'a(e/t(a# (#a$$ !p!3 a,!"$t$
H!'e H!$pta# !r 4!t)
I"3(at!" Ma"a,e'e"t !5 '!3erate t! $e6ere ()r!"( pa" " pate"t$.
Side effects/Nursing considerations confusion, sedation, dizziness, euphoria, headache, blurred vision, RESPIRATORY DEPRESSION, hypotension, bradycardia,
constipation, nausea, vomiting, physical dependence, psychological dependence, tolerance/ Use with extreme caution in patients receiving MAO inhibitors within 14 days
prior
Na'e !.2CODONE=a(eta'"!p)e" *PERCOCET+ C!"(e"trat!" &=32& ', per ta-#et D!$a,e A'!/"t 1=2 ta-#et
R!/te Ora# Fre8/e"(2 E6er2 0 )!/r$ PRN
P)ar'a(e/t(a# (#a$$ !p!3 a,!"$t$
H!'e H!$pta# !r 4!t)
I"3(at!" Treat$ '!3erate t! '!3erate#2 $e6ere pa".
S3e e55e(t$/N/r$", (!"$3erat!"$ confusion0 sedation0 di55iness0 euphoria0 headache0 2lurred $ision0 R#:@4RATORF D#@R#::4O<0 hypotension0 2radycardia0
constipation0 nausea0 $omitin%0 physical dependence0 psycholo%ical dependence0 tolerance( 9se with e/treme caution in patients recei$in% MAO inhi2itors within +, days
prior
Na'e pa"t!pra;!#e *PROTONIA+ EC ta-#et >1 ', C!"(e"trat!" 1 ta-#et *1 . >1 ',+ D!$a,e A'!/"t >1 ',
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' !
R!/te Ora# Fre8/e"(2 DAILY
P)ar'a(e/t(a# (#a$$ pr!t!" p/'p ")-t!r$
H!'e H!$pta# !r 4!t)
I"3(at!" De(rea$e re#ap$e rate$ !5 3a2t'e a"3 ",)tt'e )eart-/r" $2'pt!'$ !" pate"t$ 7t) GERD.
Side effects/Nursing considerations headache, PSEUDOMEMBRANOUS COLITIS, abdominal pain, diarrhea, flatulence, hyperglycemia, hypomagnesemia (especially
if treatment duration 3 mo)/ May M risk of bleeding with warfarin (monitor INR/PT).
Na'e ppera(e##"=ta;!-a(ta' *SOSYN+ C!"(e"trat!" 3.3@& , " $!3/' ()#!r3e 1.BC &1 '#
IVP4 M4P
D!$a,e A'!/"t 3.3@& ,
R!/te I"tra6e"!/$ Fre8/e"(2 E6er2 0 )!/r$ >=11=10=22
P)ar'a(e/t(a# (#a$$ e.te"3e3 $pe(tr/' pe"(##"$
H!'e H!$pta# !r 4!t)
I"3(at!" S:" a"3 $:" $tr/(t/re "5e(t!"$.
Side effects/Nursing considerations SEIZURES (HIGHER DOSES), confusion, dizziness, headache, insomnia, lethargy, PSEUDOMEMBRANOUS COLITIS,
diarrhea, constipation, drug-induced hepatitis, nausea, vomiting, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, rashes ( in cystic fibrosis
patients), pain, phlebitis at IV site, HYPERSENSITIVITY REACTIONS, INCLUDING ANAPHYLAXIS AND SERUM SICKNESS, fever/ Hypersensitivity to
penicillins, beta-lactams, cephalosporins, or tazobactam; Used cautiously in renal impairment or sodium restriction.
Na'e pre3"SONE *DELTASONE+ C!"(e"trat!" 2 ta-#et *2 . 21 ',+ D!$a,e A'!/"t >1 ',
R!/te Ora# Fre8/e"(2 Da#2
P)ar'a(e/t(a# (#a$$ a"t="5#a''at!re$ *$ter!3a#+
H!'e H!$pta# !r 4!t)
I"3(at!" Used systemically and locally in a wide variety of chronic diseases.
Side effects/Nursing considerations depression, euphoria, headache, hypertension, PEPTIC ULCERATION, anorexia, nausea, vomiting, adrenal suppression,
hyperglycemia, joing pain, THROMBOEMBOLISM, muscle wasting, osteoporosis, appearance (moon face, buffalo hump), M susceptibility to infection/ Chronic
treatment (leads to adrenal suppression; use lowest possible dose for shortest period of time)
Na'e p2r3!$$t,'"e *MESTINON+ C!"(e"trat!" 1 ta-#et *1 . 01 ',+ D!$a,e A'!/"t 01 ',
R!/te Ora# Fre8/e"(2 E6er2 0 )!/r$
P)ar'a(e/t(a# (#a$$ ()!#"er,($
H!'e H!$pta# !r 4!t)
I"3(at!" U$e3 t! "(rea$e '/$(#e $tre",t) " t)e $2'pt!'at( treat'e"t !5 '2a$t)e"a ,ra6$.
Side effects/Nursing considerations SEIZURES, dizziness, weakness, bronchospasm, excessive secretions, bradycardia, hypotension, abdominal cramps, diarrhea,
excessive salivation, nausea, vomiting, sweating, rashes/ Cholinergic effects may be antagonized by other drugs possessing anticholinergic properties,
Na'e r!$/6a$tat" *CRESTOR+ C!"(e"trat!" 1 ta-#et *1 . & ', ta-#et+ D!$a,e A'!/"t & ',
R!/te Ora# Fre8/e"(2 Da#2
P)ar'a(e/t(a# (#a$$ )', (!a re3/(ta$e ")-t!r$ *$tat"$+
H!'e H!$pta# !r 4!t)
I"3(at!" A3D/"(t6e 'a"a,e'e"t !5 pr'ar2 )2per()!#e$ter!#e'a a"3 '.e3 32$#p3e'a$.
Side effects/Nursing considerations confusion, memory loss, weakness, abdominal pain, constipation, drug-induced hepatitis, M liver function tests, nausea,
hyperglycemia, thrombocytopenia, RHABDOMYOLYSIS/ Contraindicated in patients with active liver disease or unexplained persistent elevations in AST & ALT
Na'e $e""a=3!(/$ate *SENOEOT=S+ C!"(e"trat!" F.0=&1 ', per ta-#et D!$a,e A'!/"t 1 ta-#et
R!/te Ora# Fre8/e"(2 2 t'e$ 3a#2
P)ar'a(e/t(a# (#a$$ $t'/#a"t #a.at6e$
H!'e H!$pta# !r 4!t)
I"3(at!" Treat'e"t !5 (!"$tpat!"9 part(/#ar#2 7)e" a$$!(ate3 7t) (!"$tpat", 3r/,$.
Side effects/Nursing considerations cramping, diarrhea, nausea, electrolyte abnormalities (chronic use or dependence)/ May N absorption of other orally administered
drugs because of N transit time.
Na'e 6a"(!'2(" *VANCOCIN+ C!"(e"trat!" 19@&1 ', " $!3/' ()#!r3e 1.BC &11
'L IV4P
D!$a,e A'!/"t 19@&1 ',
R!/te I"tra6e"!/$ Fre8/e"(2 2 t'e$ 3a#2
P)ar'a(e/t(a# (#a$$ a"t-!t($
H!'e H!$pta# !r 4!t)
I"3(at!" Treat'e"t !5 p!te"ta##2 #5e=t)reate"", "5e(t!"$ 7)e" #e$$ t!.( a"t="5e(t6e$ are (!"tra"3(ate3. Part(/#ar#2 /$e5/# " $tap)2#!(!((a# "5e(t!"$.
Side effects/Nursing considerations ototoxicit, hypotension, nausea, vomiting, nephrotoxicity, phlebitis, HYPERSENSITIVITY REACTIONS INCLUDING
ANAPHYLAXIS, chills, fever, "red man" syndrome (with rapid infusion), superinfection/ Use cautiously in patients with renal impairment.
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' A
& NUTRITION: 4nclude type o& diet0 ), 6R a$era%e home diet0 and your nutritional analysis with recommendations.
Diet ordered in hospitalD Mechanical so&t(chopped Analysis o& home diet (Compare to My @late and
Diet pt &ollows at homeD Re%ular Consider co1mor2idities and cultural considerations>
), 6R a$era%e home diet>
Brea3&ast> special . cereal with +O mil30 straw2erries Based on the a$era%e ),hr home diet0 the patient needs to
incorporate more dairy0 %rains0 and &ruits. The patient also
has a past medical history o& hyperlipidemia0 so he should
eat &oods with low cholesterol and saturated &at le$els0 and
increase his &i2er inta3e. ;oods hi%hest in &i2er include
rasp2erries0 2lac32erries0 pears0 a$acados0 %rains0 le%umes0
lentils0 2roccoli0 and 2russels sprouts.
Lunch> roast 2ee& sandwich0 salad
Dinner> chic3en0 %reen 2eans0 potatoes
:nac3s> ice cream
LiIuids (include alcohol> ) %lasses o& water0 + sweet tea
9se this lin3 &or the nutritional analysis 2y comparin% the patients
), 6R a$era%e home diet to the recommended portions0 and use
My @late as re&erence.
Accordin% to My @late0 the patient is consumin% around +G**
calories per day. ++'O o& his diet is protein0 G,O is re&ined
%rains0 +*AO is $e%eta2les0 ,'O is whole &ruit0 and !GO is dairy.
The patient is too low in the &ollowin% daily %roup tar%ets> dairy0
%rains0 and &ruits.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts desi%ned to help %uide your discussion
Eho helps you when you are illD 6is wi&e0 &amily
6ow do you %enerally cope with stressD or Ehat do you do when you are upsetD 6e said he %ets irrita2le- he usually
watches t$ or ta3es a nap when he is stressed.
Recent di&&iculties (;eelin%s o& depression0 an/iety0 2ein% o$erwhelmed0 relationships0 &riends0 social li&e 6is most recent
di&&iculties include myasthenia crisis0 which he had in Octo2er.
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' "
G2 DOMESTIC VIOLENCE ASSESSMENT
Consider beginning with: Unfortunately many children as well as adult women and men ha!e been or currently are
unsafe in their relationships in their homes. " am going to as# some $uestions that help me to ma#e sure that you are
safe.%
6a$e you e$er &elt unsa&e in a close relationshipD PPPPPPP<oPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
6a$e you e$er 2een tal3ed down toDP<oPPPPP 6a$e you e$er 2een hit punched or slappedD P<oPPPPPPPPPPP
6a$e you 2een emotionally or physically harmed in other ways 2y a person in a close relationship with youD
PPPPPPPPPPPPPPPP<oPPPPPPPPPPPPPPPPPPPPPPPPPP 4& yes0 ha$e you sou%ht help &or thisD PPPPPPPPPPPPPP
Are you currently in a sa&e relationshipD Fes
> DEVELOPMENTAL CONSIDERATIONS:
#ri3son8s sta%e o& psychosocial de$elopment> Trust $s. Mistrust Autonomy $s. Dou2t Q :hame 4nitiati$e $s. ?uilt 4ndustry $s.
4n&eriority 4dentity $s. Role Con&usion(Di&&usion 4ntimacy $s. 4solation ?enerati$ity $s. :el& a2sorption(:ta%nation H #%o 4nte%rity $s. Despair
Chec3 one 2o/ and %i$e the te/t2oo3 de&inition (with citation and re&erence o& 2oth parts o& #ric3son8s de$elopmental sta%e &or your
patient8s a%e %roup> !" y.o. male
Descri2e the sta%e your patient is in and %i$e the characteristics that the patient e/hi2its that led you to your determination>
According to Ericksons stages of psychosocial development, the patient falls under the last stage, ego
integrity vs. despair for the later adulthood years of ages 65 through end of life. Adults in this age group need to
look back on their life and feel a sense of accomplishment and fulfillment. Success at this stage leads to feelings
of wisdom, while failure in the stage can lead to regret and bitterness. This patient displays characteristics that
favor ego integrity. The patient was proud to talk about his family. His family was visiting him and he
appeared to be happy being around them. He was pleasant and demonstrated a willingness to be involved in his
healthcare plan and goals.
Cherry0 .. (n.d.. Eri#son&s stages of psychosocial de!elopment. Retrie$ed &rom
http>((psycholo%y.a2out.com(li2rary(2lPpsychosocialPsummary.htm
Descri2e what impact o& disease(condition or hospitali5ation has had on your patient8s de$elopmental sta%e o& li&e> The patient is
una2le to 2e as acti$e in his %randchildren8s li$es as he would li3e to 2e.
G3 CULTURAL ASSESSMENT:
Ehat do you thin3 is the cause o& your illnessD 6e understands that his illness is autoimmune and that they really don8t
3now what causes it.
Ehat does your illness mean to youD 48m tired all the time.
G3 SEAUALITY ASSESSMENT: *t)e 5!##!7", prompts 'a2 )e#p t! ,/3e 2!/r 3$(/$$!"+
Consider beginning with: " am as#ing about your se'ual history in order to obtain information that will screen for
possible se'ual health problems these are usually related to either infection changes with aging and(or $uality of life.
All of these $uestions are confidential and protected in your medical record%
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' C
6a$e you e$er 2een se/ually acti$eDPPFesPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
Do you pre&er women0 men or 2oth %endersD PPPEomenPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
Are you aware o& e$er ha$in% a se/ually transmitted in&ectionD PPPP<oPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
6a$e you or a partner e$er had an a2normal pap smearDPPP<oPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
6a$e you or your partner recei$ed the ?ardasil (6@B $accinationD PPPPP<oPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

Are you currently se/ually acti$eD PPPPPFesPPPPPPPPPPPPPPPPPPPEhen se/ually acti$e0 what measures do you ta3e to
pre$ent acIuirin% a se/ually transmitted disease or an unintended pre%nancyD Birth control pills( condoms
6ow lon% ha$e you 2een with your current partnerDPPPPPP,* years PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
6a$e any medical or sur%ical conditions chan%ed your a2ility to ha$e se/ual acti$ityD FesPPPPPPPPPPPPP
Do you ha$e any concerns a2out se/ual health or how to pre$ent se/ually transmitted disease or unintended pre%nancyD
<o
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' +*
H1 SPIRITUALITY ASSESSMENT: (includin% 2ut not limited to the &ollowin% Iuestions
Ehat importance does reli%ion or spirituality ha$e in your li&eD Bery much (pastor was sittin% at 2edside- they attend church re%ularly
and participate in prayer chains
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
Do your reli%ious 2elie&s in&luence your current conditionD 6is 2elie&s ma3e it easier to handle his condition since he 3nows it is
out o& his control. PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
G3 SMOEING9 CHEMICAL USE9 OCCUPATIONAL/ENVIRONMENTAL EAPOSURES:
+. Does the patient currently0 or has he(she e$er smo3ed or used chewin% to2accoD Fes <o
4& so0 whatD 6ow muchD (speci&y daily amount ;or how many yearsD )* years
Ci%ars One e$ery other day (a%e ,* thru !*
@ac3 Fears>
4& applica2le0 when did the
patient IuitD " years a%o
Does anyone in the patient8s household smo3e to2accoD 4&
so0 what0 and how muchD <o
6as the patient e$er tried to IuitD
). Does the patient drin3 alcohol or has he(she e$er dran3 alcoholD Fes <o
EhatD Eine and 2eer 6ow muchD (%i$e speci&ic $olume ;or how many yearsD
A couple o& %lasses0 once a month (a%e )G thru !"
4& applica2le0 when did the patient IuitD
'. 6as the patient e$er used street dru%s such as mariLuana0 cocaine0 heroin0 or otherD Fes <o
4& so0 whatD
6ow muchD ;or how many yearsD
(a%e thru
4s the patient currently usin% these dru%sD
Fes <o
4& not0 when did he(she IuitD
,. 6a$e you e$er0 or are you currently e/posed to any occupational or en$ironmental 6a5ards(Ris3sD <o
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' ++
11 REVIE< OF SYSTEMS
Ge"era# C!"$tt/t!" Ga$tr!"te$t"a# I''/"!#!,(
Recent wei%ht loss or %ain <ausea0 $omitin%0 or diarrhea Chills with se$ere sha3in%
I"te,/'e"tar2 H Constipation 4rrita2le Bowel <i%ht sweats
Chan%es in appearance o& s3in ?#RD Cholecystitis ;e$er
@ro2lems with nails 4ndi%estion ?astritis ( 9lcers 64B or A4D:
Dandru&& 6emorrhoids Blood in the stool Lupus
@soriasis Fellow Laundice 6epatitis Rheumatoid Arthritis
6i$es or rashes @ancreatitis :arcoidosis
:3in in&ections Colitis Tumor
9se o& sunscreen always :@;> +** Di$erticulitis Li&e threatenin% aller%ic reaction
Bathin% routine> e$eryday Appendicitis #nlar%ed lymph nodes
Other> A2dominal A2scess Other>
Last colonoscopyD , years a%o
HEENT Other> He'at!#!,(/O"(!#!,(
H Di&&iculty seein% Ge"t!/r"ar2 Anemia
H Cataracts or ?laucoma nocturia H Bleeds easily
H Di&&iculty hearin% dysuria Bruises easily
#ar in&ections hematuria H Cancer
H :inus pain or in&ections polyuria Blood Trans&usions
<ose 2leeds 3idney stones Blood type i& 3nown>
H @ost1nasal drip <ormal &reIuency o& urination> )* /(day Other>
Oral(pharyn%eal in&ection Bladder or 3idney in&ections
Dental pro2lems Meta-!#(/E"3!(r"e
Routine 2rushin% o& teeth ) /(day Dia2etes Type>
Routine dentist $isits + /(year H 6ypothyroid (6yperthyroid
Bision screenin% +.G years a%o 4ntolerance to hot or cold
Other> Osteoporosis
Other>
P/#'!"ar2
H Di&&iculty Breathin% Ce"tra# Ner6!/$ S2$te'
Cou%h 1 dry or producti$e <OMEN ONLY CBA
Asthma 4n&ection o& the &emale %enitalia Di55iness
Bronchitis Monthly sel& 2reast e/am :e$ere 6eadaches
#mphysema ;reIuency o& pap(pel$ic e/am Mi%raines
@neumonia Date o& last %yn e/amD Oct )*+' :ei5ures
Tu2erculosis menstrual cycle re%ular irre%ular Tic3s or Tremors
#n$ironmental aller%ies menarche a%eD #ncephalitis
last CHRD '()G(+, menopause a%eD Menin%itis
Other> Date o& last Mammo%ram QResult> Other>
Date o& D#HA Bone Density Q Result>
Car3!6a$(/#ar MEN ONLY Me"ta# I##"e$$
H 6ypertension 4n&ection o& male %enitalia(prostateD Depression
H 6yperlipidemia ;reIuency o& prostate e/amD +(yr :chi5ophrenia
Chest pain ( An%ina (sometimes durin%
crisis
Date o& last prostate e/amD '()*+' An/iety
Myocardial 4n&arction B@6 Bipolar
CAD(@BD 9rinary Retention Other>
C6; M/$(/#!$:e#eta#
Murmur 4nLuries or ;ractures C)#3)!!3 D$ea$e$
Throm2us H Eea3ness H Measles
Rheumatic ;e$er @ain H Mumps
Myocarditis ?out @olio
Arrhythmias Osteomyelitis :carlet ;e$er
Last #.? screenin%0 whenD H Arthritis H Chic3en @o/
Other> Other> Other>
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' +)
4s there any pro2lem that is not mentioned that your patient sou%ht medical attention &or with anyoneD <o
Any other Iuestions or comments that your patient would li3e you to 3nowD <o
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' +'
H11 PHYSICAL EAAMINATION:(Descri2e a2normal assessment 2elow non chec3ed 2o/es
?eneral :ur$ey> @atient sittin%
up ri%ht in 2ed- o$erall
wea3ness
6ei%ht> !8*88 Eei%ht> )''l2 BM4> @ain> (include ratin% Q location 6e
descri2es his pain at the incision si%ht as
dull and constant0 2ut &eels more pressure
than anythin%. 6is pain is a 7!8 on a *1+*
pain scale and is currently 2ein% treated
with morphine &or pain.
@ulse> G! Blood
@ressure> +'"(CG le&t arm
(include location
Temperature> (route ta3enD
Oral CA.G
Respirations> +'
:pO) C,O 4s the patient on Room Air or O)> room air
O$erall Appearance> JDress(%roomin%(physical handicaps(eye contactK
H clean0 hair com2ed0 dress appropriate &or settin% and temperature0 maintains eye contact0 no o2$ious handicaps
O$erall Beha$ior> Je.%.> appropriate(restless(odd mannerisms(a%itated(lethar%ic(otherK
H awa3e0 calm0 rela/ed0 interacts well with others0 Lud%ment intact
:peech> Je.%.> clear(mum2les (rapid (slurred(silent(otherK
H clear0 crisp diction
Mood and A&&ect> H pleasant H cooperati$e H cheer&ul H tal3ati$e Iuiet 2oisterous &lat
apathetic 2i5arre a%itated an/ious tear&ul withdrawn a%%ressi$e hostile loud
Other>
I"te,/'e"tar2
H :3in is warm0 dry0 and intact
H :3in tur%or elastic
H <o rashes0 lesions0 or de&ormities
H <ails without clu22in%
H Capillary re&ill R ' seconds
H 6air e$enly distri2uted0 clean0 without $ermin
@eripheral 4B site Type> @4CC dou2le lumen Location> ri%ht 2asilic $ein Date inserted> '(),(+, S +'>''
H no redness0 edema0 or dischar%e
;luids in&usin%D H no yes
@eripheral 4B site Type> Location> Date inserted>
no redness0 edema0 or dischar%e
;luids in&usin%D no yes 1 whatD
Central access de$ice Type> Location> Date inserted>
;luids in&usin%D no yes 1 whatD
HEENT:H ;acial &eatures symmetric H <o pain in sinus re%ion H <o pain0 clic3in% o& TMT H Trachea midline
H Thyroid not enlar%ed H <o palpa2le lymph nodes H sclera white and conLuncti$a clear- without dischar%e
#ye2rows0 eyelids0 or2ital area0 eyelashes0 and lacrimal %lands symmetric without edema or tenderness
@#RRLA pupil si5e ,(,mm @eripheral $ision intact #OM intact throu%h ! cardinal &ields without nysta%mus
H #ars symmetric without lesions or dischar%e H Ehisper test heard> ri%ht ear1 +) inches Q le&t ear1 +) inches
H <ose without lesions or dischar%e H Lips0 2uccal mucosa0 &loor o& mouth0 Q ton%ue pin3 Q moist without lesions
Dentition>
Comments> #yelids non1symmetric- droopin%. #yelids not symmetric due to incision and in&lammation. @eripheral0
@#RRLA0 and #OM only assessed in ri%ht eye.
9ni$ersity o& :outh ;lorida Colle%e o& <ursin% = Re$ision Au%ust )*+' +,
P/#'!"ar2/T)!ra.: H Respirations re%ular and unla2ored H Trans$erse to A@ ratio )>+ H Chest e/pansion symmetric
H Lun%s clear to auscultation in all &ields without ad$entitious sounds
CL = Clear
H @ercussion resonant throu%hout all lun% &ields0 dull towards posterior 2ases
E6 = Ehee5es
CR 1 Crac3les
:putum production> thic3 thin Amount> scant small moderate lar%e
R6 = Rhonchi
Color> white pale yellow( clear yellow dar3 yellow %reen %ray li%ht tan 2rown red
D = Diminished

: = :tridor
A2 1 A2sent
Car3!6a$(/#ar: H <o li&ts0 hea$es0 or thrills @M4 &elt at> mid1cla$icular line0 G
th
intercostal space
6eart sounds> :+ :) Re%ular 4rre%ular H <o murmurs0 clic3s0 or ad$entitious heart sounds H <o TBD
Rhythm (&or patients with #C? tracin% = tape ! second strip 2elow and analy5e <o li&t0 hea$es0 or thrills &elt on patient.
The point o& ma/imal impact was &elt at mid1cla$icular line0 G
th
intercostal space. 6eart sounds :+ and :) were re%ular. <o
murmurs0 clic3s0 or ad$entitious heart sounds heard upon auscultation. <o Lu%ular $enous pressure (TBD present upon
o2ser$ation.
H Cal& pain 2ilaterally ne%ati$e H @ulses 2ilaterally eIual Jratin% scale> *1a2sent0 +12arely palpa2le0 )1wea30 '1normal0 ,12oundin%K
Apical pulse> (' Carotid> (' Brachial> (' Radial> (' ;emoral> (' @opliteal> (' D@> (' @T> ('
H <o temporal or carotid 2ruits #dema> Jratin% scale> *1none0 U+ (+1)mm0 U) ('1,mm0 U' (G1!mm0 U,(A1"mm K
Location o& edema> n(a pittin% non1pittin%
H #/tremities warm with capillary re&ill less than ' seconds
GI/GU: H Bowel sounds acti$e / , Iuadrants- no 2ruits auscultated H <o or%anome%aly
H @ercussion dull o$er li$er and spleen and tympanic o$er stomach and intestine H A2domen non1tender to palpation
9rine output> H Clear Cloudy Color> pale yellow @re$ious ), hour output> n(a mLs <(A
;oley Catheter H 9rinal or Bedpan H Bathroom @ri$ile%es without assistance or with assistance
H CBA punch without re2ound tenderness
Last BM> (date ' ( )G ( +, ;ormed :emi1&ormed 9n&ormed :o&t 6ard LiIuid Eatery
Color> Li%ht 2rown Medium Brown Dar3 Brown Fellow ?reen Ehite Co&&ee ?round Maroon Bri%ht Red
6emoccult positi$e ( ne%ati$e (lea$e 2lan3 i& not done
?enitalia> Clean0 moist0 without dischar%e0 lesions or odor H <ot assessed0 patient alert0 oriented0 denies pro2lems
Other = Descri2e>
M/$(/#!$:e#eta#: H ;ull ROM intact in all e/tremities without crepitus
H :tren%th 2ilaterally eIual at P('PPP R9# PPP('PPPP L9# PPP('PPPP RL# Q PPP('PPPP in LL#
Jratin% scale> *1a2sent0 +1trace0 )1not a%ainst %ra$ity0 '1a%ainst %ra$ity 2ut not a%ainst resistance0 ,1a%ainst some resistance0 G1a%ainst &ull resistanceK
H $erte2ral column without 3yphosis or scoliosis
H <euro$ascular status intact> peripheral pulses palpa2le0 no pain0 pallor0 paralysis or parathesias
Ne/r!#!,(a#: H @atient awa3e0 alert0 oriented to person0 place0 time0 and date Con&used- i& con&used attach mini mental e/am
H C< )1+) %rossly intact H :ensation intact to touch0 pain0 and $i2ration H Rom2er%8s <e%ati$e
H :tereo%nosis0 %raphesthesia0 and proprioception intact H ?ait smooth0 re%ular with symmetric len%th o& the stride
DTR> Jratin% scale> *1a2sent0 U+ slu%%ish(diminished0 U) acti$e(e/pected0 U' sli%htly hyperacti$e0 U, 6yperacti$e0 with intermittent or transient clonusK
Triceps> () L. arm only Biceps> () L. arm only Brachioradial> () L. arm only @atellar> () Achilles> () An3le clonus> positi$e
ne%ati$e Ba2ins3i> positi$e ne%ati$e
H11 PERTINENT LA4 VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
a2normals0 include rationale and analysis. List dates with all la2s and dia%nostic tests>
@ertinent includes la2s that are chec3ed when on certain medications0 monitored &or the disease process0 need
prior to and a&ter sur%ery0 and pertinent to hospitali5ation. Do not &or%et to include dia%nostic tests0 such as
9ltrasounds0 H1rays0 CT0 MR40 64DA0 etc. 4& a la2 or test is not in the chart (such as one that is done preop then
include why you e/pect it to 2e done and what results you e/pect to see.
La- Date$ Tre"3 A"a#2$$
RBC '.G,
RBC '.!!
RBC ,.+*
<ormal RBC ran%e (,.!C1!.+'
'()'()*+,
'(),()*+,
'()G()*+,

Ehile the patient remains
lower than normal ran%e
in all three areas> RBC
count0 hemo%lo2in0 and
hematocrit0 the la2 $alues
are trendin% upward.
Red 2lood cell count0
hemo%lo2in0 and hematocrit
are related 2ecause they each
measure aspects o& red 2lood
cells. 4& the measures in these
three areas are lower than
normal0 it could 2e related to
2lood loss durin% procedure.
6emo%lo2in ++.A
6emo%lo2in +).)
6emo%lo2in +'.G
<ormal 6emo%lo2in ran%e (+,.+1+".+
'()'()*+,
'(),()*+,
'()G()*+,
Ehile the patient remains
lower than normal ran%e
in all three areas> RBC
count0 hemo%lo2in0 and
hematocrit0 the la2 $alues
are trendin% upward.
Red 2lood cell count0
hemo%lo2in0 and hematocrit
are related 2ecause they each
measure aspects o& red 2lood
cells. 4& the measures in these
three areas are lower than
normal0 it could 2e related to
2lood loss durin% procedure.
6ematocrit ''."
6ematocrit 'G.)
6ematocrit 'C.+
<ormal 6ematocrit ran%e (,'.G1G'.A
'()'()*+,
'(),()*+,
'()G()*+,
Ehile the patient remains
lower than normal ran%e
in all three areas> RBC
count0 hemo%lo2in0 and
hematocrit0 the la2 $alues
are trendin% upward.
Red 2lood cell count0
hemo%lo2in0 and hematocrit
are related 2ecause they each
measure aspects o& red 2lood
cells. 4& the measures in these
three areas are lower than
normal0 it could 2e related to
2lood loss durin% procedure.
EBC ++.)
EBC C.'
EBC ".A
<ormal EBC ran%e (,.G1++
'()'()*+,
'(),()*+,
'()G()*+,
The patient8s EBC count
was hi%h initially0 2ut has
2een trendin% downward
and is now within normal
ran%e.
<um2er o& in&ection
&i%htin% cells. An increased
EBC count indicates the
presence o& an in&ection or
in&lammation.
On '()+0 the patient was ta3en to the OR &or or2ital cellulitis. 4n the OR0 purulence and necrotic su2cutaneous tissue was
disco$ered within the upper eyelid and or2it0 concernin% &or necroti5in% &asciitis.
G2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet0 $itals0 acti$ity0 scheduled
dia%nostic tests0 consults0 accu chec3s0 etc. Also pro$ide rationale and &reIuency i& applica2le.
The patient is on a mechanical so&t diet. The patient is on room air and his $itals si%ns are within ran%e0 with a
sli%htly lowered temperature and 2radycardic as 2aseline. The patient8s RBC0 hemo%lo2in0 and hematocrit are
2elow normal ran%e0 as a result o& his OR procedure on '()+. 6is EBC count was hi%h0 indicati$e o& an
in&ection0 howe$er0 now is within normal ran%e. The patient is e/periencin% pain at the incision si%ht0 2ut &eels
more pressure a2o$e le&t eye. 6is pain is a 7!8 on a *1+* pain scale and is currently 2ein% treated with morphine
and @#RCOC#T &or pain. The patient is also 2ein% treated with 4M9RA< and immune %lo2ulin &or the
myasthenia %ra$is.
F NURSING DIAGNOSES (actual and potential 1 listed in order o& priority
+. 4mpaired %as e/chan%e related to ine&&ecti$e 2reathin% pattern and muscle wea3ness as e$idence 2y lowered :p*) stats.
). Acute pain related to sur%ical procedure as e$idence 2y a pain score o& 7!8 on a *1+* numerical pain ratin% scale.
'. Ris3 &or in&ection related to open incision a2o$e le&t eye.
,. 4mpaired physical '!-#t2 related to de&ecti$e transmission o& ner$e impulses at the neuromuscular Lunction as
e$idence 2y %enerali5ed wea3ness e/perienced 2y patient.
G. 4m2alanced "/trt!"> less than 2ody reIuirements related to di&&iculty eatin% and swallowin% as e$idence 2y swallow
study test.
H 1& CARE PLAN
N/r$", Da,"!$$: 4mpaired %as e/chan%e related to ine&&ecti$e 2reathin% pattern and muscle wea3ness as e$idence 2y lowered :p*) stats.
Pate"t G!a#$/O/t(!'e$ N/r$", I"ter6e"t!"$ t! A()e6e
G!a#
Rat!"a#e 5!r I"ter6e"t!"$
Pr!63e Re5ere"(e$
E6a#/at!" !5 G!a# !" Da2 (are $
Pr!63e3
The patient will demonstrate
adeIuate o/y%enation as e$idence
2y pulse o/imetry 2ein%
maintained at C)O and a2o$e until
the end o& shi&t.
Monitor o/y%en saturation
continuously usin% pulse o/imetry.
Monitor respiratory rate0 depth0 and
ease o& respirations. Eatch &or use
o& accessory muscles and nasal
&larin%.
@ulse o/imetry is use&ul &or
trac3in% and(or adLustin%
supplemental o/y%en therapy &or
patients. An o/y%en saturation o&
less than C*O and the use o&
accessory muscle use indicates
si%ni&icant o/y%enation pro2lems.
(Ac3ley Q Ladwi%0 )*++0 p%. 'AG
?oal was met. @atient8s :pO) was
at C,O and remained at a2o$e C)O
throu%hout duration o& shi&t.
Retrie$ed &rom>
Ac3ley0 B. T.0 Ladwi%0 ?. B. ()*++.
)ursing diagnosis handboo#.
(+*th ed.. Maryland 6ei%hts0
Missouri> #lse$ier 4nc.
Pate"t G!a#$/O/t(!'e$ N/r$", I"ter6e"t!"$ t! A()e6e
G!a#
Rat!"a#e 5!r I"ter6e"t!"$
Pr!63e Re5ere"(e$
E6a#/at!" !5 G!a# !" Da2 (are $
Pr!63e3
The patient will am2ulate G* &eet
with the assistance o& nurse (and
am2ulatory de$ice0 as needed 2y
the end o& shi&t.
:creen &or additional measures o&
physical &unction to assess stren%th
o& muscle %roups0 includin%
unassisted le% stand0 use o& 2alance
plat&orm0 el2ow &le/ion and 3nee
e/tension stren%th0 %rip stren%th0
and timed chair stands. @rior to
am2ulation0 the patient will ha$e
demonstrated the a2o$e physical
assessments e&&iciently.
The nursin% assessment should
include &actors related to mo2ility
pro2lems0 with nursin% %oals and
inter$entions de$eloped to promote
ma/imum mo2ility. The a2ilities
o& the patient should 2e assessed to
determine how 2est to &acilitate
mo$ement and reduce
musculos3eletal wea3ness (Ac3ley
Q Ladwi%0 )*++0 p%. G'"
Fes0 the %oal was met. The patient
am2ulated "* &eet with the
assistance &rom the nursin% student
and &amily mem2er.
H2 DISCHARGE PLANNING:
(put a V in &ront o& any pt education
in a2o$e care plan that you would
include &or dischar%e teachin%
C!"$3er t)e 5!##!7", "ee3$:
W:: Consult
H Dietary Consult
W@T( OT
W@astoral Care
WDura2le Medical <eeds
W;(9 appts
W Med 4nstruction(@rescription
W are any o& the patient8s
medications a$aila2le at a
discount pharmacyD WFes
W <o
WReha2( 66
W@alliati$e Care